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Dr Abdul Aziz al Kabba, Member of the Faculty of Medicine, King Fahd Medical City , Riyadh Saudi Arabia .
Introduction
Justice is action in accordance with the requirements of laws and rules. Whether these rules are grounded in human consensus or societal norms, they are supposed to ensure that all members of society receive fair treatment. Justice is a central issue in human rights[1]. Issues of justice arise in several different spheres and play a significant role in causing, perpetuating, and addressing conflicts arising out of a feeling of being treated unjustly. Issues of justice arise regarding fair allocation of organs for transplantation and are accompanied by a lot of ethical discussiona [2] [3] [4].
There are many theories of justice [1]; the most influential being based on the principles of utilitarian, communtarianism, feminism, libertarianism, socialism, and cosmopolitanism. Justice is a central issue in the discussion of the ethics of distribution of benefits and burdens as well as associated side effects, good or bad. So in its narrower sense, justice is fairness. The principles of justice and fairness can be thought of as rules of "fair play" in issues of social justice. There is no single principle that can address all problems of justice. Several principles of justice arguably merit acceptance, some formal and others informal.
Discussion
Shortage of organs for transplantation is a major impetus for the development of laws and regulations that affect and govern organ transplantation, directly or indirectly. Many countries possess the technical capacity and health care infrastructure to undertake transplantations, but they experience a serious shortage in the supply of suitable organs [2]. Among developments to overcome this problem have been: legislation aiming at increasing rates of recovery of transplantable organs, recovery from individuals at different stages in the process of health, and an expanded concept of legitimate donations of non-vital organs from living persons. A further development, related to the problem of scarcity, is equitable allocation of organs that become available from cadaveric sources [].
Recently my good teacher died because he had severe renal failure leaving behind many children. He was a good teacher to me and he supported me to be a successful person. He had tried to seek treatment for his end renal failure disease but his only solution was to buy a kidney for transplantation. He collected money to buy the kidney from his life's savings and also asked for help from the health system. Many people were ready to sell him the kidney. One of these was a poor man who had a big family and many children to feed. He lived in a poor old house and needed the money to improve the livelihood of his family and to educate his children. He agreed to the sale but the health system refused because the policy was only free kidney donations. The patient was faced with a long waiting list for a free kidney and died before a kidney could be found for him. The poor man and his family continued suffering from the effects of poverty. Is this system fair? Does it need change?
There is increasing pressure to allow sale of organs to meet demand but this has raised the most controversy from ethical, legal, and philosophical points of view[5]. Many countries prohibit selling human organs for transplantation[6]. This seems unjustified to me. There are many wealthy renal failure patients needing kidney transplantation. They can afford buying a kidney but are prohibited by the laws and have to be on very expensive renal dialysis for long periods of time while waiting for a free kidney. The cost of renal dialysis over a long time is very expensive compared to transplantation and contributes to high hospital and healthcare budgets []. On the other hand there are many poor people in many countries suffering from the effects of poverty and a low socio-economic status. They have big families needing adequate housing and funds to educate their children. If given the offer, they will readily agree to sell their kidneys for their and their families' benefit.
Allowing legal sale of organs will undercut illegal human organ trading and illegal renal transplant surgeries in some countries like India , Pakistan , Indonesia , Philippines
There are many factors affecting the issue of kidney sale that must be considered: donors, recipients, financial payments, conflict of interest, and safety, value of life, justice, and informed consent. I think in my opinion, there is lack of justice in this situation and we need to re-discuss this topic again and again for more international regulations[7] and for justice to both donors and recipients. Recipients want access to kidneys and donors exist who can sell their kidneys because of dire need for money because of poverty[8]. Siunce sale of kidneys is taking place anyway illegally, it will be better to legalize to be able to regulate it to protect the poor from exploitation[9].
Conclusion
From these examples and many other examples, we notice that justice is very important for everybody and everywhere and especially in the health field. It is true that there are differences in the cultures, countries, laws, policies, procedures, but that will not differentiate in the principle of real justice. We should update our health system policies and procedures to support the justice at all levels especially in the health care felid and organ transplant to help people and community.
