ORGAN TRANSPLANTATION 1869 — Successfully transplanted skin.

1906 — Cornea was successfully transplanted

Introduction
1954 — Kidney was transplanted first time.
Organ transplantation is a successful technique Recipient is
for replacing damaged organ from healthy and fit genetically identical twin.
organ. Organs may be damaged due to injury or
1959 — Kidney transplantation occurs between
some other factors. At 18th century, researchers
fraternal twins.
started their experiments on organ transplantation
and they were failed many times and don’t get their 1960 — Between Kidneys was transplanted [3].
desired results. After many years, they were 1962 — Kidney, liver and lungs was removed
successful in organ transplantation. Researchers from deceased person for transplantation.
have able to do organ transplantation of kidney,
1963 — Organs remove from brain dead person
liver, lung, heart, pancrease, cornea etc [1]. Organ
and use in transplantation.
transplantation are done on only those organ who
have the ability to regenerate or those organ whose 1966 — Pancrease was successfully
half number able to do full work like kidney, some
transplanted. 1967 — Liver transplantation
portion of liver etc. Persons who donate their
organs called donors and the persons who receive performs successfully. 1967 — Heart was
organ called recipients. Two common possibilities
transplanted in U.S
are present in organ transplantation. First is that
both donor and recipient present at same place 1967 — Heart was transplanted in Saudi Arabia.
while second possibility is that both donor and 1968 — Bone Transplantation was successfully
recipient present at different places. Also, in some achieved.
cases, transplantation occurs in same person and in
some other cases, transplantation held in two
different people [2]. It has a very long history.
Some evidence found that people of past also do
organ transplantation. Full history of
transplantation is given here.
300 — Allotransplantation (transplantation
occurs between two non-genetically identical
people) was first originated in human in middle
ages. Leg of church caretaker name Deacon
Justinian was cut to treat cancer and attach leg of
non-genetically identical person.
1668 — Bone graft was successfully grafted.
For this purpose, dog skull used. This all procedure
held in Holland.

1746 — Nose successfully regrafted and this

surgery is done by Dr. Garengeot in France.
1818 — A surgeon transfuses four-ounce blood
from a man to his wife because she lost blood due
to childbirth.
1878 — Human-human successfully bone
transplant.
 1991 — National workshop on increasing
1968 — Harvard Ad Hoc Committee donation of organs and tissue and this workshop is
successfully developed a held by summon of General Antonia who is also a
definition of brain-dead people. surgeon [5,6].
1976 — First Immunosuppressant drug was 1998 — Hand was successfully transplanted.
successfully developed for minimize the risk of 1998 — Plasmapheresis was injected in body and
rejection by immune system. First the purpose is that it helps to do transplant in those
immunosuppressant drug is cyclosporine [4,5]. people who are not ABO compatible.
1980 — Uniform Determination of Death Act 1999 — Act was passed for appreciating organ
(UDDA) developed the definition of death as donor. According to this act, if employee wants
stopping of circulatory/ respiratory systems or stops leave for organ donation then they able to get full
all function of the body. paid leave.
1981 — Heart/Lung successfully transplanted. 2001 — University of Louisville and Jewish
1983 — First awareness week for national tissue Hospital success- fully perform hand transplant.
and organ donors. 2001 — Rate of living donors is increase as
1983— First workshop held on solid organ by a compare to
surgeon name General Everett Koop. deceased donor. And this was first time in U.S.

