ETHICAL DICHOTOMIES IN ORGAN-TRANSPLANTATION - A TIME FOR BRIDGE BUILDING

Rapid advances of the past 15 years have resolved many of the technica l and immunologic limitations to organ transplantation. With the succe ss rates that can now be achieved, there is increased attention to the limited supply of donor organs and to cost considerations, the remain ing obstacles to wide application of organ transplantation. Competitio n for organs and for funding demands greater focus on patient selectio n and resource allocation. As Charles Taylor, philosopher and politica l scientist, has written, ethical formulations inevitably conflict whe n each is taken to its logical end point. In the 1960s, a life boat et hics framework predominated for selection of transplant recipients. Th e opposing egalitarian framework of recent decades has allowed for enr ollment of older transplant recipients and those with histories of sub stance abuse. In the United States, alcoholic liver disease has been t he most common indication for orthotopic liver transplantation since 1 987. Among those awaiting transplantation, urgency has been a priority over time waiting. But many potential transplant candidates who are y oung and who appear relatively stable die while waiting. Despite the s hortage of cadaveric organs, physicians and ethicists have for the mos t part eschewed rewards or reimbursement for living related organ dona tion. Stich conventions are a function of the prevailing zeitgeist and are susceptible to a paradigm shift in parallel with overall changes in societal regulation of medical practice. Theorists and practitioner s are immersed in the trends of the day and the approach at each momen t seems preferable to that of the moment preceding. From a practical s tandpoint it may be possible to bridge disparate ethical constructs. F or example, in the wait for solid organ transplantation, a bicameral a pproach could alternatively accommodate time waiting and urgency. Sele ction of older patients and those with a past substance abuse history could be limited to those with the best prognosis for compliance and p osttransplantation quality of life. Living organ donors and families o f nonliving donors could receive incentives of a noncoercive nature th at would stimulate participation without sacrificing altruism. Creativ e approaches are needed to improve fairness and efficacy in solid orga n transplantation. (C) 1996 Elsevier Science Inc.