THURSDAY, JUNE 22, 2006
Session 3: Organ Transplantation
and Procurement—The Ethical Challenges
Presentation and discussion of the staff working paper by Council senior research consultant Eric Cohen and the essay by Council member Gilbert Meilaender
CHAIRMAN PELLEGRINO: I think we're ready to go. For those
of you who have been good enough to come on time, we will start as close
to on-time as possible. We're still a little bit late. Can I have
some quiet in the back of the room please. Thank you very much. I'm
glad my voice is carrying there. Thanks for the power.
This afternoon, we're going to have a discussion of two papers
which are in the procedure book. We'll start by having one member
of the Council, our newest member, Professor Schneider, open up the
discussion of both of these papers and then we'll spend the rest
of the time with the Council making comments or queries as they see
fit. Professor Schneider.
PROFESSOR SCHNEIDER: Thank you. I was just looking around.
There is one author and the other author I assume is soon to be here.
CHAIRMAN PELLEGRINO: He'll be back. He promised to be
PROFESSOR SCHNEIDER: With a name like Meilaender, I assume
he's very prompt ordinarily.
PROFESSOR MEILAENDER: I'm right here.
PROFESSOR SCHNEIDER: There you are. I'm sorry.
PROFESSOR MEILAENDER: I just didn't bring my thing along.
PROFESSOR SCHNEIDER: I kept looking at the empty chair. I
was enormously stimulated by both papers because they were so thoughtful
and they made me think and I want to talk very quickly about some of
the things that they made me think about and to ask for your help in
understanding the papers better.
The first thing that struck me about the papers was how enormously
powerful they were rhetorically. There is language that is mobilized
here that seems to be at the outer limits of the serious. There are
phrases like "destroying ourselves in seeking to do good,"
the possibility of "our being diminished, dehumanized and corrupted"
and so on. And I'm not entirely sure that I understand where problems
at that extremity are actually materializing in the debate about transplantation.
As I looked at the arguments, I could see that carried to some possibly
imaginable extreme problems like this might be arising, but I couldn't
see that they were anywhere near to actually arising. For example,
there was considerable discussion about the consequence of our being
embodied and the fear that transplantation somehow endangered the meaning
of that. But it was never possible for me to understand how the factor
bar being embodied in the actual context in which transplantation occurs
has actually created any kinds of problems.
To take another example, I agree that death is ultimately not preventable
and that you can't try to exert all of your social resources for
solving all of the problems that death presents. But it seems to me
that we're a long way from reaching the point at which we would
say to people "Well, you're dying; death is inevitable and
we need not agitate ourselves about preventing it in this case."
Finally, I'm happy to agree that there are limits on altruism,
but it's not clear to me why those limits on altruism are being
approached here. In fact, if I were to try to think about the problems
the country has, reaching the limits of altruism does not seem to me
to be very high on the list and a situation in which it is possible
for the country to agree that altruism is a good thing and to see people
practicing it in a fairly dramatic way I think is a socially very desirable
sort of thing.
I'm certainly enthusiastic about the idea of looking, as Dr. Kass
was saying, at these questions anthropologically. I think my difficulty
is that I don't understand the anthropology in the same way that
I think a lot of the people who have been talking so far today do.
My own contact with these issues comes partly from having done research
with dialysis patients and partly from familial experience and I guess
I see a lot of these kinds of questions in a much more cheerful light.
For example, there was a good deal of concern in the papers about
the prospect that people would be coerced into donation. My reading
of the empirical literature suggests that coercion has turned out to
be far less of a problem than one might in principle anticipate and
there are a lot of reasons for this. One of them is that when people
make decisions about donating organs, they don't think long enough
to be coerced. They tend to make their decisions with such rapidity
that they've decided what to do by the time the question has been
posed. Informed consent doesn't work with donation of organs because
people have already decided one way or the other to donate their organs
and the fear of intrafamilial pressure according to the empirical literature
that I've looked at also does not suggest that very much of this
coercion goes on. I have to say that if a certain amount of pressure
goes on to recognize your obligations to help members of your family,
it doesn't unduly concern me a priori.
One more issue along these lines of the facts of the anthropological
situation: far from feeling that they've been coerced into doing
something, the record suggests to me that people who have donated organs
feel that they have benefitted enormously from it, that they very often
feel that it's the most important thing that they have done. I'm
talking about living donors and the empirical studies of them suggest
that they wind up being happier people than the average of the population
because of their donation which has changed the way that they think
And I do think that it's also worth saying that one reason you
might be interested in transplantation, whether it's a crisis or
not, and I must say I don't have any idea what the word "crisis"
means and I propose not to use it if possible. But one reason you might
be in favor of transplantation is because of the evidence that in many
kinds of transplantation at least the transplantation is cost effective.
That is, that you get more effective treatment of patients for less
So I appreciated the rhetorical and argumentative force of the papers,
but I'm still not sure that the papers ever actually go to the point
of saying not it is possible to imagine a world in which things have
come very badly apart, but in which we are actually in any danger of
reaching that point.
CHAIRMAN PELLEGRINO: Thank you very much. Eric and Gil, how
do you wish to respond?
MR. COHEN: Thank you very much for the comments. The most
forceful point I take, and let me see if I can respond, is not seeing
as clearly as you would have liked perhaps the dilemma that we confront
in the current practice of organ transplantation and even more deeply
I think the dilemmas we confront as we think about possible reforms
and way to try to boost the organ supplies. Let me see if I can quickly
paint a clearer picture of the dilemma than I did perhaps for you in
the paper and hoping that Gil will help me out.
I want to focus on the issue of living donors because I think, to
be frank about it, that's where the action is. We've done a
very good job in as much as our goal is to increase the supply of organs
with the collaborative that's been going on over the last few years
and improving the rate at which we retrieve organs from the deceased
who are eligible to be organ donors and there is frankly simply a limit
to the number of deceased owners that we'll ever have. So inasmuch
as we face the prospect of hundreds of thousands or even millions of
people in end-stage renal failure who are in need of organs and if we
think that is a crisis that needs to be ameliorated, the only place
we can look to ameliorate that crisis short of finding other alternative
medical approaches to it is to living donors.
Even before you begin to think about financial incentives and the
issue of commerce, the practice of procuring organs from living donors
"test the outer limits" to take a phrase that you began with
of the medical ethic. I think it's a testing of the outer limits
that is frankly justified in many situations. But it is a novel case
where the doctor is cutting into a healthy patient and where the person
only becomes a patient in the first place because of the action of the
doctor. It's kind of an inversion of the typical encounter between
the patient and the doctor. Usually patients arrive on the scene sick
and wants the doctor's hands to help them. Here the patient arrives
on the scene healthy and it's only the doctor's hands that put
them into any kind of a jeopardy.
Now in the kidney case, the risks are fairly limited, more severe
as I understand it in the liver case, but Dr. Arthur Matas who came
and spoke to the staff who is a very accomplished kidney transplant
surgeon and also a very articulate defender of the case for having financial
incentives with a view to trying to increase the organ supply described
the surgery of procuring the kidney from the healthy living donor as
the most terrifying surgery he's ever done. He said it's not
the most complicated. It's not the most technically difficult.
