The Promotion of Organ Donation and Transplantation

Scaria Kanniyakonil
Reproduced with Permission

Introduction

Organ transplantation is the surgical removal of a tissue or organ from one individual and the placement of the organ in another individual for the purpose of improving the health of the recipient. Most transplant programme depends on cadaveric and living organ donation. However, we find that there are scarcity of human organs and many patients face death. Organ donation and transplantation creates a culture of life and love. Many religious and secular approaches justify organ donation and transplantation because it promotes life. Catholic Church also favours it, especially in the encyclical Evangelium Vitae, which states that it is an act of the virtue of charity. This article presents the promotion of organ donation and transplantation. The first section of this article discusses the present state of organ donation and transplantation, and the second section deals with ethical issues related to organ donation and transplantation, and the final section is on the promotion of organ donation and transplantation.

1. Present State of Organ Donation and Transplantation

The present state of organ donation and transplantation includes different types of transplantation, different types of donations, medical, moral, and legal problems connected with the practice of organ donation and transplantation.

1.1 Different Types of Transplantation

There are four types of transplantation. They are auto grafts, isographs, homographs, and heterografts. 1) An auto graft (syngenic) is the transplanting of an organ or tissue within the same individual from one part of the body to another. 2) An Isograft (Isogenic) is the transplantation of organs or tissues between two genetically identical individuals, such as identical twins. 3) A homograft (allogenic graft) is the transplantation of an organ from one individual to another within the same species. 4) A heterograft (Xenogenic graft) is the transfer of organs between individuals of different species, usually from animals to human beings.

1.2. Different Types of Donations

Cadaveric and living organs are the two main sources for transplantation. The cadaveric donation includes related and unrelated donations. There are five types of living organ donations: 1) Living Related Donation: donation between genetically related persons, 2) Living Unrelated Donation: donation between non-genetic or non-emotional persons. There may be also emotionally related transplantations. 3) Crossover Transplantation: In renal transplantation certain donors cannot donate their organs to a particular recipient because of the ABO incompatibility and other problems with histocompatibility (e.g. positive T-cell cross matches) but without any ABO problem with other recipients (crossover transplantation). For instance, donor A cannot give a kidney to recipient A but he/she can give it to recipient B. Similarly donor B cannot give a kidney to recipient B; but he/she can donate to recipient A. 4) Domino: in this programme an organ may be transplanted to a patient whose own organ then still can help another patient on the waiting list. 5) Indirect Living Organ Donation: close relative of a recipient wants to donate his/her kidney to the donor. But this living related transplantation is not possible due to blood group incompatibility. The recipient is then placed higher on the waiting list, while the organ from the donor is added to the organ pool.

1.3. Medical Aspects of Organ Donation and Transplantation

Here we discuss only medical aspects of living organ donation and transplantation because cadaveric donation has no surgical risks. Living organ donation has advantages from an immunological point of view because there is often a large degree of similarity between the tissue types of the donor and the recipient.1 However, we cannot fully avoid the risks to donors and recipients.2

Many of the studies report only minor risk to the donors, but earlier there was anxiety concerning risks to the donors. Today one can find a much more positive attitude towards living organ donation. It is noted that in the case of a living donor, mortality after surgery is extremely low. For instance, a survey of U. S. kidney transplants shows that there are only 5 donor deaths in 19,368 live kidney transplants.3 Patients who decide to undergo transplantation are subject to normal surgical risks. There are also complications of urological and vascular problems, especially with regard to kidney transplantation.4 Besides, transplantation affects the recipient body's structure. The main benefit to the recipient is that he/she gets a new lease on life or even a better quality of life.

