Steinberg David
Lahey Clinic Medical Center.
Am J Bioeth. 2004 Fall;4(4):4-14. doi: 10.1080/15265160490518557.
Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors. An "opting in" paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An "opting in" program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of"organ takers"who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who "opt in" would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive. An "opting in" paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an "opting in" paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an "opting in" policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.
美国近6万名终末期肾病患者正在等待肾脏移植。由于已故捐赠者的器官稀缺，活体肾脏捐赠者已成为器官的关键来源；2001年，近几十年来首次出现活体肾脏捐赠者数量超过已故捐赠者数量的情况。用于为让活体肾脏捐赠者冒险辩护的范例包括捐赠者风险低、风险效益比有利、对捐赠者的心理益处、利他主义以及自主与知情同意；由于这些论点都存在缺陷，我们需要减少对活体肾脏捐赠者的依赖，并增加从已故捐赠者获取的器官数量。一种“选择加入”的范例将奖励那些同意在死后捐赠肾脏的人，若他们生前需要肾脏，将在分配上给予优先考虑。一个“选择加入”计划应能增加可用于移植的肾脏数量，并消除“器官索取者”这一道德上令人困扰的问题，这些人若自己需要肾脏就会接受，但却未做出成为器官捐赠者的安排。“选择加入”的人若自己不再需要肾脏时捐赠肾脏，只需付出最小代价，在自己需要时就能优先获得器官；这是一种器官保险形式，理性的人应该会觉得极具吸引力。一种“选择加入”的范例将模拟自然界中观察到的互惠利他行为，社会生物学家认为这种行为能增强群体生存能力。尽管基于需求以外的因素分配器官在道德上可能令人困扰，但与其他获取更多器官和接受器官极度稀缺现状的方法相比，“选择加入”范例具有优势。尽管“选择加入”政策将基于开明的利己主义，但通过展示互助的功利价值，它将促进这样一种态度，即利己主义有时需要我们认识到我们都是人类共同体的一部分。
