Ethical and policy issues in altruistic living and cadaveric organ donation.

Organs for transplantation are usually obtained from living genetic relatives or from heart-beating cadavers. Unfortunately, these sources have so far been unable to keep up with demand. As a result, there is a large and steadily increasing number of potential recipients awaiting transplantation, some of whom will die before an organ can be found. In an attempt to rectify this tragic situation, several solutions have been proposed. This review will consider proposals designed to increase the availability of human organs without resorting to commercialism. These include expanding the use of living donors by: 1) encouraging donations by genetic relatives; 2) allowing volunteers a greater voice in determining their own suitability; 3) encouraging the use of emotionally related individuals and accepting altruistic strangers; and 4) considering motivated identical twin minors and older adolescents as donors. Suggestions for increasing the pool of cadaveric donors include: 1) overcoming the family consent barrier by presuming consent, mandating completion of binding advanced directives, or by eliminating the need for consent entirely; 2) reconsidering non-heart-beating donors; 3) elective ventilation for organ donation; and 4) accepting organs from anencephalic infants before brain death occurs. All of these proposals raise concerns which are discussed. Those approaches considered to be ethically acceptable and to hold promise for success should be vigorously pursued, beginning with carefully designed pilot studies. Hopefully, such an approach will eventually increase the number of organs available for patients suffering from end-stage organ disease.