1984 — first combined Heart, Liver and Lungs

transplantation
done.
1984 — Congress passed an Act and banned
selling of organs and tissues. Also make organ
procurement network for equality of organ
transplantation.
1986 — First contract for OPTN by ministry of
health of U.S. OPTN work is to give facility that is
totally based on equality.
1986 — Hospitals provide very good offers for
close relatives of deceased person if they donate the
organ of their deceased relative.
1987 — Intestine transplantation was
successfully done
1988 — Split-Liver transplantation was
successfully performed. The benefit of this
procedure is that two recipient use liver of one
donor.
1989 — Performed first small intestine
transplantation.
1990— Award noble prize to Dr. Joseph and Dr.
Donnall Thomas for successful transplantation of
kidney and bone respectively.
1990 — Living donor lung was used for
transplantation.
 2002 — OPTN online the data of those patients
who were waiting for organ.
2003 — April was nominated as Donation Life
month.
2005 — In France, partial face was successfully
transplanted.
2006 — IOM issue a report in which they tell
us about ethical issues of transplantation and also
tells us how deceased person donors will increase.
check that whether a person is eligible for
transplantation or not. If they found eligible then
doctor advice a person to a specialist
transplantation center. Doctors of transplantation
center again screen a person and evaluate its health.
Common process for transplantation is:
1. Cut the skin
2. Remove arteries and vessels that attach with
organ.

