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Abstract

In the modern world, the transplanting of organs, tissues, and cells is unanimously recognized as an effective therapeutic to combat several grave pathologies. Thanks to transplants, thousands of people are saved throughout the world every year, people who would otherwise have been unable to survive or who would have had their quality of life greatly compromised. Nevertheless, and while promising, there is a, literally, fatal discrepancy between the large number of patients waiting for transplants and the scarcity of organ availability. This discrepancy constitutes the most prominent problem associated with transplants and has as such driven the establishment of various measures that allow for an increasing number of donors while maintaining accordance with the concept of donating being a free and conscious act. This entry will begin by exploring the scope and limitations of medical transplants and will continue to cover the various stages that have lent support both to the arguments in favor of organs being taken postmortem and the arguments for them being taken from the living. In conclusion, the entry will explore aspects of human transplants that are having an increasing impact on a global scale, namely, transplant tourism and the commercialization of organs.

Introduction

Examining the evolution of transplants leads us to recall one of the earliest “transplants” in recorded medical history, where the Saints Cosmas and Damian amputated the deacon Justinian’s leg and replaced it with the leg of a Moor who had just died. This emblematic scene, portrayed by many artists, represents the vision and desire of man to be able to replace ailing parts of the body with similar parts that are in a better condition. However, this desire would only become a tangible reality in the twentieth century when transplants became one of the greatest achievements ever accomplished in the ﬁeld of medicine. This speciﬁc ﬁeld has been subject to careful oversight from a bioethics perspective, which is reﬂected in several of the issues raised herein, such as experimental attempts in organ transplantation, the distribution of resources, the selection of recipients, and the ensuring of donor integrity. Currently, medical transplantation has become well established with a growing impact on a global scale. In light of this, the implications of human transplants are also becoming increasingly susceptible to scrutiny in terms of global bioethics.

The History And Development Of Transplants

There are several noteworthy stages throughout the last century which have further contributed to the scientiﬁc development of transplants and which mark the passage from an experimental to a curative stage.

The identiﬁcation of the blood system AB0 by Karl Landsteiner in 1901 and the development of surgical anastomosis techniques by Mathieu Jaboulay and Alexis Carrel in the same year are determining factors in the undertaking of the ﬁrst transplants. Yet it was only in 1936 that the ﬁrst human trial was registered. The Ukrainian surgeon, Yu Yu Voronoy, conducted six transplants with kidneys from cadavers, intending to treat the acute renal failure of his patients. In subsequent years other trials were made, almost always on animals, though sporadically on humans. The common element of these attempts is the phenomenon of rejection, which resulted in the destruction of the organ and, consequently, the death of the recipient. The importance of understanding the compatibility of tissues between donor and recipient gained new light with the work of the biologist Peter Medawar in the 1950s. Based on his studies, it became understood that rejection was the response of the immune system when it recognized the transplanted organ as being a foreign agent (Watson and Dark 2012, p. 29).

In Boston in 1954, Joseph Murray conducted the ﬁrst kidney transplant between identical twins. The success of this transplant was partially due to the shared genetic identity of donor and recipient. During the years that followed, several transplants were made between monozygotic twins with a high survival rate in the patients. This being the case, the ﬁrst registered case of success in the ﬁeld of transplants occurred with the transplant of kidneys from live donors between identical twins.

A new stage in the performance of medical transplants was reached in 1958 when the Dutchman Jan van Rood identiﬁed the human leukocyte antigen system, this being yet another important piece of knowledge in avoiding the phenomena of rejection. This discovery shed light on the possibility of using cadavers as the main source of organs, which broadened the ﬁeld of harvesting and no longer restricted it to solely the family of the patient.

The coagulation of all these factors provoked intense activity in experimental transplanting during the 1960s, not only of kidneys but other organs as well, such as the lungs, liver, pancreas, and heart. In 1960, René Kuss conducted the ﬁrst successful transplant of kidneys between people who were not family members. In 1963, James Hardy was the ﬁrst surgeon to transplant a lung, and Thomas Starzl became a pioneer in transplanting the liver. Three years later, in 1966, it was the turn of the surgeon Richard Lillehei to initiate the transplant of the pancreas (Gracia 2001, p. 18).