But it's the most terrifying.
Now I think it's in general and in many cases a very good thing
that he does this terrifying surgery, but I think it's at our peril
that we ignore the fact that we do something a little bit terrifying
or something that should terrify us a little bit when we see the healthy
as a potential source of rescue for the sick.
When you begin to move to where we are, which is people calling for
potentially significant changes in the way we do things - namely, going
from a system that is organized around the principle of gifting to a
system that is driven to some degree by the financial incentives that
might be given to living donors, we simply can't ignore the fact
that the sellers are going to be the poor, predominantly. Most well-off
people are not going to sell their organs as a way to buy a third car.
The people who are going to sell their organs are going to do it largely,
I think, as a kind of act of desperation.
Now, there's something strange about worrying about the exploitation
of those whose situation is already so desperate that in a certain sense
they live in a state of exploitation. But to talk about financial incentives
of the poor to sell their organs changes something which now in many
cases and hopefully in most cases is a kind of act of magnanimity -
an act as it confers, as you say, great benefits on the donors to an
act of desperation.
It's clearly been sort of free market conservatives who have made
a rigorous case for the buying and selling of organs, some even saying
that this would simply be a way of improve the quality of life of the
poor. But even from a conservative perspective, even from the perspective
that takes self-reliance seriously as a virtue that all of us need,
but the poor, where it's possible, need especially - one is not
self-reliant by selling a piece of one's body. Right? The constant
critique that everyone profits in some way from the organ transplantation
system except the donors is certainly true and can't be ignored
and the commercial dimension of this certainly exists.
But those who are compensated are generally compensated for professing
something. They're compensated as professionals, as doctors, as
nurses, as professionals working for the organ procurement organizations.
The donors who might potentially be compensated are not being compensated
for any profession they have, but for a part of themselves, a part of
themselves that has turned into a piece of alienable property.
So I guess the point of this and I'll close and turn it over to
Gil is: we can't ignore the dilemma in the practice as it currently
exists. We can't ignore obviously the great hardship of those who
suffer for organs, the great virtue and goodness of the physicians who
give them hope, of the family members or generous donors who give them
the organs that make that hope possible and in general, I think organ
transplantation including the living donors is better rather than worse.
But we also ought to still be a little terrified at the practice as
it currently is and we ought to recognize how much more terrifying it
might become if we turn it from an active magnanimity into an act of
desperation. I think that's really what the heart of the debate
at least about the issue of financial incentives turns on.
PROFESSOR MEILAENDER: Let me add just a couple things and
then we can see where you want to go. The "outer limits of the
serious" is exactly what I would encourage you to think harder
about, not in the sense of where we might go, but what the inner meaning,
the true meaning, of certain events is.
Let me just comment on a couple particular things that you said, but
then come back to what I took to be the central thing that I was trying
to accomplish which I may have failed to accomplish because it didn't
seem to come through very clearly to you. But I think a slightly more
careful look at some of the things I said in my paper would be useful.
For instance, you moved very quickly from saying for someone death is
not preventable to hence we need not agitate ourselves over that, whereas
I tried to take some care to work through the two angles from which
we must always look at death, the one angle from which of course it
is always an existential, deeply troubling problem, another angle from
which that simple fact can't become in and of itself a crisis, so
that there wasn't any easy move from the one to the other. I think
the trick is to learn when and where we need to talk in one way and
when and where we need to talk in the other. I'd say that.
The limits of altruism issue is not a question about whether we have
so many people performing altruistic acts in our country that we should
sort of worry that maybe we need to tamp it down a bit or anything like
that. That wasn't the issue. The issue is whether there might
be some acts which, though altruistic in spirit, nevertheless undermine
the integrity of the body, the lived self in the body. That's the
issue. It's not a question about whether there's a large percentage
of altruistic people around in our society or anything like that. So
that's the issue and I think once again your way of reading it missed
the kind of question that I was concerned about.
And that would bring me back then to what I thought at any rate I
was fundamentally trying to do which I think does make contact with
what people are currently talking about and arguing about in connection
with transplantation and that is: I was trying to understand why one
might turn in the direction of gift rather than commerce and why in
fact we have in the past turned in that direction because the pressure
to turn in a more market direction is a recurring pressure and it's
a fairly strong pressure right now.
That's what I was trying to understand and I don't think it
will be sufficient just to say this is what we've done, here is
how we've done it in the past, here are what some authorities say.
I wanted to try to understand why it is that thinking in terms of gift
might retain a certain sense of the organ. It's not just a sort
of part or a thing, but the self that is given there and why that's
lost in some ways if we think in terms of commerce. That doesn't
seem to me to be out of touch with where discussions are going with
respect to transplantation. On the contrary, it seems to be right at
the heart of one central point.
Now I may have done a lousy job of trying to do that. That's
all possible, but that seemed to me to be the chief point that I was
trying to get at and to be honest to suggest that that's not at
the nub of some important issues in transplantation right now, I would
really find that astonishing. I just don't believe that. I think
that would be mistaken. So my apologies for not getting it clear, but
that's the point and it seems to me that that's a point which
unless we think through and try to understand we really won't be
a position to say much that's useful about the commerce issue.
PROFESSOR SCHNEIDER: If I may ask one question, I did not
understand either paper to be about the specific question of selling
organs. I understood it to be much more directly about the very idea
of transplantation itself. Did I misunderstand that?
PROFESSOR MEILAENDER: Yes, but there's an important —
No, you did not misunderstand what the paper was about in one way, but
there's an important part where having talked a little bit about
what Richard Epstein had to say at our last meeting. I note from something
that he wrote elsewhere that he points out that the strongest arguments
against turning the organ, it wouldn't be organ donation anymore,
but the organ donation process into some kind of market system are
arguments that in fact might be taken to be arguments against transplantation
more generally and that therefore that's why I turn to thinking
through transplantation more generally and trying to think through the
way in which the idea of gift is at the heart of preserving some sense
of the self that's at work there in a way that it wouldn't be
preserved if we turned in the direction that Epstein was recommending.
So, yes, I turn to a discussion of transplantation more generally, but
out of that particular concern.
PROFESSOR SCHNEIDER: Out of the concern about the effect of
turning this into a market?
PROFESSOR MEILAENDER: Out of the sense that you can't
answer why you shouldn't turn it into a market without asking some
more basic questions than just that.
PROFESSOR SCHNEIDER: Let me just say one other thing. It's
not at all clear to me that compensating people for, and this is to
respond to what Eric said, that compensating people for organs means
that you're getting organs sold by poor people. I realize that's
the way it works in India. But as I've been looking at some of
the literature on the difficulties that donors face, the difficulties
they face are often economic difficulties. They're the difficulties
that arise out of not being able to work for whatever time it takes
them, sometimes a fairly large amount of time, to recover from the surgery
and I take it that one of the possible responses is to say we're
not paying you for your organ, but we are trying to keep you from suffering
economically for the gift that you've given.
