New Drugs for Rheumatoid Arthritis

© 2002 by Elsevier Science Inc., 2002

Transplantation Proceedings, 2011

Purpose. Taking in consideration the opinion of our team, which necessitates obligation of a relative relation between donors and recipients (genetic or matrimonial), we performed donor exchanges as an ethical alternative in living donor transplantations. We reviewed the outcomes of our exchange series. Methods. Between July 2003 and August 2010 we performed 110 exchange donor transplantations in four hospitals: one four-way, two three-way, and 100 two-way cases. Donors were mostly spouses (n ϭ 71) or mothers (n ϭ 15). The mean age of the donors was 48.8 (range ϭ 23-69) and the recipients 41.4 years (range ϭ 5-66). Two were transplanted preemptively and the others had a mean dialysis duration of 43 months (range ϭ 1-120). Results. Among 110 patients, three compatible pairs joined the group voluntarily; 71, due to ABO incompatibility and 36, due to crossmatch positivity. Induction therapy was used in 92 patients. HLA mismatches (MM) were: one MM in three; two MM in three; three MM in 18, four MM in 36; five MM in 34; and six MM in 18. Among 90 patients tested for panel-reactive antibodies PRA, five showed class I and 10, class II positivity. In 11 patients, B-cell positivity was detected by flow cytometry. Delayed graft function (n ϭ 2), acute rejection (n ϭ 11), BK virus infection (n ϭ 1), and cytomegalovirus infection (n ϭ 3) were seen postoperatively. Three (2.7%) patients died due to sepsis. Five patients returned to dialysis program due to interstitial fibrosis tubular atrophy (IFTA) (n ϭ 2), renal vein thrombosis (n ϭ 1), de novo glomerulopathy (n ϭ 1), or primary nonfunction (n ϭ 1). The 1-and 5-year patient and graft survival rates were 96% and 96%, 95% and 89%, respectively. Conclusion. We believe that exchange donor transplantation is as successful as direct transplants; it is a good, ethical alternative to unrelated living transplantations.

Clinical Journal of the American Society of Nephrology

Transplantation, 2002

Organ transplantation has become a proven, cost-effective lifesaving treatment, but its promise is contingent on the number of available organs. The growing gap between the demand and supply results in unnecessary loss or diminished quality of life as well as high costs for surviving patients and their insurers. Twenty years after the enactment of the National Organ Transplantation Act, it is time to rethink the moral basis and overall design of organ transplantation policy. We propose a system of national organ insurance based on a social contract of reciprocal obligation under which aggregated present consent to donate guarantees future availability of organs for those who need them, at least to the level that prevents death while awaiting an organ. The national insurance plan will cover all peri -and post transplantation costs to all. By presuming consent to enroll, we align the default with widespread expectations of reciprocity and mutual self -interest, and surmount barriers to consent that have undermined the spirit of the current legal regime. Individuals who prefer not to be either recipients or donors would be able to opt out of the insurance system.

Final Report of a 1995 project commissioned by the Kings Fund to examine the law, ethics and practicality of presuming the consent of potential organ donors to the use of their organs in transplantation surgery. The conclusion was that this change was unlikely to increase the supply of organs and created ethical problems. It would be no more than a gesture that would disappoint potential recipients and could lead to conflict between some faith groups and the medical profession.

Dr. Shemie's area of specialty is organ replacement in critical illness. He has a strong record of research leadership in current and emerging issues related to organ donation, with an emphasis on collaborative interdisciplinary research. Recent research interests include the development and implementation of intensive care unit (ICU)-based organ donation strategies on a national level. He also conducts interdisciplinary health policy research related to organ donation, transplantation, and technological support of end-stage organ failure.

Law and Contemporary Problems, 2014

The views and opinions expressed in this article are solely those of the authors and not of the Pennsylvania Legislative Budget & Finance Committee. The authors extend deep appreciation to Alan Viard for his most insightful comments, Mark Perry for graphics, and to Rita Gilles for her research and editorial assistance. ** Co-Executive Director of WaitList Zero, a nonprofit devoted to increasing living kidney donation.

Medical Principles and Practice, 2003

Clinical organ transplantation has been recognized as one of the most gripping medical advances of the century as it provides a way of giving the gift of life to patients with terminal failure of vital organs, which requires the participation of other fellow human beings and of society by donating organs from deceased or living individuals. The increasing incidence of vital organ failure and the inadequate supply of organs, especially from cadavers, has created a wide gap between organ supply and organ demand, which has resulted in very long waiting times to receive an organ as well as an increasing number of deaths while waiting. These events have raised many ethical, moral and societal issues regarding supply, the methods of organ allocation, the use of living donors as volunteers including minors. It has also led to the practice of organ sale by entrepreneurs for financial gains in some parts the world through exploitation of the poor, for the benefit of the wealthy. The current advances in immunology and tissue engineering and the use of animal organs, xenotransplantation, while offering very promising solutions to many of these problems, also raise additional ethical and medical issues which must be considered by the medical profession as well as society. This review deals with the ethical and moral issues generated by the current advances in organ transplantation, the problem of organ supply versus organ demand and the appropriate allocation of available organs. It deals with the risks and benefits of organ donation from living donors, the appropriate and acceptable methods to increase organ donation from the deceased through the adoption of the principle of 'presumed consent', the right methods of providing acceptable appreciation and compensation for the family of the deceased as well as volunteer and altruistic donors, and the duties and responsibilities of the medical profession and society to help fellow humans. The review also deals with the appropriate and ethically acceptable ways of utilizing the recent advances of stem cell transplantation from adult versus fetal donors, tissue engineering and the use of organs from animals or xenotransplantation. Data provided in support of the concept that clinical organ and tissue transplantation can be more beneficial and life saving if everyone involved in the process, including physicians and medical institutions, respect and consider the best interests of the patients, as well as honor the ethical, moral and religious values of society and are not tempted to seek personal fame or financial rewards.

General Hospital Psychiatry, 1996

Rapid advances of the past 15 years have resolved many of the technical and immunologic limitations to organ transplantation. With the success rates that can now be achieved, there is increased attention to the limited supply of donor organs and to cost considerations, the remaining obstacles to wide application of organ transplantation. Competition for organs and for funding demands greater focus on patient selection and resource allocation. As Charles Taylor, philosopher and political scientist, has written, ethical formulations inevitably conflict when each is taken to its logical end point. In the 1960s, a life boat ethics framework predominated for selection of transplant recipients. The opposing egalitarian framework of recent decades has allowed for enrollment of older transplant recipients and those with histories of substance abuse. In the United States, alcoholic liver disease has been the most common indication for orthotopic liver transplantation since 1987. Among those awaiting transplantation, urgency has been a priority over time waiting. But many potential transplant candidates who are young and who appear relatively stable die while waiting. Despite the shortage of cadaveric organs, physicians and ethicists have for the most part eschewed rewards or reimbursement for living related organ donation. Such conventions are a function of the prevailing zeitgeist and are susceptible to a paradigm shift in parallel with overall changes in societal regulation of medical practice. Theorists and practitioners are immersed in the trends of the day and the approach at each moment seems preferable to that of the moment preceding. From a practical standpoint it may be possible to bridge disparate ethical constructs. For example, in the wait for solid organ transplantation, a bicameral approach could alternatively accommodate time waiting and urgency. Selection of older patients and those with a past substance abuse history could be limited to those with the best prognosis for compliance and posttransplantation quality of life. Living organ donors and families of nonliving donors could receive incentives of a noncoercive nature that would stimulate participation without sacrificing altruism. Creative approaches are needed to improve fairness and efficacy in solid organ transplantation.