1.4 Legal Aspects of Organ Donation and Transplantation

Due to the illegal medical practice in transplantation, commercialization of human organs and so on, many countries formulated transplantation laws. The status of transplantation law can be divided into three groups: opting-out, opting-in, and required request. 1) According to the opting-out system, every human being will be considered a possible donor after death unless he/she has officially expressed a contrary option. It is also known as presumed consent.5 2) By opting-in we mean a process by which people voluntarily sign and submit a will saying that they want to become donors once they are dead. If they do not do this, they will not be legally considered donors.6 3) Required request law requires hospitals to ask the family of a deceased patient for a donation of organs and tissue if the deceased is a suitable candidate for organ donation.7

Many countries have either enacted or are in the process of drafting legislation to control the area of living donor transplantation. Although the general field of transplantation is still in a state of change and growth, the fundamental legal issues that must be confronted remain unchanged. There have been recent developments in legislation, especially giving priority to the genuine consent of the donor. Although the majority of legislation has been written for cadaver organ donation, slowly, regulation is developing for living organ donation as well. The clauses of the laws are made on the basis of medical, ethical, religious, social and cultural considerations.

In India, the Transplantation of the Human Organ Act of 1994 came into force on February 4, 1995.8 Some of the states of India had different transplant acts previous to the enactment of this new law. The new law prohibits trade in human organs and address the donor's right, the adequate supply of organs to the needy, the optimization of transplantation costs and the promotion of transplantation procedures. Indian transplantation law allows organ donation from an unrelated person for reasons of affection, attachment, or for any other special reasons.

1.5. Donor Options

In India, the preferred donors are the living relatives. If no related donor is available to give the required organ, the next option is a paid donor programme. The third option would be a cadaveric donor organ.

1.5.1. Living Related Donation

Apart from the minor organs like blood, skin, bone and so on major organs like kidney, part of liver etc. also can be donated by a person while living. Indian doctors are in favour of living related donors. Living kidneys are less likely to be rejected by the recipient's body.9 Governmental institutions and some private hospitals such as Jaslok and Breach Candy in Bombay, the Apollo Hospitals in Madras and the Christian Medical College in Vellore insist on surgeries being performed only from related donors because their success rate is higher.10

However, living related donations have certain limitations. The doctors at the Christian Medical College Hospital, Vellore point out that some of the so-called "voluntary" related donors brought in by patients were very unwilling but had been coerced into volunteering by other family members. In such cases, the doctors simply cited medical reasons to give the donors a way out. At the same time, the present method used to establish the relationship between donor and recipient, the Human Leukocyte Antigen Match, is not really conclusive. Gene mapping would provide the only reliable method, but hospitals in India do not have this facility.11 Besides, A. G. Phadeke has brought out that even close relatives go through emotional stress, feelings of blackmail and other ramifications. He says:

Though it is well said in the living room discussion that brothers and sisters born out of the same parents have very intimate emotional attachment to one another, the stark reality of day-to-day life convinces us that this is often a myth. I have seen a large number of brothers and sisters flatly refusing to volunteer to donate their kidneys. The objection to donations comes from brothers and sisters who are emotionally not attached to the patient.12

Many times, an emotional blackmail follows, with a person donating a kidney under compulsion. More often, unscrupulous related donors and their families exploit this situation for monetary gain. Money changes hands, or properties are transferred from one person to another, before or soon after the kidney is donated. Hence, M. S. Venkataraman observes "such donations are in no way different from donations...for monetary reward."13 However, the majority of Indian doctors are in favour of living related donation, and argue that it is best suited to Indian society at the moment.14

1.5.2 Living Unrelated Donation

Unrelated living paid donations have started in India due to the scarcity of living related donors. For several years, India has been known as a warehouse for kidneys, a great organ market.15 Kidney trade has expanded so greatly and rapidly that an estimated 2,000 or more kidneys taken from live donors are sold every year in the country. While initially this was restricted to hospitals in Bombay and Madras, it has moved to Calcutta and Bangalore and even to smaller cities like Pune, Jaipur and Madurai.16