MR. COHEN: I think that that's an important distinction
to keep in mind between ensuring that those who want to give as a generous
act don't incur insurmountable economic burdens in giving the generous
gift. That's different from paying people a price for their organ
as a way for them to benefit themselves economically. I think that's
a distinction that can be preserved and I think they have different
CHAIRMAN PELLEGRINO: Other comments? Questions from the Council?
I have two people, Peter and Bill.
PROFESSOR LAWLER: I agree that buying and selling is where
the action is and I agree that buying and selling is a terrible idea
and you don't have to get way metaphysical in order to reach that
conclusion. It's — I guess I can't see how it could be
done without avoiding horrible abuse. To give a dumb and flip example,
our country has lots of undocumented aliens and states are electing
to give them welfare. You can imagine a scenario where someone would
say "Welfare? You've still got two kidneys!" There would
be the expectation that your kidney might be understood as part of your
net wealth or something.
But having said that, Gil's paper in particular, I agree with
you, does seem to be an argument that causes us to reflect upon all
transplantation and maybe collapses one distinction I would want to
preserve. He says on page 14 that especially with reference to the
footnote that criticizes a great thinker that if I give my dead kidney,
my cadaver kidney, in advance I'm giving a gift of my very person
as if I can't separate my dead kidney from my being. It's a
tough question whether I can separate my live kidney from my being,
but my dead kidney is not me. So in a certain sense, one of the smallest
gift I will ever give in my life will be my dead kidney because it's
of no use to me.
So we were talking at length in a certain way I'd be more generous
if I'd bought you dessert than donated my dead kidney. Although
when I read this, Gil's reflections, I think a donation of a live
kidney has to be an act of love and nothing short of an act of love.
I don't think I would do it otherwise. So I might step up to the
plate like the speaker said this morning for one of my own relatives,
but in general, I don't think I would do it because I think it's
a powerful argument that it is a gift of my very being. My dead kidney,
I want someone to tell me what's the big deal.
CHAIRMAN PELLEGRINO: Dr. Hurlbut.
DR. HURLBUT: The issue that keeps coming back to me was brought
up this morning by Leon in the sense that there's the word "crisis"
and "shortage" that should be introduced into this equation
and it relates in a special way that a personal element of what is involved
I mean I think you bring it out, but maybe you could say more about
this. The idea that there's a shortage or a crisis, it seems to
me those are the wrong words. It seems to me it should be presented
as more an extraordinary new possibility or an opportunity to engage
a new relationship between healthy individuals and those who are in
need of cure. And to me, that implies the difference between the word
"opportunity" and "obligation" and as soon as you
start saying there's a shortage or a crisis, there's a kind
of obligation that seems to violate the very source power of the goodness
of this that is the actual lack of an obligation but the act of super
abrogation that's implied in donation.
It engages a different part of the person and in that sense, it carries
a certain beauty, truth and coherence of what we see a person to be.
As soon as we start walking the world feeling guilty because we haven't
donated, I think we're going to weight down natural life with a
new sense of obligation that would not be good. But if we don't
do that we could still lift up that notion that there's an opportunity
for a free act of genuine giving and that seems to me not to use a bad
pun but the heart and the soul of this whole matter that there is an
engagement of the best of a person in this somewhat unnatural process.
PROFESSOR MEILAENDER: I didn't know if you wanted us to
respond at all.
CHAIRMAN PELLEGRINO: Yes, I do.
PROFESSOR MEILAENDER: Okay. Just a quick comment. First,
a quick comment to Peter Lawler. Again, you said my dead kidney is
not me. How can a man who sat here and listened to Tom Lynch this morning
say that quite so straightforwardly? I mean obviously in some senses
it's not, but there are other senses in which it seems to me you
ought not quite say that. Then, Bill —
PROFESSOR LAWLER: Could I ask what they are?
PROFESSOR MEILAENDER: Pardon me?
PROFESSOR LAWLER: Could I ask what those senses are?
PROFESSOR MEILAENDER: Yeah. They want that kidney from you
while you're a changeling in the eyes of your loved ones and it
is some sense therefore you that they want.
PROFESSOR LAWLER: But they don't want, in some alien
sense, that they're coming after my kidneys.
PROFESSOR MEILAENDER: No, I don't think I said that.
PROFESSOR LAWLER: No, but I have given this thing.
PROFESSOR MEILAENDER: Yes, I understand that and I didn't
say that you shouldn't. I just was uncomfortable with the —
Well, I was originally uncomfortable as you know with your sovereign
authority language with respect to it. But in general, I would just
want to be careful and cautious about disassociating one's self
too much from those remains.
But then I was just going to say, Bill, I think I agree with the
direction you're going, though worry that I had in the paper was
that on the one hand medical progress makes possible something's
that remarkable for people. Then because it has done that, we begin
to think of it as a kind of entitlement that we ought to have and then
it's a crisis if we can't have it and the use of that language,
the reason, I mean there may be a lot of reasons, the reason I back
off from the crisis language is that I just think that that language
encourages us to do things, at least to think about doing things, that
we would not think about otherwise, tinkering with definitions of brain
death in order to get what we want, seeing the death of patients becoming,
as I said in the paper, a technicality that we need to see to in order
to get there, restructuring death in ways that seems less than humane.
Maybe any or all of these are okay. I'm happy to argue about any
of them, but I think that that language that turns it into an obligation
begins to encourage all those things in ways that I think one ought
to at least worry about.
CHAIRMAN PELLEGRINO: Dr. Rowley.
DR. ROWLEY: I have three questions and comments. The first
is a whole lot of this involves insurance and health insurance in one
way or another. And as has been commented on this morning, it was clear
that the poor and, if you will, the minorities of various sorts and
the financially disadvantaged are the ones that are, I'm not saying
this correctly, but are disproportionately on the waiting list and the
people who can afford to take care of themselves are amongst the advantaged
and less constrained by what they have to do and the kinds of problems
that they face. So I think we have to be straightforward in understanding
that the lack of universal health insurance in this country complicates
the whole situation enormously and I don't think we've faced
that issue very carefully.
And the third, not the second, issue that I have is with Dr. Pellegrino
and just where are we going with this discussion of transplantation
because I remember being part of the Council under Dr. Kass and I think
it was in 2003, but I can't be confident about the timing, but we
did have a discussion about transplantation. So you may not be prepared
to answer and I understand that, but I think that as a Council member
I wonder about that.
And the specific question I have for Dr. Cohen particularly because
in his paper he refers to the IOM report is the IOM was mainly concerned
with organs from deceased individuals and as I recall just a chapter
and I realize we're going to have a report this afternoon from the
Chairman of the committee that wrote the IOM report, but the IOM report
is mainly about organ donation from deceased individuals and, Eric,
you made the statement just now that the only place to procure additional
donors of kidneys is from the living and I think the IOM report mainly
focused on how we could improve donations, if you will, of kidneys from
the deceased. So they seem to be in direct conflict. So I wonder if
you would clarify your statement as to why you think that the only way
to increase organs, kidneys, to be specific is from the living rather
than from the deceased.