Having taken all of this into account, the biggest event to mark the 1960s was the ﬁrst heart transplant, conducted by the surgeon Christiaan Barnard in Cape Town, South Africa, on the 3rd of December, 1967. The donor was Denise Darvall, a 25-year-old female victim in a car crash. She had been declared brain dead (a concept still in its infancy at the time), but her heart was still beating. The recipient was Louis Washkansky, a 55-yearold with a clinical history of heart attacks. The report of the surgery states that Barnard waited for Darvall’s heart to stop beating and then transplanted it in Washkansky. The operation was successful, and the patient returned home after 11 days. However, because an effective immunosuppressive therapy had yet to be developed, the patient died 18 days after the operation, a victim of pneumonia (Jonsen 2012, p. 265).

In an air of expectation that had been generated by previous heart transplants carried out on animals, Barnard was the ﬁrst to accomplish what no other surgeon had until that point been able to achieve. On the one hand, this event is considered a key moment in the ﬁeld of medical transplants, but on the other hand, it did provoke a fair degree of consternation and outrage. The transplant of the heart, an organ looked upon as the source of life and also, albeit metaphorically, the seat of our emotions and affections, provoked a huge reaction from society in general and the medical community in particular. The history of this case was widely spread through the use of modern media, which in turn gave rise to ethical considerations, speciﬁcally centered around the legitimacy of the criteria of death applied to the donor and the obtaining of informed consent from the recipient. The fact of the matter is that despite the resultant wave of protest that was generated, heart transplants continued the following year. On the 2nd of January, 1968, Barnard proceeded with his second transplant, and the patient survived for 19 months. In the USA on the 6th of January, it was Norman Shumway’s turn to conduct his ﬁrst heart transplant, which also resulted in the death of the patient 2 weeks later. The ﬁrst European heart transplant was made on the 27th of April, 1968, in Paris with a team headed by Christian Chabrol. During 1968, more than a hundred heart transplants were conducted throughout the world, despite the results showing a very high mortality rate (Gafo 2011, p. 337).

The limits of this procedure, as exempliﬁed by the short and limited life span of the patients, affected not only heart transplants but also the transplanting of other vital organs. The phenomenon of rejection was isolated as the largest barrier to successful transplants, through which only effective immunosuppressive therapy could offer a solution. Above all, it is the discovery of cyclosporine at the end of the 1970s that allowed for improvement in this condition. Cyclosporine is an immunosuppressive substance, which based on clinical trials held in 1978 has since been used in the prevention of organ rejection. The introduction of cyclosporine in the treatment of transplant patients has contributed to the control of rejection through the suppression of the immune defense system.

In the 1980s, the number of transplants multiplied, and the success rate increased signiﬁcantly. From then on, a new era in the history of transplants was inaugurated, a history which then moved out of an empirical and experimental phase and into a clinical and therapeutic phase.

Potential Therapeutics And Waiting Lists

In the current ﬁeld of medical transplanting, four types of procedures can be identiﬁed, the classiﬁcation of which depends on the origin of the organs and tissue in question. The autograft refers to the transplanting of tissues or cells belonging to the patients themselves. Included in this type of intervention are strips of skin used for cutaneous reconstruction and the promising ﬁeld of stem cells provided by the umbilical cord, which are harvested and then implanted in the patient. The isograft designates transplants made between identical twins and, as demonstrated, constituted the ﬁrst successful kidney transplant during the ﬁeld’s experimental phase. An allograft is the transplant of organs, tissues, or cells between two people who are not genetically related. Today it is possible to conduct transplants of the kidney, liver, heart, pancreas, small intestine, cornea, bones, bone marrow, and other tissues. One of the most advanced areas for this type of procedure is the transplanting of limbs, such as an arm (ﬁrst accomplished in 1998) or face transplant (accomplished after 2005), in situations where the recipient, be it through accident or illness, has had these anatomical structures affected. Finally, the xenograft consists of the transplants between members of different species, such as the possibility of transplants between humans and pigs. The use of heart valves provided by pigs and cows for transplanting on humans is part of real clinical practice though there are several Bibliography : to the xenograft of vital organs scattered throughout literary history. Some examples of xenografts include the case of “Baby Fae” (1984) who survived 20 days with the heart of a baboon and of a patient with cirrhosis (1993) who received a liver, also from a baboon, and survived for 70 days. Nonetheless, these are individual cases that have arisen where human organs were not available. In these situations, the xenograft functions as an alternative to the allograft, with the primary objective of gaining time in the hope that a compatible human organ will come up.