Buijsen M. (Erasmus Medical Centre/Erasmus University Rotterdam , The Netherlands
Dossetor JB. (Bioethics Centre, University of Alberta , Edmonton , Canada
Braun WE. (Department of Nephrology and Hypertension, Cleveland
Smart B. (Department of Philosophy, Keele University
patient is at fault for the scarcity of healthy organs a principle of restitution requires that she should give priority to the faultless. Such restitution is non-punitive, and is akin to reparation in civil law, not criminal law. However, it is doubtful whether such a principle can be fairly applied within the present
culture of governmental complicity in cigarette advertising.
Rhodes R. (Mount Sinai School of Medicine, New York , NY 10029
Shroff S. (Department of Urology and Renal Transplantation, Sri Ramachandra Medical College
& Research Institute, Porur, Chennai 600 116, India India
Indian media. In most instances, the implementation of the law has been flawed and more often than once its provisions have been abused. Parallel to the living related and unrelated donation program, the deceased donation program has slowly evolved in a few states. In approximately one-third of all liver transplants, the organs have come from the deceased donor program as have all the hearts and
pancreas transplants. In these states, a few hospitals along with committed NGOs have kept the momentum of the deceased donor program. The MOHAN Foundation (NGO based in Tamil Nadu and Andhra Pradesh) has facilitated 400 of the 1,300 deceased organ transplants performed in the country over the last 14 years. To overcome organ shortage, developed countries are re-looking at the ethics of unrelated programs and there seems to be a move towards making this an acceptable legal alternative. The supply of deceased donors in these countries has peaked and there has been no further increase over the last few years. India
Schweda M, Schicktanz S. Department for Medical Ethics and History of Medicine, Goettingen University , Goettingen , Germany
Philosophical-ethical stances on this development depend on assumptions concerning the body and how people think about it. In our qualitative empirical study we analyze public attitudes towards organ donation in their specific relation to conceptions of the human body in four European countries (Cyprus
the human body and its relation to the self: a) the body as a mechanical object owned by the self, b) the body as a part of a higher order embodying the self, and c) the body as a hierarchy of organs constitutive of the self. CONCLUSION: The language of commodification is much too simple to capture what is at stake in everyday life intuitions about organ donation and organ sale. We discuss how the plurality of underlying body-self conceptions can be taken into account in the ethical debate, pointing out consequences for an anthropologically informed approach and for a liberal perspective.
Friedman EA, Friedman AL.( Downstate Medical Center , State University of New York , Brooklyn , N.Y. 11203 ,USA
hemodialysis in terms of extent of rehabilitation and long-term recipient survival. Continuous growth in the number of patients with kidney failure sustained by dialytic therapy has not been associated with substantially increased deceased donor kidney contributions, causing intensified stressful waiting periods for potential recipients lacking a live kidney donor. Neither public relation campaigns nor local government efforts have substantially increased kidney donation. Buying a donor kidney is illegal and condemned as fostering exploitation of poor people by the wealthy. Widely publicized examples of coercion of unwilling donors create a negative image of harmful, inhumane conduct deployed to obtain kidneys sold and transplanted under unsavoury circumstances. Yet efforts to establish and test governmental programs to supervise and sustain acceptable standards for the sale and implantation of
kidneys from fully informed, medically evaluated and protected, fairly compensated donors have been resisted and frustrated by those who consider such compensation loathsome. Accordingly, while selling kidneys is prohibited by law, pressure from those wanting to quench the number of deaths of wait-listed dialysis patients continues forcing reexamination of an issue that, like prohibition of the possession and sale of alcohol in the United States
Budiani-Saberi DA, Delmonico FL. (Center for Bioethics, University of Pennsylvania , Philadelphia , PA USA . debra@cofs.org). Organ trafficking and transplant tourism: a commentary on the global realities. Am J Transplant. 2008 May;8(5):925-9. The extent of organ sales from commercial living donors (CLDs) or vendors has now become evident. At the Second Global Consultation on Human Transplantation of the World Health Organization's (WHO) in March 2007, it was estimated that organ trafficking accounts for 5-10% of the kidney transplants performed annually throughout the world. Patients with sufficient resources in need of organs may travel from one country to another to purchase a kidney (or liver) mainly from a poor person. Transplant centers in 'destination' countries have been well known to encourage the sale of organs to 'tourist' recipients from the 'client' countries.