2006 — In U.S. 100 million people were 3. Remove the organ

registered as donor. 4. Take the new and healthy organ
2008 — National Medal awarded for those who 5. Place it into the body
donate their organs.
6. Attach arteries and vessels
2009 — A Campaign start that title is “END
7. Close the skin cut [12].
THE WAIT”. This is due to increase the kidney
donors to abolish waiting list of kidney recipients. A necessary thing is that instruments are
sterilized. Now days, number of recipients is very
2010 — Full face was successfully transplanted.
high as compared to donors. People wait many years
2011 — Dr. Cavadas successfully transplant first for organ/tissue. Sometime people died due to pain
double leg. but cannot get any donor [13-15].
2014 — Uterine transplant successfully
performed first time
Types of Transplantation
in Sweden.
There are six ways that are useful in
2014 — In South Africa, penis was successfully transplantation of organ/ tissue.
transplanted [7-10].
1. Autograft
As described earlier that it is successful
technique for replacing damaged organ/tissue. 2. Allograft
Donors play a very good rule in transplantation 3. Isograft
because if donor not agrees to donate his organ/ 4. Xenograft
tissue then doctors not able to do transplant. Donor
has two types. 5. Domino transplant
6. Transplantation is Obese People
1. Living donor and
Autograft
2. Deceased donor
Type of transplantation in which transplantation
If a living person donate their organ, then it is
occurs within same subject. It occurs only in those
called living donor. If deceased person donates,
tissues that have the ability to reproduce it or present
then it is called deceased donor. Sometime person
in excess amount [16].
is cardiovascular dead and sometimes it is brain
dead. If a doctor believed that this person is not Allograft
more live, and they will die soon then they contact Transplantation occurs in those people who are
to person closest relative and suggest donating the not genetically identical. Transplantation between
patient’s organs. If relative allow then doctor genetically different people can causes many
remove the patient organs and save it. Researchers problems like tissue rejection because recognized
have able to save human organ for five to six the organ/tissue as foreign particle. Some tests are
years. Cornea is the only organ that cannot be present that measure organ rejection e.g. Panel
saved [3-11]. First doctor screens a person and Reactive Antibody (PRA). PRA is simple test that
 check the person’s blood. High PRA mean immune Obesity directly disturbs the health and causes
system make antibody against transplant many diseases. Renal transplantation is not possible
organ/tissue. Higher PRA, higher chances of in obese people. In 2009, researchers work on
rejection. obese people and successfully performed
Isograft transplantation in obese by using Robotic technique
In this type, both donor and recipient are [18].
genetically identical (identical twins). Immune Types of Donation
response cannot activate against this type of People donate their organ only for some reason.
transplantation because both are genetically Some donate for their love ones and some donate
identical. due to need of money. Given are the important and
Xenograft common types of donation.
Transplantation occurs between two different Living related donor
species e.g. porcine heart valve. This type is unsafe Close relatives donate their organ and tissue to
as compared to others and rejection is very high. In their family member because they don’t see their
addition, disease may also attack that person. A loved ones in pain and disease. That’s why they
scientist name Eugene Gu study on transplant type donate organ and free their relative from pain
that how heart of fetal can be transplanted into
Good samaitan
animal [18].
Some people donate their organ and tissues to
Domino transplant
unknown people and they do it for helping needy
This type is commonly applied on those who person and sometimes it is due to the need of
have cystic fibrosis disease. In CF, both lungs can money. Jesus Christian was the first people who
be damaged. So, person needs lungs donate their kidney to needy people
transplantation. Heart also transplanted in CF
Financial Compensation
patient. The reason is that in some cases, one lung
is large and other is small as a result, heart location Now days, organ transplantation is a business
is disturbed. This type of transplantation is very and people sell and buy organs. This method is
successful. very common in worldwide but this is illegal
because donor demand money e.g. 16,000$ for one
In obese people
kidney, 2000-4000$ in Iran. It is localized in some
As we know that obesity is the excess countries like Australia. This method of donation is
accumulation of fat. only acceptable in case of kidney only because
research on people reported that people will able to
survive with one kidney. Gary Becker reported that
free donation could solve the problems of that
people who cannot able to buy organ. He also gives
an approximate calculation about human organ
prices. Average market price is 15,000$ for kidney,
32,000$ for liver. In USA, human organ sale is
banned while in Iran, it is legal since 1988. About
40-50% people that live in different villages of
Pakistan sale their one kidney for 2500$ [15].
Forced Donation
Many organizations and authorities present in
different regions of world that do business of
selling and buying organs. World Medical
Association gives a report that mostly prisoners
organs missed, and this is due to because these
 organizations remove it forcefully. Another report recipient and donor can reduce the rejection risk.
that is given by Deputy Minister of Health China But perfect match is not possible. 100% perfect
that approximately 95% organs that are used is match mean genetically identical and genetically
transplantation are remove from prisoners. Another identical are only twins. So, a doctor refers some
report given that almost half of the organ sources drugs that suppress immune response, and these are
that are transplanted in last six years not know . called immunosuppressant minimize the chances of
Challenges blood transfusion reactions. Cornea is the only part
where blood transfusion not occurs because blood is
Researchers and patients both face many
not present [23]. It also has two types.
different challenges. Many types of viruses are
attacked when transplantation perform. Or 1. Induction drugs — doctor or surgeon uses
sometimes very lethal disease comes due to this drug at a time of surgery.
instruments that cannot be sterilized. When private 2. Maintenance drug — it is use for long time
people forcefully remove the organ then they use for reducing the risk of rejection [24].
those instruments that needs sterilization. Most Maintenance drug further four types.
common challenges are as fallow.
i. Calcineurin Inhibitor
Transplant Rejection
ii. mTOR Inhibitor
It is common problem that seen after most
transplants. It is due to the attack of immune iii. Anti-Proliferative
system that protects our body from different iv. Steroids
pathogens attacks that causes disease. It works very
These all are the type of maintenance drug and
accurately. When any foreign particle or pathogen
doctor recommends it. But it is also not good for
enter in body then the immune system active and
health. Its long-term use causes many diseases like;
check that whether a particle is self or non-self. If it
identifies as non-self, then release specific proteins a. 100-degree fever
that are antibody for the destruction of that foreign b. Severe cold and cough
particle and also remove that particle [20]. When
c. Burning feels in urine
doctors do surgery and transplant organ into body
then immune system recognize it as non-self
because particle that attaches on organ are different
to those that are naturally present or organ. So, it
releases immune response for destroy organ [21].
Sometimes, blood transfusion reaction occurs that
make clogs of blood. Rejection has commonly three
types.
Hyperacute rejection
This type of rejection occurs after few minutes
of transplantation and it is only when organ and
tissue not match with recipient. Person have blood
group A and donor blood group is B.
Acute rejection
Its time period is first week of transplantation to
3 months.
Chronic rejection
It occurs after many years of transplantation.
Immune system slowly damages the organ/tissue
that is transplanted [22]. Perfect matching of
 These are some symptoms that indicates that Organ transplantation is basically a replacing of
amount of immunosuppressant is high in blood. If damaged organ. Organs are damage due to some
not notice these symptoms, then risk of lethal injury or any other problem like a disease. Workers
disease is present. So, go to the transplant center take organ from donor that may be living or
and tells doctor about symptoms and feeling deceased and transplant it into recipient. Donor
[25,26]. donate their organ for many reasons like for loved
Diabetes one, forced donation, for money, etc. In many
countries, organ selling is illegal like in America,
Diabetes also diagnosed in some cases. And the
but in some countries, it is legal like in Iran. About
reason is high amount of immunosuppressant in
90% organs are removed from prisoners who were
blood.
not able to take decisions and the authorities
High Cholestrol remove their organs forcefully that increase the
No symptoms occur at start but it’s dangerous chance of disease transfer
for health. It creates clogs and blocked the blood instruments and also screen the donor for HIV,
vessels. So, blood can’t reach every site due to Hepatitis B & C, etc, before removing organ. After
clog that causes many diseases like paralysis etc. transplant, some issues occur like rejection,
Gastro-Intestinal Problems diabetes, high cholesterol etc. Doctors refer some
It’s due to steroids that doctor recommends us immunosuppressant for reducing the risk of
as an immunosuppressant rejection. But long- term use of immunosuppressant
causes many diseases like high blood pressure,
Sexual Problem
anxiety, etc.
Sex drive becomes low due to high amount of
immunosuppressant in blood.
Some other diseases also occur like bones
week, anxiety, hair loss, anemia, puffy face etc.
Cost
In transplantation, cost is matters a lot. Some
people sell their organs and their cost is very high.
Also illegal authorities also active and involve in
selling and buying organs. Price of kidney in
different countries of world like, in Manila, its
price is 1000- 2000$, America (10,000$), South
Africa (20,000$) and China (70,000$). These
prices are not affordable for poor person
Safety
Transplant technique is control by FDA that
makes very strict laws. Use of un-sterilize
instruments causes many lethal diseases like HIV,
hepatitis B, C. In past, a person who suffered
Hepatitis B and C donate their organs to needy and
poor people. Doctors don’t screen the donor and
transplant the organs without checking it. So, FDA
makes laws and regulate transplant technique.
People who suffer from lethal diseases (diabetes,
AIDS, Hepatitis) are not able to donate their
organs and tissues for transplantation [30].
Conclusion
1. ETHICAL ISSUES IN ORGAN DONATION

