Transplantation ethics: are we approaching the crossroads?

Ethical issues of organ transplantation are of extreme importance to involved physicians and to society. The basic principle is that the donor cannot be considered as a commodity; financial incentives must not occur. Regarding deceased-donor organ transplantations, ethical issues are related to the consent for donation, determination of death, and principles of organ allocation. Living donors should be healthy, giving free consent after being fully informed about the risks of the procedure. Transplant professionals have a double responsibility because they must remember about the rights of the organ recipient as well as of the donor. Because of the organ shortage we commonly use organ recovery from donors after cardiac arrest and extend the living-donor pool, practices that may influence some important ethical principles. A proper detailed determination of donor death is of utmost importance. The dead donor rule must be preserved. However category III non-heart-beating donors (so-called controlled cardiac arrest) raise doubts as to the time of the decision to transfer the dying (not yet dead) patient to the operating room to withhold supportive treatment. In certain centers, not quite healthy living donors are being used; they are called extended-criteria or complex donors. Although organ trade is condemned, some workers agree to use as complete strangers donors, obviously believing in pure altruistic motivation of such donors without the additional incentives. Finally, is the trend to consider utility in organ allocation justified? It seems that quite soon we may need a new transplantation ethics code that is not totally directed by transplant professionals exclusively to the needs of potential recipients.