The success of medical transplantation is now dependent upon a complex structure. In the ﬁrst instance, as a result of the advanced technical and scientiﬁc skills involved, are the waiting lists, the capacity to harvest and preserve organs in a timely manner, the surgical procedures, and the posttransplant support. Secondly, success requires a compatible political and legal framework in speciﬁc regards to the patients having fair access to medical resources, as well as conditions in place to allow for the donation of organs or tissues by the general populace. Nonetheless, the global scenario points to a large discrepancy between the small amount of available organs and the elevated number of patients on the waiting lists.

The waiting lists represent the biggest problem involved in the ﬁeld of organ transplantation and trigger further issues of justice and legalities based on the suitability of organs. Taking into account that only a small percentage of patients will receive transplants, what criteria should be used to establish priority? The medical criteria of HLA compatibility combined with the degree of urgency? Or should other criteria such as possessing health insurance that covers the cost of surgery and immunosuppressive therapy be similarly considered? A further consideration is until what point it can be considered legitimate to beneﬁt patients whose own negligent behavior gave rise to the need for a transplant, such as in the case of patients who due to excessive smoking or drinking now require a new liver or heart. Do further factors, such as the age of the patient and their social or cultural status, assume some importance in the managing of priority in waiting lists? These are some of the issues that are raised in relation to the allocation of resources and are issues which each country must consider.

Postmortem Donation

The deceased donor currently represents the main source of organs for transplantation. When deceased, the person may donate speciﬁc parts of their body to contribute to the well-being of those who need a transplant.

The utilization of the body after death requires that two clinically necessary and ethically relevant aspects are adhered to. The ﬁrst one consists in the conﬁrmation of death, which can be done through the criteria of brain death or by the heart stopping. The second is consent, which may be given in accordance to either the informed consent model known as the opting in system or the presumed consent model referred to as the opting out system.

In the ﬁrst place, it is important to remember that death was traditionally declared when the person no longer gave any signs of breathing or of continuing to have a heartbeat. It is based on these criteria that the ﬁrst transplants with cadavers were conducted in the 1950s and 1960s. With the development of mechanical ventilation in the 1950s, it became possible to artiﬁcially maintain a cardiorespiratory state without the person showing any brain activity. In 1959 this state was designated as “death of the nervous system” by Wertheimer, Jouvet, and Descotes. It was also designated as “coma dépassé” (beyond coma) by Mollaret and Goulon in the same year.

The practice in which the vegetative state of a body which has deep, irreversible brain damage is maintained through artiﬁcial means led to the elaboration of criteria for death within a neurological framework. A commission was created at the Harvard School of Medicine to establish the exact medical criteria that determined brain death. This commission was chaired by the anesthesiologist Henry Beecher and was composed of members from diverse ﬁelds of study including the humanities. Their report, published in 1968, deﬁned brain death as “a state of irreversible coma” and recommended that the cessation of brain functions were to be considered the criteria of death aside from the already established cardiorespiratory arrest. In 1971, new neurological criteria then appeared for the diagnosis of brain death, this time focused solely on the irreversibility of the functions of the brain stem. These are the “Criteria of Minnesota,” resulting from the work of the neurosurgeons A. Mohandes and Shelley N. Chou. In 1976, the Department of Health and the Royal Medical College in the UK published two articles about brain death that supported the ﬁndings of the Minnesota group. These documents reafﬁrmed that the irreversible cessation of the brain stem constituted, per se, brain death, which was inevitably followed by cardiac arrest.