Organ donors can be classified as live or cadaveric. Live donors can

come from family members when they are known as “live related”
donors (LRD) or from close friends, relatives or spouses, when they are
known as “emotionally related” donors (ERD). As mentioned above
there are also donors who sell body parts, and they are called
“commercial” donors.

Ethical issues in live organ donation

The ethical issues of live organ donation should be considered in the

light of the four basic principles of biomedical ethics:
 respect for autonomy
 non-maleficence
 beneficence
 justice.

No one would argue against a parent’s decision to donate a kidney

or part of a liver to his/her child. It is seen as a selfless, altruistic and
noble act. On the other hand the actions of doctors, nurses and other
allied health staff to fulfil the parent’s wishes may on surface appear to
violate the basic principles of medical practice and ethics, which is
primum
non nocere or “first do no harm”. However all clinicians involved in
transplantation and the public have accepted live donor transplantation
for kidneys as the risks involved are minimal and the benefits to the
recipient are enormous.

Respect for Autonomy

Since the beginning of organ transplantation, clinicians have

emphasised altruism as the basis for organ donation. The element of a
freely given consent without any duress is central to the altruistic act.
Transplant teams clearly appreciate that live donors will have to make
the decision to donate voluntarily without any duress if the principle of
autonomy is to be respected. One justification for living organ donation
is that it is an exercise of individual autonomy and in practice most
donors have made the decision on their own free will. Clinicians
practising organ transplantation using live donors are cognisant of the
fact that despite their best efforts, there are instances when donors have
donated organs under subtle forms of coercion. Relatives who are
economically dependant on the family one of whom needs an organ,
may see it as their obligation to donate. Similarly spouses who are
dependent on their life partner may find it difficult to refuse requests for
organs.

Institutions practising live donor transplantation usually develop

mechanisms to allow a potential donor who is under pressure to
withdraw without unduly upsetting family relationships. In facilitating
the potential donor to make a free and informed decision on organ
donation, the institution should provide him/her with adequate
information on all aspects of donor surgery including short and long
term risks.