India has become one of the largest centres for kidney transplant in the world, the reasons being the low costs and the immediate availability of organs. Rich people in India, and those from the Gulf countries, marry poor young ladies from villages and slums in India. Since the spouse is a near relative in the Indian transplantation law, one partner can donate his/her kidney to the other partner. After the marriage, these young women are forced to remove one of their kidneys for their husbands. After the kidneys are taken, these men divorce the women. As well, other people sell their organs for small amounts of money.17 As regards the paid organ donations, there are middlemen who get money from these kidney trades. As A. P. Pandey writes, "touts took advantage of the shortage of donor kidneys and the readiness of many people to sell them to defray expenses in the family. Every day 10 kidneys are sold in Madras."18 The most unfortunate feature of this trade was that many doctors colluded with these unscrupulous individuals in Madras. Pandey receives nearly a letter a week from volunteers offering their kidneys to needy patients. But the "voluntariness" disintegrates when the donor gives the reason - he has to meet the expenses for the marriage of a sister or for constructing a house. Instances were many in which young women were forced by their husbands to sell their kidneys.19

1.5.3 Cadaveric Organ Donations

The removal of cadaveric organs for transplantation is not practised to any significant degree at any centre in India. Most religious Indians are Hindu. The rites to be observed after death include burning the intact body in the presence of the family. It is generally thought permissible for eyes to be removed, but society would not accept the removal of kidneys. It seems that the crippled financial state of the health service, together with cultural and religious problems around the idea of death, inhibit any initiatives towards cadaveric transplantation in the majority of Indian centres.20

The effect on the establishment of cadaver donation has so far been minimal, but at least there has been a start. Due to the vastness of the country and the small number of transplant centres, it may not be logical to initiate a national organ storage and distribution system. There are not enough intensive care units, which can supply cadaver kidneys or provide for the storage of brain-dead cadavers. Another fact is the poor transportation system, which makes it difficult for the timely retrieval of organs to implement the cadaver transplantation. India's hot climate makes it hard to store and preserves kidneys. The lack of trained cadaveric transplant surgeons also affects the transplantation. According to M. Bhandri, it may be ideal to create a central model wherein each centre generates cadaveric organs from its surroundings to meet its own requirements.21

Today, many transplantation centres started taking organs from brain death patients and transplanted them to the patients. For instance, in Kerala, under the leadership of Society for Organ Retrieval and Transplantation (an organization of hospitals, doctors and volunteers to promote organ donation and transplantation, in Kochi) arrangements are made to share organs from willing donors.22 There are many hospitals in Kerala, which has the facility to conduct transplant surgeries.23 The following are the common forms of transplant surgery conducted today. 1) Renal transplant surgery where a donor kidney is transplanted into a recipient; 2) Liver Transplant surgery, where part of a liver from a donor is transplanted into a recipient; 3) Bone Marrow transplant, an essential therapy in cases of leukemia; 4) Corneal transplant, practiced routinely in eye donation and so on. At present there is inter-hospital transfer of organs possible in Kerala and in future it will be a great help to a large number of patients in the country.

2 Ethical Issues in Organ Donation and Transplantation

The practices of organ donation and transplantation raise many ethical questions. How can we morally justify organ donation and transplantation? What are the ethical issues connected with the donor, with the recipient, and xenotransplantation?

2.1 Justification of Organ Donation and Transplantation

Catholic Church holds that the virtue of charity is the norm for the justification of the cadaveric, and living organ donation and transplantation. Pius XII in his address to ophthalmologists in 1956 argues that acts of donation cannot be viewed as a duty or as obligatory. Such acts are supererogatory and not obligatory.24 Moreover, John Paul II justifies organ donation and transplantation based on charity in general. In the address on blood and organ donations of August 1984, John Paul II commended the National Association of Italian volunteer blood and organ donors for their spirit and initiative. He urged them "to promote and encourage such a noble and meritorious act as donating your own blood or an organ to those of your brothers and sisters who have need of it."25 In addition, in an address to a Congress on Renal Illness and Transplants (April 30, 1990), he speaks about the Church's main concern for renal illness and donations. The Pope asks the directors of Catholic institutions to encourage this generous act of organ donations: "Those who believe in our Lord Jesus Christ, who gave his life for the salvation of all, should recognize in the urgent need for a ready availability of organs for renal transplants a challenge to their generosity and fraternal love."26 Further, in his address to the participants of the first International Congress of the Society for Organ Sharing (June 20, 1992), the Pope considered organ transplantation as a new way of serving the human family.27 In organ transplantation man/woman has found a way to give himself/herself, in blood and body. This gesture allows others to continue to live.28