MR. COHEN: Let me see if I can be clearer than I was before.
I don't think there's no room to procure more organs from the
deceased. I do think we probably can by improving the procedures, by
considering some of the recommendations in the IOM report which we'll
obviously hear more about later today. We might be able to increase
the number of organs available from the deceased. The point I was trying
to make is that I think we're already, different people have different
numbers, but over 50 percent is what's called a conversion rate
which is the number of eligible deceased donors whose organs we actually
Now presumably there is going to be some portion of people for their
own reasons, perhaps good, perhaps not good, who actually have substantive
reasons why they don't want to be donors which means, while there's
room for improvement, there's limited room for improvement and there's
a limitation that is grounded in how people die which makes them eligible
or not eligible to be donors. So when we take that fact and then juxtapose
it with the numbers we saw this morning about the size of the population
that has or might have or will have end stage renal disease, the point
I was trying to make is that inasmuch as we see this as a crisis that
needs to be ameliorated the only way we'll ameliorate the crisis
is to not only try to increase the organs we can get from deceased donors.
But to try to increase significantly the organs available from living
donors and that's an area where there isn't as much of an inherent
limit because any healthy person in theory could donate a kidney. We're
talking only in the kidney case and to some degree in the liver case.
So I didn't mean to suggest that there's no room to get more
organs from deceased donors, but I think the real debate that we're
going to confront, not the most important debate ethically, but the
biggest practical debate, is going to be about policies regarding living
DR. KASS: Excuse me. I wanted to speak primarily to Gil's
paper and begin with my praise for the form of it and the shape of the
argumentation leaving aside some of the details. First to say, I think
Gil is absolutely right that this Council at least ought not to —
The discussions that we're having, Janet, may very well be triggered
by the fact that even in the three years since we first talked about
it, the "shortage of organs and the need to do something about
it" has become really a much more lively topic. There are articles
about it in lots of places. The passion that was generated by this
discussion that we had at the last meeting indicated this seems to be
a problem that you would have to be an ostrich with your head in the
sand to ignore these days.
Nevertheless, if this Council wants to do its job, I think Gil is
right in saying that we might take that as the point of departure for
our reflections, but we have to step back and begin to think about the
human significance of what these innovations produce so that the place
that he would like us to begin is not to simply begin in the middle
of the things taking the shortage for granted and its place, but to
begin prior in an earlier place. And he tries to do that for us by thinking,
to begin with, about the limits of how we think about mortality as such.
Carl Schneider's qualification, I think, Gil would probably accept
and then to encourage us to think about the strangeness of having started
down this road in the first place of what it really means to start to
look upon the embodied whole which is our life as also a source of resources
in part to benefit other people and the reluctance to start by thinking
about the living body as such a resource naturally to go in the direction
of the cadaver.
And there I think he does well, forgive me if I'm simply rehearsing
what strikes me as the important parts of this, reminds us that in the
first instance the dead body is not rightly seen if it's seen only
as a natural resource for the benefit of others, but is the mortal remains
with which the family and associates have to deal and that in all kinds
of ways even if you can't harm the dead person, there is at least
and especially in this limited period of what Bill May beautifully called
"the newly dead," I don't know whether we've all read
that article or not but it should be out amongst us for rereading, that
this all too much resembles the person whose life this once was for
us to abstract from those considerations and say "Ah, here is a
kidney to save Patient X down the road."
How have we managed to get ourselves to the point where we've,
as a culture, accepted this practice overcoming certain kinds of scruples
and reluctances? Gil gives a kind of an account that we've done
so not because we think natural resources in the absence of objections
we will harvest them or collect them, but we've done so because
we see that there is the possibility of gifting, even under these circumstances.
And that the giving of the organ is in a way a gift of oneself even
when one is no longer here to present that gift and I think it's
terribly important when we think about the new proposals to remember
why it was we've adopted the practice of giving as opposed to the
practice of routine salvage, which is what the French and the other
Now faced with a kind of critique of this practice because these moral
scruples seem to be the major obstacle to finding the necessary organs
to shorten the list, there is I think a great deal of pressure to encourage
living donation and since living donations are odd, I mean for a loved
one it's easy but how to get more people to come forward, that's
where it seems to me where the major push of the financial incentives
is today. They're modest proposals for funeral expenses and things
of that sort to try to increase donation from the deceased, but in public
meetings and in publications, we will hear from Dr. Hippen I think later
today, more and more people are thinking that the only way you're
really going to address this shortage is to begin really to offer financial
incentives and even a market in organs.
I guess I'm inclined to say that unless we go through a kind of
an analysis of the sort that's here and see if we can either defend
or find fault with the justification for the system which has been in
place from the beginning of transplantation and codified in the 1984
Act, we will not be in a position to justify or think clearly about
these new proposals which begin not with anthropology or not with these
larger questions but begin with the simple fact people are dying on
the list. What are we going to do about it?
So I would like very much to endorse the paper. I have some minor
difficulties with this or that, but as a form for us to think about
this question, I think this is the right shape and I guess my invitation,
Mr. Chairman, would be to my colleagues not so much to Gil whose paper
this is. Are there weaknesses in the development of this argument which
seem to me to be primarily a justification of the practice we now have
made with some fear and trembling and worrying about that there are
too many potential transplant surgeons hovering over the family close
to the time of death and all of that. He worries about those things,
but he's not asking us to go back on that. But are there difficulties
with the form of the argumentation and in particular with the substance
of it? But that would be my encouragement to my colleagues to see whether
he hasn't provided us with at least the beginning of a framework
with which to stand before the new proposals one way or the other.
CHAIRMAN PELLEGRINO: Thank you.
DR. KASS: Sorry to be so long-winded.
CHAIRMAN PELLEGRINO: Any further comment on Dr. Rowley's
question? To me which I think depends very much on what the Council
thinks about the question mark at the present moment, as Leon has pointed
out, you've started a lengthy discussion, a good discussion. As
we look back at the record, it's kind of unfinished business in
view of the fact so much has happened since the things you've just
So the question really is is there something that we can contribute
of a positive nature that has not been approached and that's the
question before us and the reason for the papers for the rest of the
program after which I think we'll take a fresh look at it and try
to give you a more specific answer. But I think I'd like to hear
what the Council members feel about this. It is a very urgent, ethical
and social problem and it's going in directions Leon has very capably
and eloquently outlined that will change the atmosphere and I think
I would like to know how more of you feel about it and I think the two
papers we've had were meant to be a stimulus to you to see in what
direction perhaps we ought to go. One has one's own ideas, but
I'd like to hear yours.
I want to emphasize our doing that this afternoon and the rest of
today if we can because we look forward to the summer if we're going
to make this a major project to trying to get it in its final form so
that in the fall you can have something very concrete to look at or
we may not undertake it if we decide that after we hear the internal
medicine report or something that there isn't anything significant
that we can add. I happen to think there is, but I'd like to open
it up to your comments, Members of the Council.
PROFESSOR LAWLER: I agree with the general —
DR. PELLEGRINO: And excuse me. I just want to be sure I
get both of you.
PROFESSOR LAWLER: Okay.