Many institutions provide “donor advocates” who are physicians

independent of the team looking after the recipients or the transplant
team. These donor advocates help the potential donors with their
decision making by providing independent and objective advice.
Potential donors
should have access to other members of the team, such as nurses and
social workers, whom they may find easier to relate to. Finally, the
potential donor should be assured that at any time he changes his mind
about donating an organ, his wishes will be respected. Persons, who are
mentally incompetent to decide should not be allowed to donate.

Recent issues on abuse of autonomy have risen where unrelated

donors have specified which type of patients should receive their organ.
This is not acceptable.

Principle of non-maleficence

In the surgery of organ retrieval for transplantation, actual physical

harm is being inflicted on the donor who is otherwise healthy and well.
Donors run the risk of mortality and both physical and psychological
morbidity. The act of live donor organ donation thus is a balance
between risks and benefit. One may argue that the donor does not
accrue any direct benefit by his act. However, it has been shown that
live related donors may benefit from the act of donation through
improvement in self esteem and a sense of satisfaction that they have
done something for their loved ones.

The risks to the donor are normally minimal and all potential donors
should be made aware of this fact. In donor nephrectomy, the mortality
rate has been reported to be around 0.03% in some studies. Hence the
medical work-up of the potential donor should be as thorough and
comprehensive as possible and where any doubt exists that the potential
donor may undergo more than the minimum risk, the surgery should not
be carried out.

The surgical team should also be well trained and have all the
necessary technical support.
Principle of beneficence

The principle of beneficence dictates us to do good for others

especially when there is no risk involved for the benefactor. In the
context of live organ donation, the goal of beneficence may override
that of non- maleficence if the probability of benefit greatly outweighs
the risks.

Principle of justice

This is more relevant to the allocation of organs (see below) as it

calls for a fair, equitable and appropriate treatment in the light of what
is due to the patient based on his failing health and not influenced by
other factors, like usefulness to society, social standing and so on.

Commercialisation of transplantation - a moral and ethical issue

In the 1980s survival of transplanted kidneys improved considerably

with the introduction of newer forms of drugs to suppress the body’s
immune system. At the same time it is well known that kidney
transplant patients enjoy a better quality of life compared to dialysis
patients. The demand for kidney transplant increased but the supply
from cadaveric sources remained low. This led to the phenomenon of
selling of organs by the poor. This became rife in some of the third
world and developing countries and rich patients from other part of the
world went to countries like India, Pakistan or the Philippines, to
purchase organs for transplant.

The sale of organs became a lucrative trade for some except that
the poor donor was often paid a paltry sum for his kidney or eye
while the unscrupulous doctors and middle men profited. The rampant
commercialisation and exploitation of the poor shocked the
international transplantationcommunityandthe International Society of
Transplantation and many national societies condemned the practice.
 The trafficking in organs has confounded medical ethics. Questions
of law, morality, justice and economics emerge. Although the
governments in these countries have passed laws to ban such
commercial donation of organs for transplantation, the practice has not
totally ceased and in fact has slipped into an illicit trade. A number of
ethical issues can be identified in this rampant commercialisation of
transplantation.

The person who lives in abject poverty, or who has to support his
starving family, has very few options. The doctor who operates purely
for monetary gains will obviously lower his standards of donor
selection with concomitant harm to the donor in terms of morbidity and
even fatality. The rampant commercialisation has led to criminal
activities where persons are kidnapped and organs removed and in some
countries prisoners are forced to donate their organs as well as organs
removed from executed prisoners. Some potential recipients choose not
have organs from prisoners.

There are attempts to regulate this sordid commercialisation with

proposals such as rewarded gifting and other measures. However these
measures remain open to potential abuse. Other proposals have treated
organs as commodities with one suggesting that there should be a
futures market in organs. The American Medical Association has, after
some heated debate, recently considered it not totally unfavourable to
pay for cadaveric organ donation. There are also proposals, not yet
universally accepted, that live donors should be financially rewarded.
2. ETHICAL ISSUES IN CADAVERIC ORGAN DONATION

The major source of donor organs in the Western countries is the

cadaver. Even in organ transplantation where live donor is possible and
available, such as kidney transplantation, the main or preferred source
of organs is still the cadaver. There are a number of ethical issues
relating to cadaveric organ donation.