The concept of brain death required that rigorous neurological testing be carried out in accordance with the protocols of veriﬁcation. In modern times this established criterion is crucial in the world of transplantation, just as it is in crucial in other scenarios involved with the termination of life support. In the case of organ transplantation, brain death legitimizes the taking of organs in situations where the cadaver may be a potential donor as long as previous consent had been given for the donation and that the biological criteria, such as age, absence of disease, and infections, are all met. If all of these conditions have been fulﬁlled, the donor is then connected to life support to guarantee the viability of the organs while preparations are made to acquire a recipient and schedule the transplant surgery. Although it did not arise from the ﬁeld of medical transplantation, the criteria of brain death are now a determining factor in the success of medical transplants, contributing indirectly to the quality of extracted organs.

Currently, brain death is recognized as a legal medical state in various regions of the world, namely, most countries of Europe and North and Latin America. Nonetheless, when analyzed on a global scale, various cultural, religious, and even scientiﬁc issues arise, and no demonstrable consensus in its acceptance can be found. Such is the case in Japan where harvesting organs is seen as a violation the cadaver’s integrity according to their holistic view of union of body and soul, a relationship which should not be disturbed even after death (Rodrigues et al 2013, p. 274). So despite the Japanese law regarding medical transplants (1997) permitting the taking of organs from donors in a state of brain death, there is a very low rate of postmortem donations due to the cultural inﬂuence.

However, not only the concept of brain death is called into question when observed from a global perspective. Equally important ethical issues have been raised in countries where the harvesting of cadavers certiﬁed as brain dead is permitted by law and where guidelines for this medical practice exist. But it is primarily from the point of view of certain communities and certain social perspectives that a lack of awareness about brain death may cause the biggest impact. Society, familiarized with the common view of perceptible death, tends to reject the neurological concept of death which depends on specialized technical determination. Often potential donor’s families are confronted by this criterion of brain death when questioned or informed about the potential for organ donation. In these circumstances, what stands out from an ethical standpoint is the reaction of emotionally fragile family members when faced with someone who is deceased from a medical point of view but who maintains the appearance of someone who is alive.

In spite of this, the devastating growth of waiting lists for transplants has triggered alternative mechanisms for obtaining a larger number of organs. It is in this context that a renovated interest in harvesting from donors after cardiac arrest can be witnessed. These donors are also known as non-heart-beating donors. This procedure brings us back to the experimental phase of transplants. In practice, it is veriﬁable that some organs, such as the kidney and liver, and some tissues, when taken from non-heart-beating donors, preserve the same characteristics of organs provided by donors who are brain dead. This is not the case with the heart and lungs, whose lack of oxygen leads to their rapid deterioration thus rendering the transplant unfeasible.

However, with an established scientiﬁc protocol creating robust deﬁnitions for cardiac arrest, it is becoming increasingly common for medical teams to go to great lengths to conduct harvesting procedures on non-heart-beating donors, and there are already some countries, namely, Spain, the USA, the UK, and the Netherlands, that have integrated these procedures into their transplantation system (Council of Europe 2014, pp. 36–38).

The second ethical consideration when performing harvest procedures on deceased donors is that of consent, and it is important to highlight the relevance that consent, when realized postmortem, holds in the context of medical transplantation. Consent is a central requirement in all areas of medicine. In the case of postmortem donation, the obtaining of consent is the legal and ethical safeguard in place to ensure the respect for the wishes of the deceased and guarantee that the utilization of their body would not have been done against their will. It is the place of the state to adopt the best criteria for its needs, and it may achieve this either through the opting in or opting out system.