This gift is actually an authentic form of human and Christian solidarity.29 Similarly, John Paul II writes in Evangelium Vitae no. 86 that organ donation is an act of love when it is done in an ethical manner.30 The death and resurrection of Jesus Christ establishes the supreme act of love. This extends a deep meaning to the donor's offering, which is saving the life of another person.31 Love (charity) constitutes the main element in organ donation and transplantation, especially in the case of the organ donor.32

Moreover, other religions also support organ donation and transplantation even if their point of emphasis is slightly different. In Judaism, Rabbi R. P. Bulka observes: "One may laud the donor who makes ... a heroic sacrifice, but it certainly would not be proper to place pressure on individuals to be so altruistic."33 Similarly, from the Greek Orthodox Church, Stanley S. Harakas writes about the donation of a kidney. Organ donation rescues "the life of another person as a loving act of mercy. The donor is to be commended if he perceives his sacrifice not as a violation of his bodily integrity, but as a gracious and loving unselfish act."34 Based on several passages from the Qumran and Hadith (the Prophet Mohammed's sayings and examples), the Islamic Code of Medical Ethics (1981) upholds: "If the living are able to donate, then the dead are even more so; no harm will afflict the cadaver if the heart, kidneys, eyes or arteries are taken to be put to good use in a living person. This is indeed charity."35 In the Buddhist tradition, organ donation is an act of helping another person in his/her extreme need. It is an act of generosity and compassion.36 Organ donation and transplantation is acceptable also in the Hindu tradition.37

Care for the other and altruism are the secular terms that we can find in the literature on organ donation and transplantation. Even if many use these terms, the basic idea behind them is charity. Here, care for the other or altruism in organ donation is not self-sacrifice alone, but there is sufficient self-concern for one's own self. Many scholars justify organ donation on the basis of altruism, charity, love or care for the other.38 From what has been stated there is no moral obligation for organ donation. The virtue of charity is the main motive for it.

According to the Catholic perspective, donors can donate organs except brain and reproductive organs. The brain is significantly determinative of personal identity. The reproductive organs are associated with reproductive identity. Neither the brain nor the reproductive organs may be procured from human beings or animals for transplant to a human person (Evangelium Vitae no. 63).

Church also holds that "to take tissue from a live foetus for transplantation is unethical" (Evangelium Vitae no. 63). Great concern must be given to ensure that all cadveric foetal tissue to be used for transplantation is derived from natural miscarriages or from ethically obtained cell lines.

Commercialisation has a serious negative impact on many of the medical and ethical values intimately connected with organ transplantation. The Catholic Church is against paid organ donation.39 Parts of the human body are not to be treated as commodities. Trade in human body parts is unacceptable, as in any other disrespectful use of the organs or tissues of a living or deceased person. At the World Congress of the Transplantation Society (Rome-2000), John Paul II said "any procedure which tends to commercialize human organs or to consider them as items of exchange or trade must be considered morally unacceptable, because to use the body as an "object" is to violate the dignity of the human person."40 Paid organ donation spoils the spirit of altruism.41 In paid organ donation, one does not fully respect the other.42

2.2 Ethical Issues Connected With Donor

Here we discuss the ethical issues related to the living and the cadaveric donor.

2.2.1 Living Donor

The main ethical concerns related to living organ donation include functional integrity, and the consent of the donor.