DR. PELLEGRINO: Go head, Peter.
PROFESSOR LAWLER: I agree with the general sentiment expressed
by Leon and Gil that the metaphor of the crisis produces the thought
that there needs to be an immediate response, decisive action, executive
action. But when you think about it, this is a crisis if it is a crisis
specific to a very definite stage of medical technology. Not so long
ago, we couldn't do transplants and presumably, and I'm no expert
on this, somewhere not that far down the line, we will no longer need
to do transplants because we'll have xenotransplantation, some kind
of regenerative medicine, artificial kidneys and things I'm not
capable of even imagining, but will surely be there.
And so the danger is in crossing boundaries now that would apply to
other areas reacting to a crisis is relatively, although real, it's
a real problem of people who will die because of end stage renal failure
and the inadequacy of dialysis and all that, but there is the danger
in over reaction without sufficient reflection and we may be the guys
to do the reflecting on that. For example, a rough parallel is an issue
of euthanasia. The two arguments for euthanasia that were nontrivial
would be tremendous depression and horrible physical pain. We can now
deal with the depression and the physical pain and the same way to cross
the boundary and enter into the buying and selling of body parts in
response to this alleged crisis I think in the long term we would regret
because of this uncertain applicability down the road and the inability
of preventing abuse and all that.
I think you can reach those conclusions with some reflection, with
deep reflection, and the character of embodiment and all that, but there's
a lot of good common sense that falls short of deep reflection which
is also in Gil's paper. So I agree with Leon that this is something
we are well equipped to take up and we should take it up.
CHAIRMAN PELLEGRINO: Dr. Bloom.
DR. BLOOM: Unless there was some a priori decision that you
all made to look at this focused issue, I would want us to take a broader
look because it seems to me that while there is certainly a shortage
of organs to transplant than there is to people who have end stage renal
disease, if we only look at that piece of the puzzle, there is always
going to be a shortage and it seems to me we have to look at the causative
upstream events that we should speak out about with equal vigor which
is obesity, Type II diabetes and secondarily renal disease which are
items of self-responsibility. These people got themselves into this
problem. Maybe they had genetic vulnerabilities that got them further
down the path than others facing the same metabolic and environmental
circumstances might have.
But if we only patchwork this issue without taking a look at the bigger
issue of what causes them to start down this road to disease and even
broader issues than that in terms of, to me, self responsibility for
your own health, is a major thing that we should speak to because it's
unethical for us to pretend that medicine is going to solve all bodily
ills and we have to start to convince people or it's always going
to be 20 plus years down the road before preventive medicine pays its
due bills on this society. If we learn anything from the genome in
terms of vulnerability factors, it's not going to eliminate self
responsibility and there's not going to be always a magic pill or
a magic organ or a magic cell that's going to make somebody well
again after a life of abuse. So in response to Leon's comment about
the form of Gil's paper, I would see an equal stream be devoted
to the upstream events for which this is a partial solution downstream.
CHAIRMAN PELLEGRINO: Thank you very much. That's very
helpful. Other Members of the Council? Alphonso?
DR. GÓMEZ-LOBO: I want to back up a little bit again,
but in another sense, not in the medical sense as Dr. Bloom wants to.
Many of these issues were completely new to me in many ways. So I'm
trying to think through the arguments and the reasoning behind them.
Now I think that the Council has helped me a lot in this discussion
of the crisis language because surely it's one thing to say there's
a crisis and we should do anything to solve it and a different thing
to say there's a shortage here which may be caused by other reasons,
but on the other hand, that may not generate entitlements or rights,
the kind of thing that Bill was pointing to. So I found it very useful
to tackle these problems from a broader perspective.
Now what have I gained from this discussion right now? At least the
following. The death of people on the waiting list is of course deeply
painful to me, but equally worrisome is the cutting through the healthy
body as Eric has pointed to. So it seems that the altruistic motive
at the moment is the only thing really morally holding the practice
in place and that's why it seems to me that that should be a matter
of further reflection because that's exactly where the big differences
are going to arise when we get to the issue of buying and selling of
organs because I think that's where the pressure is going to go.
Now as a minor contribution in that regard and I'm probably jumping
ahead of what Jim Childress and Dr. Hippen are going to be saying I
think the question of the freedom of an agent who doesn't have resources
and therefore sells a part of the body as a form of income that there
is also a crucial issue. Is there the alleged freedom in that transaction
or not? Because of course, that impinges on the American ideal of autonomy
and of course if autonomy is assumed in that case, we may have a justification
for the free markets or the regulated markets that would not exist if
we questioned that assumption.
CHAIRMAN PELLEGRINO: Thank you very much. Other comments
on this subject? Dan?
DR. FOSTER: I just want to make one clarification about I've
heard all morning people talking about doctors cutting on living bodies
that are not ill. I think that most people in the room might have forgotten
that we have a huge occupation of doing that right now in plastic and
reconstructive surgery. We cut into these bodies all the time. We
do liposuction and all of these things in normal healthy people and
many times with great risk and we don't have — I mean there
have been a lot of deaths here and so forth. So we shouldn't try
to set out that there's something magical about cutting into a living
body when we're doing that all the time now and it's one of
the fastest growing things.
One of the things that was said this morning is the most lucrative
salaries in medicine are not neurosurgeons. They are plastic surgeons
and they're paid in cash and I'm talking about the fact that
there are huge amounts of money there. So I just want to clarify here
that that is not a valid argument about saying that we shouldn't
CHAIRMAN PELLEGRINO: Thank you.
DR. KASS: You're not using that as an endorsement I trust.
DR. FOSTER: No.
DR. PELLEGRINO: Thank you.
DR. FOSTER: I'm not endorsing.
CHAIRMAN PELLEGRINO: Dr. Gazzaniga.
DR. GAZZANIGA: Yes, just a point of information and maybe
the staff can dig this out, but we've heard about how various European
countries handle this problem differently by almost conscription by
the Dutch by the assumption the state owns the body and so forth and
we also have a number of those countries that have basically one payer
socialized medicine. Can we look at their organ transplantation numbers
just as an experiment to see whether the things we're puzzling here
in fact move to solve the problem? There must be data on that. I don't
MR. COHEN: I certainly don't have it at my fingertips the
data on other countries, although I think this would be a very beneficial
thing for the Council to hear an expert come and talk about. Obviously
different countries have different systems, some with a kind of conscription
system. Iran has some system of regulated payment in fact. So I think
it would certainly be very important for the Council to hear either
through a staff paper or an invitation of an expert how things are working
in other countries.
Could I respond quickly to Dr. Foster whose comment I've very
grateful about? One has to begin with an important distinction between
plastic surgeons who are trying to restore a body that has been disfigured
in some way, work that I think is heroic, and plastic surgeons who are
being paid in cash to perform changes on the body that are optional
at best. It seems to me that should only further awaken us to the problem
here. I mean the fact that doctors are doing this doesn't mean
it's a good thing for us to do.