The opting in system was the ﬁrst system to be implemented in the regulation of transplants, and, similar to other medical situations requiring consent, it is based on the premise that informed consent must be explicitly stated for postmortem donation to occur. This model is currently in place in some European countries, namely, Germany, Greece, and the UK (with the exception of Wales that in June 2013 adopted the opting out system). It is also the adopted system in the USA and Turkey. From an ethical point of view, the opting in system guarantees that the potential donor is both informed when expressing a desire to donate, that they do so from their own free will, are free from persuasion and are acting in their own best interests. Consent in this model is assumed to be a conscious act of free will which favors the wellbeing of those who may need a transplant. Because of this, and in accordance with a perspective focused on autonomy and individual rights, the opting in system is considered as preferential when compared to the opting out system. However at the same time, it is known that in countries where this system of consent is used, there is a reduced amount of postmortem donors. To combat this decline, in some countries, such as the USA, when the person has not manifested in life the will to donate their organs, the ability to grant consent can be extended to their family who are seen as being able to exert the rights of property over the cadaver.

Alternatively, the opting out system considers all citizens as potential donors. This model is also known as a model of presumed consent since the omission of any contrary statement presumes that the person is willing to donate their organs. Nonetheless, citizens have the possibility in life to declare themselves as non-donors through principles of self-determination. At the essence of this system is the recognition that donation is an altruistic gesture of solidarity that may be expressed by any citizen, an indispensable gesture that will consequently help mitigate the extensive waiting lists and without which, such a volume of transplants as is necessary cannot be made. Consequently, this system is found in place in most European countries. The adoption of this system, when factoring in other conditions, results in a much higher level of postmortem donors. This is emphasized in Spain, a world leader in transplants with the highest levels of postmortem donors. However, other countries with this system, such as Croatia, Belgium, and Portugal, have signiﬁcantly increased their own capacity to collect organs from deceased donors.

Yet the opting out method is considered a controversial system of donation, leading to a risk in extracting organs from those who were not properly informed either legally or medically of the conditions of transplantation and may compromise the right of citizens to be informed participants in the process. This being the case, the central ethical issue becomes the possibility of violating a person’s right to self-determination since the omission of opting out may not necessarily equate to a conscious decision but rather be simply ignorance of the procedure to do so. While this model adequately contributes to the strategy of increasing organ availability, it exists as a potential backdoor that may lead to eventual abuses in the continued search for sources of organs for transplants. While it is true that in some countries such as Spain (once again a pioneer in the organization of organ donation awareness campaigns) there is a code of conduct to clarify the procedure, it is also true that in other countries there may not be enough information to allow the average citizen to be an informed donor.

Living Donation

One of the great dilemmas with which Murray was confronted when he initiated transplants between twins in the 1950s was the legitimacy of violating a healthy person’s physical integrity in order to extract an organ for another. In reality, the harvesting of organs from someone who is alive contradicts the ultimate goal of medicine, which is generally accepted as upholding the health of each individual. For this reason, deceased donors are considered preferential for organ donation, given also that the possibility for damage caused by organ failure is minimal in this situation, particularly in comparison to the expected beneﬁts bestowed upon the recipient. However, out of a necessity to increase the resources available for transplants, the concept of living donations has been (re)planted in the overall picture of transplantation politics. In terms of living donations, it is currently permitted to harvest speciﬁc parts that do not place the donor’s life at risk or potentially risk compromising the donor’s health or quality of life. Therefore, the donation of double organs such as the kidney, regenerative organs like the liver, and tissues such as bone marrow has all become permissible.

From a technical point of view, taking donations from a living donor is considered advantageous when compared to that of a postmortem donor given that the compatibility with the recipient may be enhanced, and the scheduling of surgery and consequent maintaining of organ or tissue functions are all better. In general, in Europe and North America, donations of organs by the living appear as a secondary resource at a lower percentage of donors than that of postmortem donors. In other regions of the world, living donors present themselves as the main resource. Such is the case in countries like Jordan, Syria, and Egypt where there are no postmortem donors and where consequently kidney and liver transplants are made exclusively through living donors.

Integrity is the primary ethical perspective, through which mechanisms for ensuring the donor’s dignity and for combating against their exploitation are triggered. In this way donation involves a delicate procedure which should take into consideration the proximity between the donor and the recipient, the obtaining of informed consent from the donor, in conjunction with the gratuitous altruism of the act.