2.2.1.1 Functional Integrity

Catholic Church has used the principle of totality for the justification of living organ donation and transplantation. A simple expression of the principle of totality means, "the parts of the physical entity, as parts, are ordained to the good of the physical whole." From the medical perspective, the principle of totality would mean "all the parts of the human body, as parts, are meant to exist and function for the good of the whole body, and are thus naturally subordinated to the good of the whole body."43 The term "totality" points to the duty to preserve intact the physical component of that integrated whole.44 The official statement of the Church regarding the application of the principle of totality to medical problems can be seen mainly in the period of Pius XII. He reaffirmed, clarified, and applied the principle of totality to medico-moral questions in many addresses delivered from 1944-1958. According to him, "a part of the body has no meaning outside its reference to the whole, that as a part is to be thought of only in relation to the whole."45

With regard to the application of principle of totality to living organ donation and transplantation, we have to understand the difference between functional integrity and anatomical integrity.46 Mark J. Cherry states "[o] ne must distinguish between the good of the adequately functioning body and the good of the full integrity of the anatomical whole." The principle of totality is concerned with the former and not the latter.47 Theologians have seen the principle of totality in relation with functional integrity. B. M. Ashley & K. D. O'Rourke presents their own formulation of the principle of totality and calls it the principle of ‘Totality and Integrity.' It reads as follows: "Except to save life itself, the fundamental functional capacities which constitute the human person should not be destroyed, but preserved, developed, and used for the good of the whole person and of the community." On the one side this principle grants priority for some human values over others. On the other side, it breaks the "fundamental integrity" of human person for certain kind of worth, "except in the most extreme choice between life and death."48

For Benedict M. Ashley and Kevin D. O'Rourke, organ transplants are justified when the functional integrity of the donor is maintained.49 They give a summary of moral reflections on living organ donation and they present certain principles for living organ donation and transplantation: 1) There should be a serious need faced by the patient, which can only be satisfied by organ donation. 2) Even if donation reduces "anatomical integrity, it should not diminish the "functional integrity" of the person. 3) The risk in donation as "an act of charity is [to be] proportionate to the good resulting for the recipient."50 4) There should be "free and informed consent" by the donor.51 All these norms can be seen in the principle of totality.

The 1975 Ethical and Religious Directives for Catholic Health Care Facilities states "[T] he transplantation of organs from living donors is morally permissible when the anticipated benefit to the recipient is proportionate to the harm done to the donor." The Directives also mention that the donations of organ should not reduce the "functional integrity" of one's body.52 Moreover, the 1994 Directives, section no. 30 directly deals with the need of safeguarding functional integrity in living organ donation and transplantation. It reads as follows:

The transplantation of organs from living donors is morally permissible when such a donation will not sacrifice or seriously impair any essential bodily function and the anticipated benefit to the recipient is proportionate to the harm done to the donor. Furthermore, the freedom of prospective donor must be respected, and economic advantage should not accrue to the donor.53

In short, many moral theologians and the documents of the Church argue for the justification of living organ donation and transplantation by the principle of totality.

2.2.1.2 Informed Consent of the Donor

The informed consent of the donor is another key requirement in living organ and transplantation. If donor's decision is not autonomous or self-determined this leads to treating a person without respect. Respect for autonomy requires that the donor must be able to exercise the power of free choice. In the case of living organ donation, no physiological benefit is to be expected by the donor. It is clear that the first matter of critical importance is how far the amount of risk, pain, and length of incapacity is communicated to the donor so that an informed decision can be made.54

It is difficult to apply presumed consent in living donation. One can find genuine consent with regard to living organ donation in many of the transplantation law. For instance, Art. 3 of the WHO Declaration states that "the donor should not be influenced or abused."55 Organ donation, says John Paul II, is a free and conscious decision either on the part of the donor, or of someone who legitimately represents the donor. It is also a decision of giving without any remuneration. Really, donation concerns the well being of another person.56 It is very difficult to make an assessment of fully informed consent of the potential donors, especially in the case of prisoners, mentally challenged persons, and minors.

