HARVARD GAZETTE ARCHIVES

Canton, Mass.-based MatchingDonors.com was created in 2003 to put organ donors and recipients together. Since then, seven people have successfully matched with donors and had transplant surgery through the Web site. (Staff photo illustration Justin Ide/Harvard News Office)

The practice, which has resulted in several transplants already through a locally run Web site, has sparked a discussion over its ethics, a topic debated Thursday (May 12) at a Harvard Medical School (HMS) Medical Ethics Forum, "Soliciting Organs on the Internet," sponsored by HMS's Division of Medical Ethics.

Jeremiah Lowney, medical director of Canton, Mass.-based MatchingDonors.com, said work on the site was begun in 2003 after the father of one of Lowney's patients died while waiting for an organ to become available. The patient, Lowney said, ran a Web site that matched employers with potential employees and asked whether a similar site could be run to match organ donors and recipients.

Seven people have successfully matched with donors and had transplant surgery through the Web site so far, Lowney said, with another 22 matched and in the presurgery stage.

Lowney acknowledged that some have voiced ethical concerns about the site, and asked whether it undercuts the nationwide organ donation system, the United Network for Organ Sharing (UNOS). But he said the site had become increasingly necessary as waiting lists have lengthened - to 89,000 from just 31,000 in 1993.

Seventeen people die each day while waiting for an organ, some of whom may have been saved through stepped-up efforts to identify and match donors.

"Is it ethically acceptable to let 17 people per day die while waiting for an organ transplant while there are potentially thousands of people out there willing to donate?" Lowney asked.

The harshest criticism of the site came from Douglas Hanto, Lewis Thomas Professor of Surgery at HMS, chief of the division of transplantation at the Beth Israel Deaconess Medical Center, and chair of the Ethics Committee at the American Society of Transplant Surgeons.

Hanto said he sympathized with the difficulty of patients and their families as they wait - and sometimes die while waiting - for an organ.

But he also said that it is critical to ensure the fairness of the donation system so that potential donors aren't discouraged. UNOS, he said, was created to do just that. The problem, he said, is not the current system of distributing organs, but rather that there aren't enough donated organs to go around.

In most cases today - 75 percent of organ donation cases - the organs are given to anonymous recipients who are chosen through the UNOS system. Most of the rest of the cases, he said, are cases of living donors who give up an organ for a family member.

Difficult as it is to determine between potential transplant recipients, Hanto said it has to be done. UNOS, he said, allows physicians to determine whether recipients can benefit from the transplant. It also allows monitoring, and enforces compliance with the system.

Organizations like MatchingDonors.com, Hanto said, open the system to abuse. They allow the possibility of payment-for-organ-donations, which is illegal. They bypass a fair waiting system. They don't provide for medical screening that ensures the donated organs are not "wasted" by going to patients who will die from other causes anyway.

Such private donations can also favor people of means because they have the resources to pay the $295 monthly subscription fees charged by MatchingDonors.com and potentially favor people who are physically attractive or whose personal story is particularly poignant.

Arthur Caplan, chair of the Department of Medical Ethics and director of the Center for Bioethics at the University of Pennsylvania, said the entire system of procuring organs from living donors is suspect.

Living donors can give a single kidney, because people can live with just one, and parts of other organs that either regenerate, such as the liver, or that can function with diminished capacity, such as a lung. Most of those sorts of donations are between family members.

But Caplan said those highly charged family situations can be as coercive as one in which money is offered. It may be difficult to say no, Caplan said, when a sibling needs a transplant, even though the potential donor may not want to participate.

At the other end of the living donor spectrum, Caplan said, are the donations between strangers, where the possibility has to be considered that the donor has mental health issues, since the act is one of such extreme altruism.

"I have had and continue to have a lot of doubts and reservations about living donations," Caplan said. "There is a fundamental weakness on the living donor side of transplantation."

Dan Brock, Frances Glessner Lee Professor of Medical Ethics and director of HMS's division of medical ethics, said that if the practice of soliciting living donors is effective in causing the donation of organs that otherwise would not be donated, then the people on the UNOS waiting list aren't hurt by the practice.

If the organ would have been donated anyway - and there's no evidence yet which situation is the case - then people on the waiting list are hurt because the person receiving the privately donated organ presumably would have jumped their space in the line.

"I think we just don't know to what extent this practice increases supply," Brock said.

Still, Brock said, it appears that a person's own organs are private property that can be used as the individual chooses - by, say, making a donation to a family member or refusing to donate at all. Therefore, he said, it should be within a person's rights to make a private donation.

What's important, Brock said, is that such donations be regulated to guard against possible abuses - such as making payments for organs.

"We don't want organs put on the table like it is an auction," Brock said.

But, he continued, the current UNOS system itself isn't absolutely fair. Organs can be donated locally if donors want someone in their home region to benefit, he said, and savvy people can ensure they get put on each regional list to improve their chances of getting an organ.

"My conclusion is not to endorse donation over the Internet without regulation," Brock said. "But I think some of the arguments against directed donation and solicitation are weaker than they're sometimes [thought] to be."