Ethical dichotomies in organ transplantation. A time for bridge building

Rapid advances of the past 15 years have resolved many of the technical and immunologic limitations to organ transplantation. With the success rates that can now be achieved, there is increased attention to the limited supply of donor organs and to cost considerations, the remaining obstacles to wide application of organ transplantation. Competition for organs and for funding demands greater focus on patient selection and resource allocation. As Charles Taylor, philosopher and political scientist, has written, ethical formulations inevitably conflict when each is taken to its logical end point. In the 1960s, a life boat ethics framework predominated for selection of transplant recipients. The opposing egalitarian framework of recent decades has allowed for enrollment of older transplant recipients and those with histories of substance abuse. In the United States, alcoholic liver disease has been the most common indication for orthotopic liver transplantation since 1987. Among those awaiting transplantation, urgency has been a priority over time waiting. But many potential transplant candidates who are young and who appear relatively stable die while waiting. Despite the shortage of cadaveric organs, physicians and ethicists have for the most part eschewed rewards or reimbursement for living related organ donation. Such conventions are a function of the prevailing zeitgeist and are susceptible to a paradigm shift in parallel with overall changes in societal regulation of medical practice. Theorists and practitioners are immersed in the trends of the day and the approach at each moment seems preferable to that of the moment preceding. From a practical standpoint it may be possible to bridge disparate ethical constructs. For example, in the wait for solid organ transplantation, a bicameral approach could alternatively accommodate time waiting and urgency. Selection of older patients and those with a past substance abuse history could be limited to those with the best prognosis for compliance and posttransplantation quality of life. Living organ donors and families of nonliving donors could receive incentives of a noncoercive nature that would stimulate participation without sacrificing altruism. Creative approaches are needed to improve fairness and efficacy in solid organ transplantation.