Donation in life may be justiﬁed where there exists an affectionate proximity between the donor and the recipient, such as through them being either related (sharing the same blood) or non-related (having marital ties or those of friendship). More exhaustively the Additional Protocol Relative to the Transplantation of Organs and Tissues of Human Origins (Council of Europe 2002) deﬁnes the potential donor as someone who has established a “close social relationship” with the recipient (Art. 10. ). The donation, whose speciﬁc relationship depends on the legislation of each country, requires under any circumstances the obtaining of free and informed consent. Informed consent stands out as an ethically unavoidable requirement so that the donation can be made freely and without psychological, emotional, or social pressure. This pressure may be more evident in family contexts, given that donations are mainly made from parents to children, between brothers and sisters, and between spouses. It is in the context of emotional relations that some ethical questions come up, such as the pressure for one of the parents to donate an organ to one of their children when, for whatever reasons, they would prefer not to; the pressure from parents for one of their children to donate to the other; giving birth to a child with the intent of them being a donor for their sick brother or sister; and lastly, the donating of organs and tissues from a person with a mental or psychiatric disorder, authorized by their sibling for their own personal beneﬁt. This being the case, informed consent should express the autonomy of the person who has freely decided to donate part of their body in order to save the life of someone whom they love. Only under these circumstances can the act be considered truly altruistic and one performed out of solidarity, guaranteed through valid consent and with a morally solid motivation (Barcelos and Patrão Neves 2009, p. 35).

Nonetheless, donations from the living have been extended to other volunteers beyond those of just the recipient’s family. This initiative which arose, understandably, to make it possible for a larger number of transplants to happen allowed people who are not related, such as friends, or even, in extremis, strangers, to donate an organ for the beneﬁt of a sick person. In these situations where there is no blood or marital bond, other forms of pressure or coercion may be hidden, namely, some kind of ﬁnancial compensation, that could compromise the altruism of the act of donating an organ. The possibility of willing volunteer organ donations by the living brings up an ethical question with even greater relevance, namely, the commercialization of organs. A person may make use of the status of being a volunteer donor to become eligible to donate a kidney or part of their liver and then later be ﬁnancially compensated for the act. It is important to emphasize that international ethical and legal frameworks are based on a consensual model to promote organ donation as an act of gratuitous solidarity. In a similar vein, the act of donating can become abusive and make people into products to which a price may then be established. Therefore, allowing donations between people who are not related may open the backdoor for various forms of abuse to arrive, possibly even leading to the organized commercialization of the human body in the global panorama of medical transplantation.

Transplant Tourism And The Commerce Of Organs

The unbridled search for new strategies to counter the shortage of resources for transplants has led to a growing trend in the illegal commerce of human organs. The most frequent form is “transplant tourism,” an expression used to characterize the temporary relocation of sick, wealthy people to poor countries with the objective of buying an organ, and in this way getting around the existing waiting lists in their home countries. In this respect, it is estimated that 5–10 % of the total transplants conducted annually throughout the world are a result of organ commerce (Bagheri and Delmonico 2013, p. 887).

Transplant tourism and the commerce of organs occur speciﬁcally in countries where the legal framework does not expressly prohibit the buying or selling of organs. Destinations for this kind of transplant tourism are generally Asian countries such as India, Pakistan, and the Philippines. China presents itself is a peculiar case given that its current practice is to extract the vital organs of executed prisoners, a reality known for some time and strongly contested by various international institutions. Several other regions have been identiﬁed as centers of organ commerce, namely, countries from Latin America as well as South Africa. Recipients of organs in these situations are generally citizens from Australia, Canada, Israel, Japan, Oman, Saudi Arabia, and the USA (Shimazono 2007, pp. 956–957).

