Transplanting Human Tissue: Ethics, Policy, and Practice
http://www.100md.com
《新英格兰医药杂志》
In the past two decades, public and professional debates over the procurement and allocation of solid organs for transplantation have led to specific changes in policy and to organizational reforms. However, transplantation procedures for nonorgan tissues such as bones, ligaments, heart valves, and skin have evolved with much less scrutiny and oversight. To date, aside from discussions in a few newspaper articles, the controversial issues remain largely unrecognized and unexplored. Ethicists, policymakers, and health care providers who are involved in organ transplantation often do not realize how large the tissue industry is or appreciate the unique problems it raises.
In 1999, more than 20,000 people served as tissue donors. Since each tissue source can be used by dozens of recipients, every year hundreds of thousands more tissue transplantations are performed than are organ transplantations. In addition, tissues, unlike organs, often undergo considerable transformation between donation and transplantation. This transformation involves numerous organizations — both nonprofit and for-profit agencies — that buy and sell the tissue until it becomes the final "product" available for transplantation.
Transplanting Human Tissue is a comprehensive examination of the ethical and policy questions raised by transplantation of musculoskeletal tissue and skin. Part I of the book's four sections covers historical, technical, clinical, and regulatory information concerning the industry's growth, development, and oversight. Although tissue donation is addressed in the National Organ Transplant Act of 1984, the organization and the operation of tissue banks do not follow systems used for solid organs. In the 1980s, local tissue banks began to proliferate. Proprietary processing techniques and patented tissue configurations were developed in the 1990s, often by for-profit tissue processors; this led to strategic alliances between nonprofit tissue banks and for-profit companies that manufacture medical devices.
Part III compares tissue transplantation with organ transplantation with respect to the legal aspects of dealing with human body parts as property and to the industry's ability to regulate itself. These chapters assume that the reader is fairly knowledgeable about the transplantation of organs and other tissues. Although this section is useful for readers who are familiar with these fields, it would have benefited from greater exposition.
What makes this book valuable is the authors' willingness to offer a nonjudgmental description of the business side of tissue transplantation, juxtaposed with personal accounts and ethical and policy analysis. Part II contains two poignant essays by the family members of donors regarding their decision to donate and the "gift" of donation. The tension of whether to analyze the donation as a gift or a market commodity reaches its climax in an invaluable chapter in part IV by Courtney Campbell, who characterizes tissue donation as an impersonal gift between the donor and the community at large, in contrast with more traditional gift giving that creates a specific moral relationship between the donor and the recipient. An ethic of stewardship for medicine is necessary to mediate the gift relationship to ensure that the gift is used responsibly and respectfully.
Chapters in part IV address other ethical and policy issues, including the process and substance of informed consent. Although there is consensus that the consent process must be improved, proxy consent by family members will always be inadequate, given the less-than-ideal circumstances in which it is obtained. An improvement in the process might be an educational campaign to ensure that those who sign cards to become organ or tissue donors understand what tissue donation entails. In this regard, the authors offer specific suggestions regarding what should be told to potential donors and their families. For example, some aspects of particular procurement procedures may be disturbing to families (e.g., the procurement of heart valves involves the removal of the donor's heart from the corpse, and some tissue may be used for "cosmetic" purposes). However, some aspects of the procedures may actually be reassuring (e.g., bones are often replaced with synthetic materials to make a body aesthetically acceptable for viewing). The book's appendixes offer model consent documents and a bill of rights for the families of donors.
I highly recommend this wonderful book for professional and personal reflection, since all of us may need to make an informed decision regarding our own willingness to serve as a donor, to consent to a loved one's donation, or to become, or to clinically care for, a tissue recipient.
Lainie Friedman Ross, M.D., Ph.D.
University of Chicago
Chicago, IL 60637
lross@uchicago.edu(Stuart J. Youngner, Marth)
In 1999, more than 20,000 people served as tissue donors. Since each tissue source can be used by dozens of recipients, every year hundreds of thousands more tissue transplantations are performed than are organ transplantations. In addition, tissues, unlike organs, often undergo considerable transformation between donation and transplantation. This transformation involves numerous organizations — both nonprofit and for-profit agencies — that buy and sell the tissue until it becomes the final "product" available for transplantation.
Transplanting Human Tissue is a comprehensive examination of the ethical and policy questions raised by transplantation of musculoskeletal tissue and skin. Part I of the book's four sections covers historical, technical, clinical, and regulatory information concerning the industry's growth, development, and oversight. Although tissue donation is addressed in the National Organ Transplant Act of 1984, the organization and the operation of tissue banks do not follow systems used for solid organs. In the 1980s, local tissue banks began to proliferate. Proprietary processing techniques and patented tissue configurations were developed in the 1990s, often by for-profit tissue processors; this led to strategic alliances between nonprofit tissue banks and for-profit companies that manufacture medical devices.
Part III compares tissue transplantation with organ transplantation with respect to the legal aspects of dealing with human body parts as property and to the industry's ability to regulate itself. These chapters assume that the reader is fairly knowledgeable about the transplantation of organs and other tissues. Although this section is useful for readers who are familiar with these fields, it would have benefited from greater exposition.
What makes this book valuable is the authors' willingness to offer a nonjudgmental description of the business side of tissue transplantation, juxtaposed with personal accounts and ethical and policy analysis. Part II contains two poignant essays by the family members of donors regarding their decision to donate and the "gift" of donation. The tension of whether to analyze the donation as a gift or a market commodity reaches its climax in an invaluable chapter in part IV by Courtney Campbell, who characterizes tissue donation as an impersonal gift between the donor and the community at large, in contrast with more traditional gift giving that creates a specific moral relationship between the donor and the recipient. An ethic of stewardship for medicine is necessary to mediate the gift relationship to ensure that the gift is used responsibly and respectfully.
Chapters in part IV address other ethical and policy issues, including the process and substance of informed consent. Although there is consensus that the consent process must be improved, proxy consent by family members will always be inadequate, given the less-than-ideal circumstances in which it is obtained. An improvement in the process might be an educational campaign to ensure that those who sign cards to become organ or tissue donors understand what tissue donation entails. In this regard, the authors offer specific suggestions regarding what should be told to potential donors and their families. For example, some aspects of particular procurement procedures may be disturbing to families (e.g., the procurement of heart valves involves the removal of the donor's heart from the corpse, and some tissue may be used for "cosmetic" purposes). However, some aspects of the procedures may actually be reassuring (e.g., bones are often replaced with synthetic materials to make a body aesthetically acceptable for viewing). The book's appendixes offer model consent documents and a bill of rights for the families of donors.
I highly recommend this wonderful book for professional and personal reflection, since all of us may need to make an informed decision regarding our own willingness to serve as a donor, to consent to a loved one's donation, or to become, or to clinically care for, a tissue recipient.
Lainie Friedman Ross, M.D., Ph.D.
University of Chicago
Chicago, IL 60637
lross@uchicago.edu(Stuart J. Youngner, Marth)