Surman OS, Saidi R, Burke TF. (Department of Psychiatry, The Transplant Service and The Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. osurman@partners.org). Regulating the sale of human organs: a discussion in context with the global
market. .Curr Opin Organ Transplant. 2008 Apr;13(2):196-201. PURPOSE OF REVIEW: Insufficient availability of human organs for transplantation has given rise to a flourishing global market. This review addresses current thinking and practical considerations regarding legalization of organ sales. RECENT FINDINGS: Increasing competition for human organs has led to egregious human rights violations. Governmental proscription of organ sales has failed to slow this process. Organ sales in China and the regulated market in Iran
transplantation. Some countries have enacted presumed consent laws that have increased cadaver organ donation. In the USA
of the global organ market, and to assess attitudes about stakeholders with regard to proposed changes in transplantation policy.
Naqvi SA, Ali B, Mazhar F, Zafar MN, Rizvi SA. (Sindh Institute of Urology and Transplantation, Civil Hospital , Karachi Pakistan Pakistan Pakistan Pakistan Pakistan
Bakdash T, Scheper-Hughes N. (Bioethics at Damascus University , Damascus
world's poor? PLoS Med. 2006 Oct;3(10):e349. BACKGROUND TO THE DEBATE: In many countries, the number of patients waiting for a kidney transplant is increasing. But there is a widespread and serious shortage of kidneys for transplantation, a shortage that can lead to suffering and death. One approach to tackling the shortage is for a patient with renal disease to buy a kidney from a living donor, who is often in a developing country, a sale that could--in theory at least--help to lift the donor out of poverty. Such kidney sales are almost universally illegal. Proponents of kidney sales argue that since the practice is widespread, it would be safer to formally regulate it, and that society should respect people's autonomous control over their bodies. Critics express concern about the potential for exploitation and coercion of the poor, and about the psychological and physical after-effects on the donors of this illegal kidney trade.
Rothman SM, Rothman DJ. (Columbia University-Columbia College of Physicians and Surgeons, New York , New York , USA.
the intended and unintended consequences of such a practice. This article addresses these issues by exploring the tensions between 'extrinsic' and 'intrinsic' incentives, suggesting that donation might well decline were financial incentives introduced. It also contends that social relationship and social welfare policy would be transformed in negative ways and that a regulated market in organs would be extraordinarily difficult to achieve. Finally, it argues that organ sale would have a highly detrimental affect on medicine as a profession.
Friedman EA, Friedman AL
& Human Services: '17 people die each day waiting for transplants that can't take place because of the shortage of donated organs.' Strategies to expand the donor pool--public relations campaigns and Drivers' license designation--have been mainly unsuccessful. Although illegal in most nations, and viewed as unethical by professional medical organizations, the voluntary sale of purchased donor kidneys now accounts for thousands of black market transplants. The case for legalizing kidney purchase hinges on the key premise that individuals are entitled to control of their body parts even to the point of inducing risk of life. One approach to expanding the pool of kidney donors is to legalize payment of a fair
market price of about 40,000 dollars to donors. Establishing a federal agency to manage marketing and purchase of donor kidneys in collaboration with the United Network for Organ Sharing might be financially self-sustaining as reduction in costs of dialysis balances the expense of payment to donors.
Kishore RR. (Indian Society for Health Laws and Ethics, D-II/145 Kidwai Nagar (West), New
Delhi-110023, India
Jha V. (Postgraduate Institute of Medical Education and Research, Chandigarh , India
vjha@iname.com). End-stage renal care in developing countries: the India
patients and their families. There is no data on the true incidence and prevalence of chronic renal failure in the developing world. Delayed diagnosis and failure of institution of measures to slow progression of renal failure result in a predominantly young ESRD population. Renal replacement therapy (RRT) is a low-priority area for healthcare planners in developing nations with two-tier healthcare delivery system. There is a severe shortage of nephrologists and hospitals offering dialysis and transplantation, more so in the poorest regions. There is a direct relationship between the number of dialysis centers and per capita gross national income of developing nations. Shortage in the number of government-funded hospitals has fanned the growth of a large number of private hospitals offering RRT. The high cost of hemodialysis (HD) puts it beyond the reach of all but the very rich and maintenance HD is the exclusively preserve of private hospitals. Government-run hospitals are busy with renal transplantation, which is the only realistic long term RRT option for a majority of patients. There are no state-funded or private health insurance schemes and patients have to raise finances for RRT on their own. Entire families are
involved in such endeavors, with resulting loss of income of other family members too. A number of measures are utilized to bring down the RRT costs. For HD, these include cutting down the frequency of dialysis, use of cheaper cellulosic dialyzers, dialyzer reuse and nonutilization of expensive drugs like
erythropoietin. Paradoxically, chronic peritoneal dialysis is more expensive than HD; patients use outdated connection systems and are suboptimally dialyzed on 3 exchanges/day. Most patients on dialysis are inadequately rehabilitated. Renal transplant recipients are forced to discontinue expensive drugs like cyclosporine after variable periods leading to high rates of graft loss. Financial considerations often preclude appropriate treatment of steroid-resistant rejection and cytomegalovirus infection. There is no organized cadaver donation program and an overwhelming majority of transplants are performed using living donors. This led to the practice of the sale of kidneys for transplant. To conclude, the financial burden of RRT in developing nations impacts on the lifestyle and future of entire families, and extracts a cost far higher than the actual amount of money spent on treatment.
