Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on if it was ethical to let an oil tycoon jump the liver transplant line by advertising for an organ.
Yes: 19%
No: 81%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt adapted from his book, .
Advertising for organ donation can be highly effective. In 2014, the nonprofit organization Reborn to be Alive hired Belgian advertising firm Duval Guillaume to promote organ donation. The result was a series of ads that depicted individuals engaged in foolish, life-threatening behavior (e.g., using a blowtorch alongside an oxygen tank) with the tagline "8 of his organs can be donated. Luckily for us his brain is not one of them." The campaign was noncontroversial and highly successful. More contentious are efforts by private individuals, like Tex, to advertise for organs on their own.
In the U.S., the allocation of most organs is managed by the United Network for Organ Sharing (UNOS), a nonprofit organization that follows rules enacted by the U.S. Department of Health and Human Services. The so-called Final Rule of March 2000, which governs the allocation of organs, allows donors to earmark their body parts in advance of their deaths.
Under limited circumstances, this approach makes sense: if the close relative of a patient on the waiting list dies suddenly, a strong moral case can be made for allowing the family to transfer the organ to their own kin -- as doing so likely would fulfill the wishes of the deceased, may tip those on the fence into donation, and does not in any substantial way undermine the fairness of the existing system. Presumably, the rich and powerful are no more likely to benefit from such intrafamilial allocations than the indigent.
In the years following the enactment of the Final Rule, well-off individuals like Tex have taken to advertising for organs. In 2004, cancer patient Todd Krampitz of Houston advertised for a new liver on billboards, ultimately receiving a liver from an anonymous family that earmarked the organ specifically for him. (Krampitz, 32, died of his disease 8 months afterward.) A year later, 31-year-old Red Cross publicist Shari Kurzrok, diagnosed with acute liver failure, advertised for a donor in the New York Times. (She ultimately received a liver from the waiting list, married, became a mother, and has enjoyed a successful career in advertising.) Ethicists and transplant surgeons remain deeply divided on the ethics of these maneuvers.
Critics like Arthur Caplan, PhD, of New York University, argue that allowing patients like Krampitz and Kurzrok to jump the line undermines the fairness of the system. Under federal law, organs are supposed to be allocated to those patients most in need, regardless of wealth or influence -- and allowing the rich and powerful to run ad campaigns circumvents that principle. The risk also exists that others will perceive the system as unjust and will refuse to donate. As a result, UNOS and the American Society of Transplant Surgeons have both issued statements opposing such advertising campaigns, including open solicitation on the internet and social media.
Yet, even without advertising, donors from the community often step forward to give organs to celebrities. Supporters of advertising are aware of the potential image problems created by such donations, but believe that the practice will increase the overall availability of organs. For example, there is no reason to believe that the family who donated to Todd Krampitz would have given an organ otherwise; any patients who secure outside organs through advertising, the thinking goes, also free up organs for others on the waiting list.
In 2005, Alex Crionas learned the hard way precisely how divided the medical community remains on the subject of advertising for organs. He had lined up a kidney donor, Patrick Garrity, only to be refused a transplant by his local hospital's transplant-coordinating nonprofit because he had advertised for a donor online. (Ironically, he had not met Garrity through his online ads.) Fortunately for Crionas, he was able to transfer his care to another hospital, which performed the transplant successfully, with no ethical objections.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
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