If current organ donation systems don’t adapt, alternative solutions to the global organ shortage will hopefully emerge from biotechnology.
Making organ donation work?
Organ shortage is costly in terms of human lives, public expenditure and lost productivity from unserved patients. Long-term dialysis, for example, is more expensive than kidney transplantation. Additionally, dialysis patients cannot maintain a regular job unlike successful transplant recipients. Both consequences result in higher costs to national health and social security systems. The most tragic result of the shortage is that patients die whilst waiting for suitable transplant organs.
Presumed consent with soft opt-out is now sweeping across the UK as England and Scotland are following Wales’ example. However, this does not entirely eliminate the ethically critical question of ownership of the human body and the lack of adequate compensation for the donor’s family.
There are various ideas for direct and indirect incentives to enhance the number of organ donors. These include futures contracts for cadaveric donations which mitigate some of the main criticisms of payment for human body parts. Yet, the enduring ethical bias in current legislation does not permit meaningful financial compensation for organ donors. As long as regulators hold on to current policy guidance, it is extremely unlikely that futures or other compensation beyond (perceived) financial neutrality will ever emerge. Altogether, no type of financial incentive above monetary break-even is without controversy, neither is failing to adequately compensate donors for their sacrifice and implied acceptance of risk. No side has a moral high-ground. Hence, a more pragmatic approach is required. If fundamental changes for cadaveric donations are impossible, improved compensation and protection of altruistic living donors may be a more feasible path to significantly increased organ supply.
No side has a moral high-ground.
Biotechnological advances may one day reduce or even eliminate the need for donated organs rendering incentivisation superfluous. Three major fields of research are
- cell-based regenerative therapy and
- 3D bioprinting.
Understanding of xenotransplantation – the transplantation of living cells, tissues or organs across species boundaries – has grown tremendously. It may soon be possible to genetically engineer pigs that serve as organ sources for humans, in particular for hearts and kidneys. The WHO is currently updating regulatory requirements for xenotransplantation clinical trials to keep pace with those scientific developments.
Cell-based approaches that create organ-like structures have evolved to be useful tools for biological discovery and drug testing. Their readiness as functional organ replacements is still far off. However, transplantation of liver cells as alternative to liver lobes is already in an early stage of therapeutic clinical practice.
3D bioprinting is a technology that essentially uses cells as ink. Recent strides have enabled creation of a miniature human heart with its main blood vessels. Whilst not a functional organ yet, its complex composition is close to the natural structure. 3D bioprinting may solve issues resulting from 3D scaffolds used in other cell-based methods and may, thus, be a more promising avenue towards bioartificial organs. Legislation governing 3D bioprinting is patchy, as it has not yet caught up with technological developments.
Future research should evaluate the impact of technological advances on organ and tissue supply, healthcare costs, quality assurance, legal frameworks and medical ethics. Whilst biomedical advances are encouraging, their full-scale clinical implementation lies decades in the future. Until then the global organ shortage should be redressed by other means.
- ANDERSON, T.N. and ZARRINPAR, A., 2018. Hepatocyte transplantation: past efforts, current technology, and future expansion of therapeutic potential. Journal of Surgical Research, 226, pp. 48-55.
- COOPER, D.K.C., HARA, H., IWASE, H., YAMAMOTO, T., LI, Q., EZZELARAB, M., FEDERZONI, E., DANDRO, A. and AYARES, D., 2019. Justification of specific genetic modifications in pigs for clinical organ xenotransplantation. Xenotransplantation, 0(0), pp. e12516.
- HAWTHORNE, W.J., COWAN, P.J., BÜHLER, L.H., YI, S., BOTTINO, R., PIERSON III, R.N., AHN, C., AZIMZADEH, A., COZZI, E., GIANELLO, P., LAKEY, J.R.T., LUO, M., MIYAGAWA, S., MOHIUDDIN, M.M., PARK, C., SCHUURMAN, H., SCOBIE, L., SYKES, M., TECTOR, J., TÖNJES, R.R., WOLF, E., NUÑEZ, J.R. and WANG, W., 2019. Third WHO Global Consultation on Regulatory Requirements for Xenotransplantation Clinical Trials, Changsha, Hunan, China December 12–14, 2018. Xenotransplantation, 26(2), pp. e12513.
- HOLLOWAY, E.M., CAPELING, M.M. and SPENCE, J.R., 2019. Biologically inspired approaches to enhance human organoid complexity. Development, 146(8), pp. dev166173.
- LEVY, M., 2018. State incentives to promote organ donation: honoring the principles of reciprocity and solidarity inherent in the gift relationship. Journal of Law and the Biosciences, 5(2), pp. 398-435.
- LI, P. and FAULKNER, A., 2017. 3D Bioprinting Regulations: a UK/EU Perspective. European Journal of Risk Regulation, 8(2), pp. 441-447.
- MACHINO, R., MATSUMOTO, K., TANIGUCHI, D., TSUCHIYA, T., TAKEOKA, Y., TAURA, Y., MORIYAMA, M., TETSUO, T., OYAMA, S., TAKAGI, K., MIYAZAKI, T., HATACHI, G., DOI, R., SHIMOYAMA, K., MATSUO, N., YAMASAKI, N., NAKAYAMA, K. and NAGAYASU, T., 2019. Replacement of Rat Tracheas by Layered, Trachea-Like, Scaffold-Free Structures of Human Cells Using a Bio-3D Printing System. Advanced Healthcare Materials, 8(7), pp. 1800983.
- NATIONAL ASSEMBLY FOR WALES, 2013. Human Transplantation (Wales) Act 2013. Enacted edn.
- NOOR, N., SHAPIRA, A., EDRI, R., GAL, I., WERTHEIM, L. and DVIR, T., 2019. 3D Printing of Personalized Thick and Perfusable Cardiac Patches and Hearts. Advanced Science, 0(0), pp. 1900344.
- WISEMAN, A.C., 2018. Protecting Donors and Safeguarding Altruism in the United States. Clinical Journal of the American Society of Nephrology, 13(5), pp. 790-792.