The commercialization of organs requires a complex structure, involving advanced technology and specialized professionals, in particular doctors who possess the necessary technical competence for surgical procedures. Organs are, in the vast majority of cases, provided by the local population, often from vulnerable people who live in extreme poverty and have very high rates of illiteracy. Nepal, for example, is considered one of the poorest countries in the world and has recently been identiﬁed as a source of kidneys for transplants later completed in India. Generally, the donors are persuaded to sell a kidney or part of their liver in exchange for minor quantities of money. Often there are no medical follow-ups after the extraction, thus compromising their health as well as their lives (Biller-Andorno and Alpinar 2014, pp. 776–777). The process of transplants is arranged by intermediaries who can make signiﬁcant proﬁt from the discrepancy between the amount they are paid by recipients and the amount which is paid to the donor. The recipient is a vulnerable element in this process too as they are subject to a transplant in questionable sanitary conditions which are not always adequate. The origin of the organ is also unknown, leading to the possibility of the proliferation of diseases or infection. Furthermore, the existence of a commercial market for organs debilitates the system for transplantation in the countries where this practice takes place, given that this reduces the possibility of residents getting an organ since efforts are channeled into supplying the needs of foreign patients.

Transplant tourism and organ commerce stand out as one of the main issues in global bioethics not only because it is a reality composed of illegal networks that operate throughout the world but also because its control and resolution require a unanimous decision with a global impact. As such, the topic of liberalizing the market for organs has been amply debated, and there are various arguments in its favor. The principle argument is based on the autonomy of the person who, ultimately, is free to use their body as they please and is therefore entitled to take the decision of whether or not to sell their organs themselves. From this perspective, the liberalization of organ commerce has the potential to mitigate the exploitation of donor vulnerability as well as that of the recipients. Iran is a country that has a legalized market, affording residents access to available organs and also ensuring the donors are entitled to follow-ups for the year following extraction.

Nonetheless, the dominant perspective with the greatest consensus is the one that considers organ commerce an ethically unacceptable activity due to it reducing the individual to a mere instrument, devaluing their dignity and integrity. Various international ethical and legal treaties are in agreement on this matter. Some that can be emphasized are the European Convention on Human Rights and Biomedicine (1997) and the Additional Protocol Relative to the Transplantation of Organs and Tissues of Human Origin (2002) which prohibits the obtaining of proﬁt in organ donation in regard to the trafﬁcking of organs and human tissue (Art. 21. and Art. 22. ). The UNESCO Declaration of Bioethics and Human Rights (2005) also gives guidance in this matter when it refers to the “respect for human vulnerability and personal integrity” (Art 8. ) and it being “non-discriminating and non-stigmatizing” (Art. 10. ). In a more restricted context and speciﬁcally directed at the commerce of organs, the Declaration of Istanbul (2008) is worth emphasizing, a document worked upon by specialists from all over the world and within which several strategies for combating organ trafﬁcking and transplant tourism are noted. Most recently, the World Health Organization’s Guiding Principles on Human Cell, Tissue and Organ Transplantation (2010) has as an objective of optimizing donations and the practices of transplantation, with the consequence of reducing illegal activities associated to organ commerce.

In conclusion, the dominate perspective is that the commercialization of organs contradicts some of the fundamental principles governing all medical transplants, that the donation be done through free will, as an altruistic act and with consideration of another’s well-being being the end result of this decision.

Conclusion

It is clearly demonstrable that the number of existing organs available for organ donation is insufﬁcient to fulﬁll the waiting lists. Consequently, the ﬁeld of medical transplantation is investing in the creation of measures that can raise the number of potential donors. Organs provided by humans are the only viable resource that assures a likelihood of transplant success. In this case several ethical questions emerge in regard to the donors – postmortem or living – revolving around the autonomy of the person, their sense of altruism and solidarity in becoming a donor. Bearing this in mind, the ﬁeld of medical transplants predicts that in the future, alternative solutions to human organs will be explored, such as the discovery or creation of new organ sources, for example, the xenograft, bioengineering organs, or medically regenerating organs. These options, that are currently only possibilities, are still far away in time from being able to tangibly contribute to the reduction of waiting lists. A long journey from the ﬁeld of investigation to the reality of therapeutics is implicit in the discovery of any new solution. However, on making this journey, new and important ethical issues will arise, namely the selection of candidates for clinical trials and the legitimacy of depriving them of an effective therapy in order to receive a treatment that is still experimental and, for that reason, potentially life threatening.

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