Grazi RV, Wolowelsky JB. (Maimonides Medical Center , Brooklyn , New York 11228 , USA
drgrazi@genesisfertility.com). Jewish medical ethics: monetary compensation for donating kidneys.
Isr Med Assoc J. 2004 Mar;6(3):185-8. The Israel Health Ministry is preparing legislation that would allow a person to receive monetary compensation in exchange for donating a kidney for a lifesaving transplant. Such a bill would be the first of its kind, and would seem to establish a policy that is in contrast with both existing international professional ethics and major Christian and Islamic religious ethics. In an attempt to investigate the extent to which such a bill would be consistent with traditional Jewish ethics, we reviewed the opinions of major traditional Jewish ethicists/halakhists, with emphasis on contemporary opinions, and found that compensating an organ donor for his or her time, discomfort, inconvenience, and recovery is fully consistent with traditional Jewish law and ethics. While non-altruistic sale of kidneys might be theoretically ethical from a Jewish perspective, ultimately its ethical status is inextricably connected to solving a series of pragmatic issues, such as creating a system that insures that potential vendors/donors are properly informed and not exploited, controlling and supervising medical screening and support of the donors to insure that their health is not permanently endangered, protecting minors and incompetents, and regulating payments so that they reasonably reflect compensation for pain and suffering.
References [indicate relevant place in the text, format according to journal]
Robert T. Buttram, Robert Folger, and B.H. Sheppard, "Equity, Equality and Need: Three Faces of Social Justice," In Conflict, Cooperation, and Justice: Essays Inspired by the Work of Morton Deutsch, eds. B.B. Bunker and Morton Deutsch (San Francisco, Jossey-Bass Inc. Publishers, 1995)
Maiese, Michelle. "Distributive Justice." Beyond Intractability. Eds. Guy Burgess and Heidi Burgess. Conflict Research Consortium, University of Colorado , Boulder
miller, David. "Distributive Justice: What the People Think." Ethics 102:3, 199
Dickens B. Legal Approaches to Health Care Ethics and the Four Principles, in Principles of Health Care Ethics ed. Gillon R, Willey 1994, 305-317.
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[2] Braun WE.. Allocation of cadaver kidneys: new pressures, new solutions. Am J Kidney Dis. 1994 Sep;24(3):526-30.
[3] Smart B. Fault and the allocation of spare organs. 5. J Med Ethics. 1994 Mar;20(1):26-30.
[4] Rhodes R. (Mount Sinai School of Medicine, New York , NY 10029
[5] Schweda M, Schicktanz S. The "spare parts person"? Conceptions of the human body and their implications for public attitudes towards organ donation and organ sale. 2. Philos Ethics Humanit Med. 2009 Feb 18;4:4.
[6] Friedman EA, Friedman AL. Reassessing marketing of kidneys from the 2008 perspective. 3. Blood Purif. 2009;27(1):53-7
[7] Surman OS, Saidi R, Burke TF. Regulating the sale of human organs: a discussion in context with the global market. .Curr Opin Organ Transplant. 2008 Apr;13(2):196-201.
[8] Naqvi SA, Ali B, Mazhar F, Zafar MN, Rizvi SA. (Sindh Institute of Urology and Transplantation, Civil Hospital , Karachi Pakistan
[9] Bakdash T, Scheper-Hughes N. (Bioethics at Damascus University , Damascus
world's poor? PLoS Med. 2006 Oct;3(10):e349