The first reported successful kidney transplantation occurred in 1954, between twins. Since then, organ donation and transplantation has become less a medical marvel than a common expectation of patients with a variety of diseases resulting in organ failure. Those expectations have caused demand for organs to skyrocket far beyond available supply, fueling an organ shortage and resulting in over 60,000 patients on transplant waiting lists. In this special issue, our contributors attempt to shed new light on some of the many old ethical questions raised by transplant in the contemporary context of extreme scarcity.

Organ allocation policy involves a mixture of ethical, scientific, medical, legal, and political factors, among others. It is thus hard, and perhaps even impossible, to identify and fully separate ethical considerations from all these other factors. Yet I will focus primarily on the ethical considerations embedded in the current debate in the United States about organ allocation policy. I will argue that it is important to put patients first—in the language of the title of one of the major public hearings—but even then significant ethical questions will remain about exactly how to put patients first.

Medical advances in transplantation techniques have driven an exponential increase in the demand for transplantable organs. Unfortunately, policy efforts to bolster the organ supply have been less than effective, failing to provide a stopgap for ever-increasing numbers of patients who await organ transplantation. The number of registrations on waiting lists exceeded 65,245 in early 1999, a 325% increase over the 20,000 that existed 11 years earlier in 1988. Regrettably, more than 4,000 patients die each year while awaiting transplantation.

Bioethics has entered a new era: as many commentators have noted, the familiar mantra of autonomy, beneficence, nonmaleficence, and justice has proven to be an overly simplistic framework for understanding problems that arise in modern medicine, particularly at the intersection of public policy and individual preferences. A tradition of liberal pluralism grounds respect for individual preferences and affirmation of competing conceptions of the good. But we struggle to maintain (or at times explicitly reject) this tradition in the face of individual preferences that we find distasteful, suspect, or even repugnant, especially where the broader social good or respect for equality is at stake. Directed donation presents us with such a dilemma: can we uphold the right of self-determination through respect of individual preferences regarding disposition of transplantable organs while at the same time maintaining an allocation system that reflects values of equity and justice claimed to underlie the socially negotiated practice of transplantation? Or are some preferences simply to be deemed unethical and not respected, even if that leads to a reduction in the number of transplantable organs available and to an apparent disregard for the autonomous decisions of the recently deceased?

In late December 1998, Renada Daniel-Patterson's father offered to donate a kidney to his daughter and ignited a controversy in the bioethics community. Renada had been born with only one kidney, which began to fail early in her childhood. At age 6, Renada had to receive dialysis three times a week. She was unable to attend school or venture very far from home. This pattern continued until Renada was 13, when Mr. Patterson called from prison to offer her his kidney. Renada was surprised to hear from her father, who was serving 12 years at California State Prison for burglary and drug convictions. Mr. Patterson was determined to be a compatible donor, and the family proceeded with the transplant operation. As a result of this surgery, Renada was able to live the life of a healthy girl for 2 years. Because the medication to prevent rejection of the transplanted organ made her feel ill and bloated and caused her to develop a hump on her back, Renada gradually began to skip doses. As a result, her donated kidney began to fail. It was under these circumstances that David Patterson offered to donate his second kidney to his daughter in 1998.

The crisis in donor organ and tissue supply is one of the most difficult challenges for transplant today. New policy initiatives, such as the driver's license option and required request, have been implemented in many states, with other initiatives, such as mandated choice and presumed consent, proposed in the hopes of ameliorating this crisis. At the same time, traditional acquisition of organs from human cadavers has been augmented by living human donors, and nonheartbeating human donors, as well as experimental animal and artificial sources. Despite these efforts, the crisis persists and is perhaps most tragic when it threatens the lives of children, driving parents to sometimes desperate measures. Herein, we address one very controversial step some parents have taken to obtain matching tissue or organs for their needy children—that is, having a child, in part, for the purpose of organ or tissue procurement.

Organ donation and transplantation touch on profound, and at times elusive, values and beliefs. These involve personal identity, embodiment, the relationship between the individual and the community, and death. Different cultural and religious perspectives, reflecting deeply ingrained but often unspoken assumptions about human identity and responsibilities, subtly but profoundly affect attitudes to donation and transplantation.

These CQ Sources were compiled by Bette Anton.

It is now a widely shared opinion in the Western countries that a child's disability would probably place an unexpected burden on her parents, a burden that the parents have not committed themselves to dealing with. A child with a physical or mental disability is not, so to speak, a part of the package the parents ordered. This line of reasoning has recently been supported by Rosamond Rhodes in her article “Abortion and Assent.”

When surgeons transplant animal organs into humans, people who did not receive the organs incur risks. These third parties may stand near or far in time or space. No one knows the likelihood, breadth, or nature of the risks in question. The common wisdom among infectious-disease specialists is that in the best of xenotransplant conditions, such third-party risk may be minimized but not eliminated.

On April 10, 2001, after extensive committee deliberations, the Second Chamber of the Dutch Parliament passed a bill that was introduced in August 1999 legalizing physician-assisted death. The bill is officially called “The Evaluation of Ending Life on Request and Assistance in Suicide and a Change of the Penal Code and the Burial Act (Law Evaluating Ending Life and Assistance with Suicide).” It was passed by a majority vote in the Second Chamber of Parliament and was supported by the majority parties constituting the present coalition government (i.e., liberals and socialists). Opposition to the law came mainly from a minority of Christian parties. In this report we explore the meaning of this bill and describe some of its problematic and paradoxical items.

As a medical student doing a rotation, I was feeling positive as we knocked on the door of an elderly lady who I'd seen just 2 days earlier. Even though seriously ill for many months, this patient had always lived life in her own way, refusing to go to a nursing home. It was clear that her condition had deteriorated rapidly, and the nurse informed me privately that she was dying, sooner rather than later.

The moral and professional anguish experienced by the medical student in response to the request “Help me die” is a fundamental sentiment that needs to be retained within the ethos of the medical community. Especially as laws on professional assistance in dying undergo increasing liberalization, society should not want its physicians (or its prospective physicians) to either be so callous, so lacking in compassion that they would dismiss such a patient request out-of-hand, or to be so cavalierly accustomed to acquiescing in such requests that it simply becomes a routine pattern. Either approach on its own betrays the moral integrity of medicine. We instead want those professionals who are present to us in our dying to express both care and respect, to display both compassion and dignity for the dying person, even when, as in this circumstance, these core values come into conflict. In such a situation, moral anguish protects both the professional and the patient, not to mention society, from callous paternalism and/or callous indifference.

This case is both an excellent as well as a sad illustration of the complexities, intensities, and foibles of the issue of “helping” sick people to die. Although the reaction expressed here is that of a student, it is also, sadly, the reaction of many an experienced physician in being emotional, irrational, and hasty. The description is a perfect example of the student's dilemma: “I would like to help but I can't because to do so would threaten my position”—altruism versus egocentric motivation.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will igve you an opportunity to respond in the letters section. Your input is desired and anticipated.