Now I think certainly in the case of kidney donation and certainly
in the case where the living donor is doing this as an act of love to
a family member, one in a certain sense could praise the courage of
the doctor who is performing such a terrifying surgery precisely because
he knows the life of a healthy person in certain sense is in his hands.
But I don't think we can ignore that there is something that should
give us pause here and that there's a reason why, as I cited Dr.
Matas before, doctors see these surgeries that are not the most technically
difficult as the most terrifying and this is not saying that we ought
not be performing them, but it does invite us to think about the different
human meaning of that surgery and how that meaning might be changed
even further if the person upon whom the surgery is being conducted
is doing it for pay as opposed to as an act of love or as an act of
CHAIRMAN PELLEGRINO: Dr. —
DR. FOSTER: I want to make one other caution. I think one,
Eric, ought to be very careful about the big point you made of an expert
that came to talk to you and said this was terrifying surgery. I would
say that if you looked at 1,000 transplant surgeons that you would be
very lucky to find five that felt the same way, I mean, in the sense
that every surgery is at risk.
But I was astonished to hear that this was terrifying surgery. I
guess what you meant was that because this was a person who didn't
have to have surgery and I suppose that's why that was there. But
I know the person who is the most involved in living liver transplants
out in Dallas and so forth and so on and I don't get any sense that
this, they want to be very careful about this and so forth.
But I wouldn't want to put too much statement in one person's
feeling about doing this, surgeons. I mean we think we always talk
about evidence-based medicine. If we're going to quote something
that is meaningful, then we ought to have evidence for it rather than
a singular statement by one transplant surgeon. Okay? I mean if we're
going to be a serious council we need to look into that as well is the
only point, the only response, I want to make.
MR. COHEN: I'll respond only quickly. I'm not trying
to use this one surgeon's remark as a way to have you see how every
surgeon thinks about this. I will simply repeat that the human meaning
of a surgeon performing surgery on a patient for whom the surgeon can
do no good for that person's body, he can only do harm, and especially
in the liver case, there's a fairly high rate of complication, not
serious complications, and again I'm not saying that the surgeon
isn't doing something heroic by performing the surgery.
But I think we need to be at least willing to think about the fact
that we have a different kind of encounter here between a patient and
a doctor; when someone arrives not as a patient but becomes a patient
because of the doctor's action. I'm not suggesting that doctors
are terrified because they're worried about their competence and
that was precisely the point I was trying, perhaps failing to make which
is that the point here is that the greater pause is not because the
surgery is technically more difficult but because the meaning of the
encounter between the surgeon and that patient is different and I'm
simply trying to make note of that.
DR. FOSTER: Gil, as long as I have this microphone for one
second, I mean to get back to what has been approached here, we have
a pretty straightforward problem. Now if you're worried that taking
an organ out somehow diminishes human dignity as I think probably Gil
thinks even from the dead, then that's not going to address the
problem here. We take organs out of people all the time and spleens
and everything else. We don't think they're demeaned or it's
undignified. We do it for health and so forth but there's not something
magical in my view for doing it.
The problem is a very simple one. That is we have a lot of people
whose lives we can save and save money if we transplant and that number
of people is increasing very dramatically and we may be able to increase
50 percent in deceased donor things with incentives of one side or the
other. Our first speaker this morning said that she preferred to do
that first of that. So I don't know how and Dr. Hippen is probably
going to tell us that in some advanced hospitals, he told me this this
morning, that the conversion rate is as high as 70 percent with some
things. But over all, we could probably double the number of kidneys
which are there.
Then we have to ask ourselves the problem, I don't want to sound,
the philosophers, Robby George is not here, saying I'm being utilitarian
and so forth. We have to decide is the loss of these people who could
be saved such that we take the risk of doing living donor transplants
and that has to do with the percentage risk that's there statistically.
If you get in a car, you're going to have much more chance of dying
from within a few blocks of your house than you are from doing the surgery.
Now it sounds like I'm speaking for this. I'm not. I'm
not at all sure that I think that we ought to expand this. That's
what I'm trying to understand, but that's the problem and I
think it's maybe one thing to go back and look to say what it means
to be a human or what a dead body is.
But I'm interested in the practical problem that we have 93,000
people that are on the waiting list. Some of them are dying. Can we
do anything about it or do we simply say as a society that's tough
luck that that's their problem that we can do that? And that's
what I think we ought to focus on and we may say we don't think
that we should do that or we could say that we think the risk is minimal
enough that an informed patient might be willing to do that along those
I'm not against these discussions. I always enjoy reading Gil's
papers. I mean they always make me think even when I don't agree
with them. But that's where to get down to the core, Mr. Chairman,
that I think that we can really say something about it. Now that doesn't
mean that we can't couple that with philosophical discussions along
the lines we did with enhancement and other things, but it's the
practical final answer that we have to - I think that people want to
hear from us as a thoughtful group.
PROFESSOR MEILAENDER: If I could just make two quick comments
sort of intervening in the exchange you and Eric have had. One, I do
not believe you're just interested in practical questions at all,
Dan. You're interested in what it means if a human being suffers
and what our obligations are to those who suffer and how we ought to
think about them and so forth. These are by no means only practical
questions and I just want to — Don't shortchange what you
yourself are interested in.
The other is with respect to the business about a doctor finding doing
the transplant surgery a terrifying thing in a way. I would like to
put the point normatively. I haven't made any studies about whether
a 1,000 transplant surgeons do or do not feel that way but they'd
better. They should and if they don't feel that way about it, then
we need to ask ourselves what's gone wrong, what have we lost that
they've lost all sense of the trepidation they ought to have in
simply cutting into a living body in order to help another one.
I don't mean that it's wrong to do that necessarily, but I
think we can only understand what's going on if we have a certain
kind of sense of something very peculiar there and it's very peculiar
for medicine. That's all. That's a normative claim. I have
no surveys to back it up but they ought to think that way.
DR. FOSTER: Last thing. I do want to say one other thing
before this conference is over, but in one sense I couldn't agree
with you more about both things you've said. Of course, I'm
interested in a lot of other things besides the practical problem, but
right now, the practical problem is before us.
But a terrified surgeon or a terrified internist is not a good doctor.
If you're terrified, then you don't make the right decisions.
You want somebody who's concerned about the thing, but if you're
shaking about the implications, I think that the guy ought to be worried
about how he's taking out the kidney rather than worrying about
the implications along these lines. I talked about the Dallas Mavericks.
They worried so much about what was happening to them that they couldn't
shoot shots and that's all I'm trying to say.
PROFESSOR MEILAENDER: But he shouldn't — Of course,
you're right. We don't want his hand trembling while he's
cutting, but we also don't want him to come to think of what he
does as such a matter-of-fact thing that important and deep questions
about it can no longer be raised.
CHAIRMAN PELLEGRINO: Dr. Hurlbut and then Dr. Carson.
DR. HURLBUT: I was just going to make a very obvious comment,
but since you just made that comment, I would like to add that your
comment about the plastic surgery does raise, it doesn't just argue
for the similarity here on the positive sense of transplantation surgery,
but it argues for the strangeness of quite a few things we're doing
in medicine today and I think we're all a little, as a physician
I'm a little, uneasy about the trend toward plastic surgery and
I think we should reflect on that as the larger arena of the way we're
disposed toward thinking about the body.