Prisoners should not be excluded if they accept all the norms of a free informed consent.57 There are different opinions regarding the use of organs from prisoners. J. Stewart Cameron and Raymond Hoffenberg present consequentialist approach of using prisoners' organs: "1) the process of execution may be modified with donation in mind. 2) Executions might be organized specifically to obtain organs for transplantation. 3) Coercion of the prisoner will always be present. 4) The use of executed prisoners' organs condones and exploits execution. 5) Organs of executed prisoners may be sold for profit, which is unacceptable."58 Even if there are different arguments about organ donation of prisoners, according to Robert A. Sells, taking the organs of prisoners indicates a utilitarian concept of organ transplants. This is a benefit-maximizing approach,59 which is against the principle of justice.

Regarding mentally challenged persons, they cannot make decision for themselves, and it is also difficult to give proxy consent. According to H. Nys, in this context, "law should exclude mentally incapacitated persons acting as living donors."60 Besides, a minor is, in general, not capable of giving valid consent. Preferably, this is expressed in the law under the requirement that the donor must be an adult person. For example, the legislation in Portugal from 1993 states that "any donation of non-regenerative substances by minors or incompetent persons is prohibited."61 The Italian law of 1967 describes that the donor should have a proper age.62 Section 2(f) of the Indian law defines a donor as a person "not less than 18 years of age."63 This points to freedom from force or coercion, and respect for the vulnerability of a minor.

2.2.2 Cadaveric Organ Donation

The donation of organs and tissues after death is a generous act. With regard to the cadaveric organ donation and transplantation, the main ethical issues include the concept of brain death, and consent.

2.2.2.1 Brain Death

People can donate the organs after their death too. Deceased person means a person in whom permanent disappearance of all evidence of life occurs, by reason of brain-stem death or in a cardio-pulmonary sense, at any time after live birth has taken place. Brain death refers to the complete and irreversible loss of function of the brain as consequences of the brain having died in its entirety, while intensive care and mechanical respiration initially keep the remaining parts of the body alive. All functions of the brain stem have permanently and irreversibly ceased, which is the valid criterion of death in many transplantation laws. At present brain death has ethically and legally accepted for the procurement of vital organs for transplantation.

Catholic Church argues that the families of the potential donors should be offered adequate evidence that provides them with appropriate assurance that death has occurred.64 Besides, Charter for Health Care Workers (no. 86) states that donation of non-generative organs and tissues are permissible, provided it would not lead to impair function determination of death by appropriate health care practioners.65 Infants with prolonged loss of consciousness must not be treated as dead for the purpose of organ extraction.

2.2.2.2 Consent of the Donor or the legal guardian

Consent is the main ethical question also to cadaveric organ donation and transplantation. Catholic Church says that "organs and tissues may be removed from a deceased person who has bequeathed them verbally or in writing or, in the absence such clear expression of the deceased person's will, with permission of the family." Further Church notes that "even in the face of a clear expression by the deceased of intent to donate organs at death, Catholic facilities should always take into account the wishes of those grieving the person's death and seek to ensure that sufficient time and information have been given them to comprehend the situation before proceeding."66

2.3 Ethical Issues Connected with the Recipient

There are certain diseases, which affect the functions of human organs, and eventually lead to the death of the patient. Patients with organ failures can go for different types of treatment. Other treatments should be made available whether or not the patient opts to take part in organ or tissue replacement. The general principle is that transplantation should be a last resort and it is done out of urgency.

Another point is that there should be a proportionate relation between physical risk to the donor and good for the recipient. The risk in donation as "an act of charity is [to be] proportionate to the good resulting for the recipient."67 CCC no. 2296 states:

Organ transplants confirm with the moral law and can be meritorious if the physical or psychological dangers and risks incurred by the donor are proportionate to the good sought for the recipient. It is morally inadmissible directly to bring about the disabling mutilation or death of a human being, even in order to delay the death of other persons.68

The general principle that surgery cannot be carried out without the consent of the person to be operated upon is equally applicable to organ transplantation as well. Recipients also should give their consent for the operation.69 The physician should inform the donor and the recipient in an honest, appropriate and comprehensible manner of the possible risks of organ donation and transplantation.

