Ethical considerations in transplantation.

Volunteerism versus commercialism in the procurement of blood for transfusion was the subject of considerable debate a decade ago. Proponents of an altruistic system won the day on the basis of real or imagined risks of hepatitis resulting from the act of payment.

A vocal minority insisted

that the act of payment was irrelevant--the socioeconomic status of the prospective donor pool determined the risk. This argument fell on deaf ears, however. The other side prevailed with threats of litigation in the event that hepatitis ensued from transfusion of purchased blood. But that was not the only reason favoring volunteerism.

Blood and bone marrow are uniwue tissues for transplantation in that they are renewable. When you remove a unit of blood from a donor, or marrow from his bones, it regenerates in a short time. There are no permanent adverse effects of donation that will compromise the health, appearance, or longevity of the donor. This is not the case with other tissues or organs. A kidney once removed leaves the donor permanently compromised.

Then, too, prospective recipients of transfusions can receive blood from a large percentage of donors. The number of alleles in the ABO and Rh blood group systems, and the low antigenicity of all but the D antigen in the Rh system, make it relatively easy to supply blood in virtually unlimited quantities to patients requiring hemotherapy.

The histocompatibility system is more complex. Many more alleles are involved, and the ability to provide a transplant tissue or organ that is appropriately matched with the HLA designation of the recipient is extremely limited. If a similar limit had applied to peripheral blood, the volunteerism versus commercialism debate might have ended differently.

As we enter an era of increasing sophistication in the technology of transplanation--from HLA typing to harvesting, preserving, and implanting donor organs, and most recently, preventing rejections--increasing numbers of transplant procedures are being undertaken. These operations provide a better quality of life for some recipients and prolong life for others. But with the technology come serious ethical dilemmas, akin to those addressed by the blood banking community a decade ago.

Two such cases have recently been addressed in the courts. In the first of these, Robert McFall, a 39-year-old construction worker, developed aplastic anemia. It was determined that only a marrow transplantation offered hope of saving his life. McFall's cousin, David Shimp, was found to be HLA compatible but refused to donate. A Pennsylvania judge upheld Shimp's right not to donate. McFall died two months latter (Viewpoint, MLO, November 1978).