Consent for organ donation following death is usually given in two

ways. In the “opting in” system presently practised in this country a
person states his intention to donate his organs when he is alive and this
is recorded in a document. Upon his death and in circumstances where
organ retrieval is possible, the doctors who note his wishes can then
proceed to harvest the organs. Doctors will also have to take note of the
views of the immediate relatives of the deceased. As with the case of a
live donor, consent should be freely given without any form of pressure
or inducement.

In another system of giving consent, “the presumed consent” or “the

opting out system”are considered. In “presumed consent”, a person is
deemed to have consented if he had not clearly stated that he did not
wish to donate his organs. Such a system is practised in many countries
including Singapore and a number of European countries and has led to
improvements in organ donation rates. In the “opting out system” one
assumes that the citizens of the country have access to all the
information required to make an “informed” decision and have the
freedom to make a decision not to donate his organs without fear of
being “blacklisted”. Administrative mechanisms must be in place to
help the individual decide.

Respect for the dead is a fundamental part of our religion and

culture. In organ transplantation removal of organs from the dead is
carried out with due care and concern like in any other surgery, without
mutilation or disfigurement of the body.
 As the practice of transplantation develops further more and more
organs can be transplanted and this can lead to multiple organ retrieval,
which will leave the cadaver with few organs remaining. It is important
for doctors to maintain respect for the dead and exercise discretion on
the proper limits of organ retrieval.

In cadaver organ transplantation, the definition of death is crucial as

organs are best removed when the heart is still beating but the patient is
dead. Such a situation is called brain death. It is important that
pronouncement of death is done using rigid criteria and persons
performing tests to determine brain death are independent of the
transplant team as well as the team looking after the recipient. Although
arguments still continue on the definition of death, most doctors accept
the notion that brain death is the final criterion of death.

3. ETHICAL ISSUES IN ORGAN ALLOCATION

The numbers of organs have never been sufficient to meet the

demands and the waiting time for patients to receive organs continue to
grow. In heart and liver failure, transplantation is life saving. A system
of allocation of a very scarce resource, that of organs, has to be
instituted. This has become a subject of much discussion and debate
among not only the medical community but also the public at large. The
ethical principles utilised in allocating organs include utilitarian, justice
and autonomy.

The utilitarian principle emphasise that an action is considered

right if it results in more good than an alternate action. In organ
allocation this principle may make use of medical indicators which
predict better outcome as justification for giving an organ to a particular
recipient. Such medical indicators include tissue typing characteristics.

It precludes consideration such as the social worth of the patient.

MMC Guideline on Brain Death, 2006
 The principle of justice attempts to ensure equitable access of patients to an organ sharing system. It
allows consideration of other factors than just utilitarian ones. Thus a patient who is waiting for an organ
for a long time should also be considered as a potential recipient even though another patient may have a
better tissue match.

The principle of autonomy may be applied when a patient refuses to receive an organ allocated to
him, in which case it can be given to the next suitable waiting candidate. Although there are doctors who
emphasise utilitarianism as the main criterion for allocation of organs, in general in any given situation all
factors are considered together and a consensus achieved.

4. CONFIDENTIALITY

The entire process of live un-related or cadaveric organ retrieval from the donor and the
transplantation into the recipient should be carried out in strict confidence at all levels of healthcare
workers and doctors involved. The persons involved should not be revealed to each other or their
relatives, as subsequent outcome, whether favourable or unfavourable, may have serious repercussions
when the parties involved become mutually identified.

5. PROTOCOL FOR ORGAN TRANSPLANTATION

The annexure to this Guideline sets out the protocol to be adopted in the administrative procedures in
organ transplantation. It includes objective evaluation of the living related donor. Unrelated living donors
are usually not accepted, except under special circumstances, and only after strict evaluation by the
Unrelated Transplant Approval Committee (UTAC).