Now even as I agree with the central point you were making, there
is something a little strange when you read an account of somebody who
had plastic surgery and then died. You feel like why did they do that.
There's something about the natural body that remember Galen said,
"The physician is only nature's assistant."
It seems to me that you have to take some beckoning from the way nature
is organized. I know there's a big so-called heresy in modern world,
the naturalistic fallacy, that you're not supposed to look to nature
to get any sense of how things should be ordered. Nonetheless, there
is a certain order in the arrangement of being and eminent powers within
the being that we should keep as part of our guiding principles in medicine
and plastic surgery does raise some challenging new questions that we
should take seriously.
Having said that, I want to get back something much more pedantic
or more procedural. When Mike brought up the question of the scope
of our inquiry and made, I think, the important contribution that we
should look to the experience of comparative cultural approaches and
different social practices and starting assumptions, that's a really
I think we should also extend that a little bit within our own sphere
because it struck me this morning as we were hearing about the number
of organs versus the number of transplants, that there's something
implicitly nonequal about those two statistics. The yearly transplants
are not the same as the number of people on the transplant list. Those
people live for years. So we need to do a sort of statistical analysis
that show how many people really are not receiving organs who rightly
could receive them. Obviously, the — I think that's maybe
obvious what I just said. It's just simply a matter of kind of
a magic of numbers. If somebody is on the list for five years, you
don't compare the yearly rate of donation to the actual need on
the year-to-year basis.
Second, it would be useful if we're going to do this kind of inquiry
to request perhaps for the organized bodies some kind of an analysis
of outcomes, true added years and how they relate to the age of donor
and recipient and I think this isn't a very popular comment to make
because I don't want to dissuade anybody from donating if it's
a positive thing to do.
But I think in all honesty we have to ask ourselves the question of:
Are there any adverse outcomes? We've heard a little bit about
that in previous presentations, but let's be honest about it. You
have two kidneys. Why do you have two kidneys? Is it because people
historically or all antecedent animals had some ongoing kidney damage
from infections? We now have antibiotics. We have probably much more
healthy kidneys at 50 years old than in people in the past who were
not treated for a urinary tract infections for example.
But we should ask ourselves and we should all honestly look if there
are any downsides before we make any recommendations. That should be
an honest part of our inquiry. Does donation at once involve some risk
to the individual who makes the donation and that wouldn't necessarily
preclude it? It might actually increase the dignity of the donation
and the depth of the gift, but we should admit that.
And finally, we should explore more of what Eric was mentioning in
the positive outcomes and somebody should do some kind of analysis on
that as part of the scope of our inquiry. Because if it really is a
really deep engagement of another possibility like an invitation not
an obligation, it might be a very positive invitation to our civilization.
But let's not start with the assumption that there are superfluous
parts that are just there that we don't really need. It might be
a genuine sacrificial gift, a very high invitation, to our deepest humanity.
CHAIRMAN PELLEGRINO: Thanks Bill.
DR. CARSON: First, I would like to thank Dr. Foster for putting
the salary of neurosurgeons into the proper perspective. You know as
a surgeon I would like to say that certainly we're not terrified
when we go into the operating room, but certainly there's a healthy
respect for what's being undertaken and the degree of urgency of
the situation I think plays into it. If you're going in to do something
that's lifesaving and there's no question about that, you're
probably going to enter that perhaps with a little less trepidation
than something that's questionable not only for ethical reasons,
but for legal reasons.
But recognizing that surgery tends to be something that works very
well for people, I don't particularly like surgery to be honest
with you. But it's something that the Lord gave me talent to do.
I don't like the sight of blood. Some people find that very amazing.
They say, "You're a surgeon" and I just say, "Would
you rather have a surgeon who likes to see blood?"
But the fact, the other thing, I wanted to bring into play here is
there have been several mentions of paying people for the procurement
of organs and of course, it's usually mentioned in a negative light,
but I think we also need to recognize that this is not something that
hasn't been done for a long period of time with blood transfusions.
We've been paying people for blood for a very long time. We pay
people for sperm donations. These are things that in one case can be
lifesaving and in another case life creating. So there is certainly
plenty of precedence for that. It's not to say that it's right
or wrong. It's to say that we need to make sure that we keep all
of these things in perspective.
CHAIRMAN PELLEGRINO: Thank you very much. Other comments.
I'm glad we're getting into the situation or giving us some
advice here which is very helpful. I can at least make this passing
comment. The intensity of the discussion almost answers some of the
PROFESSOR LAWLER: According to this theory of surgeon terror
and I agree you guys shouldn't be reading Kierkegaard or anything
like that, but the most terrified surgeon should be the cosmetic, plastic
surgeon because he in fact does no one any good. Yet he's cutting
on people. Yet my limited experience, these are some of the happiest
and self-confident people around, not to mention well paid or anything.
CHAIRMAN PELLEGRINO: As long as we're talking about terror,
I don't want you to exclude us internist either, risk out of everything.
Okay. Sorry. I keep forgetting. (Turns microphone off.) I very much
appreciate any comments you want to make.
DR. FOSTER: Since nobody else is, let me make one other comment
in response to Floyd's issue of prevention which is a huge problem
and as all of you know, but I just want to tell you, it's become
a little more complicated and that has to do with the worldwide epidemic
of obesity and its capacity to induce diabetes which is the leading
cause of renal failure in the world and the interesting thing is that
this whole epidemic does not require medicines, surgery, anything else.
It just requires eating fewer calories. That's all. I mean, Type
II Diabetes is curable right now and you don't have to get pancreas
transplants. Yet the epidemic is hugely increasing in countries that
you never thought to be able to see obesity, France and so forth. It
was just us and so forth.
So the problem is that Gazzaniga is going to hop all over me, but
at least the people who are working on addiction that I know about now
begin to talk about hedonic. I think they also say hedonistic, but
hedonic neurons where there's pleasure and fulfillment involved.
They're coupled with all of these things. So you can't —
I've talked to I can't tell you how many people who weigh 400
pounds and who have renal failure, early renal failure, and I say, "Miss
So-And-So, if I were you I would have my mouth wired together and not
eat another bite until I had lost 200 lbs. You don't have to get
back to normal weight. You just have to do it."
So we have a problem there and it's not just because McDonald's
is there. It's not genetic in the sense. It's too fast for
genetics to be here. So it's we just can't get people to quit
smoking or to quit eating and so forth. So it's going to be a real
problem, but it's a little more complicated than that. Although
I should say that many of you know about new drugs like rimonabant.
Rimonabant binds the canniboid receptor I which is where marijuana hooks
in, but we now know that there are normal canniboids. The universe
doesn't give us receptors so we can take opium, the opiate receptors.
It doesn't give us a canniboid receptor so you can smoke marijuana.
But one of the side effects we've known is that the canniboid
receptor then crosses over to the micro-opiode receptor. It hooks in.