According to Catholic perspective "patients should be treated equally when being admitted to transplant programmes. There should be no unjust discrimination on the basis of social factors such as inability to pay, mental illness, past misuse of substances, lack of family support, lack of education, advanced age, remoteness or ethnicity. Only clinical factors such as urgency, need and ability to benefit should be taken into account."70

2.4 Xenotransplantation

Transplantation of animal organs to human being is permissible provided the procedure will not impair the integrity of the recipient nor impose inordinate risks on the recipient or others. With regard to the animal-human hybridisation, Church says that "the introduction of parts of the human genome into animal tissue or vice versa must not involve extensive animal-human hybridisation, inheritable changes to a human being, or the formation of an organism possessing some human and some animal material which may capable of further development as an embryo."71

3. Promotion of Organ Donation and Transplantation

We have seen in the last section the ethical issues related to organ donation and transplantation. The virtue of charity will be an important element in increasing organ donation. This kind of value education can be promoted both by religious groups and by secular agencies.

This inter-human relationship is very clear in the case of organ donation and transplantation, which expressed in the relation between donor and the recipient. It is not an "I-It" relationship, but an I-Thou relationship. This means the donor is moved by the face of the other (recipient) who is in a critical stage, which is helpless. The deep relationship shows the empathy with the other.72 For instance, the French philosopher Merleau-Ponty writes: "1) There is an essential relationship between body and consciousness such that the body is never - even throughout transplant surgery - just a body, but rather a perceiving entity, that is to say animate. 2) Every body receives its specificity and becomes animate through the perception of another."73

Organ donation also highlights the value of solidarity in society, especially in medicine. Organ donation points to a social dimension where donors and the recipients are part of the society. The social aspect is also one of the elements that assist in making decisions in organ donation and transplantation. The value of solidarity encourages the donors and recipients, and others who participate in transplantation, to make responsible decisions. We also argue that from a moral point of view, commercialisation of organs does not promote organ donation and transplantation. Selling body parts for money reduces the value of the person. There should be no material profit in charitable or altruistic organ donation.74 In the present situation where we are facing a crisis of organ shortage, helping patients who are in a critical stage, really shows the social character of the human person.

Conclusion

There is a real scarcity of human organs even though organ transplantation facilities are widely available. In this context, both living and cadaveric organ donation and transplantation should be promoted. We need clear norms about organ donation and transplantation. 1) In order to prevent commercialization, transplantation laws are to be promulgated effectively. Eliminating poverty is another step towards decreasing the commercialization of human organs. 2) Governments should control agencies and hospitals engaged in transplantation with respect to their profit motives. 3) International co-operation should be promoted in organ donation and transplantation. Developed countries can help developing countries in promoting research in transplantation technology. A global vision associated with a local vision can facilitate the promotion of organ donation and transplantation. 4) One of the efficient means to promote organ donation is to educate people about the scarcity of human organs.

Evangelium Vitae (no. 101) speaks about the proclamation and promotion of life: "The Gospel of life is given to us as a good to be shared with all people: so that all men and women may have fellowship with us and with the Trinity." Organ donation and transplantation highlights the relational and social dimensions of human life. Through organ donation and transplantation also one can proclaim and promote the gospel of life. More clearly, patients in a critical stage of kidney or other organ failure have to either undergo transplantation or face death. In these people one has to see the real face of the ‘other.' We have to promote basic ethical care for the other. We cannot force anyone to donate, but people should be motivated to make free and voluntary donations. In this condition, a spirit of charity, relevant both from religious and secular points of view can work properly with regard to the promotion of organ donation and transplantation.

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