That's why it enhances the pain release with marijuana. But if
you block this, it must have some effect on the hedonic pathways because
25 percent of people who are smoking quit cold on this and there's
a significant weight loss with that. So there may be some possibility
that the scientific approach would be a way that we could begin to bring
this in an increase in fatty acid oxidation. So we can't do it
by what the self-responsibility should be to just cut down on what you
eat, but we have to look at this and we usually treat lung cancers even
though they're due to smoking.
Now here's the complication and it's really quite new. The
reason that obesity makes you get diabetic if you have diabetes as
a gene is that it gives you insulin resistance so insulin doesn't
work. All Type II patients have insulin resistance. They have a high
levels of insulin in the blood but it doesn't work because you have
resistance and then if you become obese too, it moves the time. That's
why the leading cause of diabetes in pediatric practice now is Type
II diabetes which didn't used to start until you were 40 years old
and so forth.
Here's the problem. Gerald Reaven at Stanford University was
the one who described what's called a metabolic syndrome. This
is a syndrome that predisposes to diabetes associated with diabetes
and so forth. This obesity by the way is now the leading cause of
liver disease in the country, more than alcohol, more than anything
else. Fatty livers due to obesity is the leading cause just like it
is leading to kidney failure with diabetes.
What Reaven has discovered is that 25 percent of us that are normal
weight and have no diabetes have insulin resistance and he has now followed
a group of these people for ten years. They are normal people and they
have the same increase in vascular disease, stroke and atherosclerosis
as diabetics and so forth do. So it gets more and more complicated.
We don't know what causes this, but even if we cut the weight loss
down, it will help. We still may have a problem with some of these
other things going on.
Professors like to tell you about new stuff in science. So I thought
that that's not very well known. There's a new paper in cell
about this, about the insulin resistance, in and of itself being the
cause of vascular disease that goes on. I hope that's clear.
CHAIRMAN PELLEGRINO: Professor Schneider.
PROFESSOR SCHNEIDER: And before we leave that topic because
I've spent a good deal of time with kidney patients, I do want to
say that there are a lot of them who have inherited their disease and
got it for reasons that have absolutely nothing to do with the virtue
of their behavior. But I wanted to obey the request to comment on this
as a topic and I'm not quite sure how to do that because it's
not clear to me what you exclude as another topic by choosing this as
a topic and I certainly can think of a number of topics that are equally
interesting. But it's obviously a topic of social importance that
is directly relevant to the kinds of questions that we're talking
I would like to say two things. First, we are not the first people
to think about this. Socially, we have not leapt into this unthinkingly.
We have actually moved very slowly in making transplants more available
and in assaying small experiments, very incremental kinds of experiments
to try to increase the pool and each step has been taken I think actually
quite thoughtfully. So I hope that we don't neglect in our anxiety
to think about things basically, the considerable amount of social thought
that has already gone into this.
Second, I confess that I am still failing and I have no doubt that
it's my failure and not the failure of my preceptors to understand
all of the reasons that it is disturbing to cut into a healthy body
in order to help another person. I sometimes wonder whether it helps
to think in the language of all things of economics. If you have interdependent
utility functions with somebody else, it's perfectly easy to understand
why cutting into your body to help somebody else is no big deal and
the idea that it's possible to understand it if you're doing
it for somebody you love, but almost inhuman to quote from one of the
papers "to do it for somebody whom you don't know" just
reminds me of what I read some years ago about the Good Samaritan and
the question who was your neighbor.
So to come back to where I started the discussion off, I am still
very much at a loss, while granting that it's important to ask these
questions, I'm still very much at a loss to understand what it is
particularly about the donation of your organs that is in some way interfering
with your integrity as a person and with the function that doctors ought
CHAIRMAN PELLEGRINO: Mr. Cohen.
MR. COHEN: I wonder if I might quickly try again to respond
first just very briefly on the issue of the almost inhuman. That cuts
in both directions. There is both better than human and then less than.
I mean there's a certain sense in which giving an organ to a stranger
simply as an act of charity or altruism or even love is in some sense
better than perhaps most of us are willing to do. But there's also
something strange about it and that's why people who are purely
anonymous or altruistic donors go through a kind of rigorous psychological
screening in fact to decide to whether this is a freely made decision
and a decision that is truly informed.
But on the deeper question about how do we understand the meaning
of doing surgery on the healthy, introducing now that it's a theory
of terrified physicians. But presumably we have to think about the
acceptable level of risk. Right? In the kidney case, it seems pretty
clear to me that this is an acceptable level of risk. There are some
outcomes that are bad. There's a fairly low, but a real risk of
mortality for the healthy donor. But it seems to me both morally justifiable
and in many cases morally heroic to do the surgery that removes an organ,
a kidney, from the living donor to put it into someone who is sick and
whose very life hangs in the balance.
At the other extreme, it would be the case of the parent who wants
to donate a heart to his dying child. One can understand the nobility
of the motive and the desire for the parent to save the child and perhaps
give the rest of his organs to other people who might be saved. You
could save many lives at the cost of one, but obviously no surgeon would
even contemplate performing such a surgery.
Somewhere in the middle we have to decide what is the acceptable level
of risk. I think that's something that probably has to be made
a judgment case by case, family by family, doctor by doctor. I don't
think there's one formula. But again, I don't think we should
ignore the moral dilemma here, the dilemma that exists even in the low
risk cases. It gets even more and more complicated for us as you go
from removing a kidney to removing a part of the liver and I think we
can't ignore the moral difference in that kind of surgery compared
to other kinds of surgeries where the patient is sick and the medical
intervention is the best effort to try to help them.
CHAIRMAN PELLEGRINO: Thank you. I think we are at the time
for the break.
PROFESSOR McHUGH: You just asked that we should all volunteer.
Now you're going to shut me off. You're a tough chairman.
CHAIRMAN PELLEGRINO: We'll watch you, Paul.
PROFESSOR McHUGH: Anyway, let me just make the simplest points
that I had made somewhat before that first of all our issues of getting
the organs and getting them from both loved ones and from the deceased
will really depend upon doctors themselves being more engaged on both
the donor and the recipient or it's going to be a cash market thing.
Those are the two things that are going to go if human organs are going
to be the only way. And I said it the last time. I believe that the
major solution here ultimately is going to be xenotransplantation and
we need to know where we are in that arena.
I absolutely agree though with what was said by Gil and what was said
by Eric and also it was said by Peter that I don't want to find
us in a situation where poor people are exploited and are forced into
it and led to believe that they must do this as an act of desperation.
That's not a new idea by the way. In literature, that's spelled
out. I think Les Miserables has a description of that similarly not
with anything so serious as an organ transplant.
So I think that one of the places that this Council should be since
it's discussed the importance of research both in what Floyd says
going backwards. I think it should also talk about the very great importance
of cultivating xenotransplants as the solution really for these things.
CHAIRMAN PELLEGRINO: I think we're at the point now of
our break. Return at 3:45 p.m. Again, a comment. Almost everybody
has commented on this and again we'll take that under serious consideration.
Off the record.
(Whereupon, at 5:36 p.m, the above-entitled matter concluded.)