‘Recycle yourself: Be an organ donor’

At the recently concluded 16th biennial congress of the Asian Society of Transplantation held in New Delhi, over 1,300 transplant medical workers met to discuss and compare notes on the latest advances in organ transplantation.

The concept of organ transplantation is not new. In the third century, Saints Cosmas and Damian were two Arab physicians and twin brothers, and also early Christian martyrs, who treated their patients for free. According to legend, the saints appeared in a dream and transplanted the leg of a dead Ethiopian to replace the rotting leg of a Church official.

Skin was grafted as early as 1869, and in 1906, the first corneal transplant was performed. The French surgeon Alexis Carrel performed animal transplants in the 1900s like exchanging the heads of animals, a practice obviously not permissible today. In 1954, the first successful kidney transplant was performed at the Harvard teaching hospital, where a living donor gave a kidney to his identical twin. The surgeon, Dr. Joseph Murray, received the Nobel prize in medicine belatedly, 36 years later.

The dramatic 1967 heart transplantation performed by Christiaan Barnard in South Africa generated renewed interest in transplantation. But as is usual in surgical advances, the technical aspects came ahead of the basic understanding of the transplantation process — that incompatible organs will eventually get rejected.

It was not until the discovery of the effective antirejection drug cyclosporine in 1976 that survival outcomes significantly improved for liver, intestinal, pancreas and double-lung transplantation. Even transplanting hands, arms and legs, the face, uterus and penis, also called vascularized composite allografts or VCAs, are now being performed.

The bitter truth about transplantation is that someone has to die in order for somebody else to live. The field of organ donation and brain death is an ethical minefield. My mentor in cardiothoracic surgery, Juro Wada, performed Japan’s first heart transplant in 1968—one of the world’s earliest—at the Sapporo Medical University, where he took the heart of a 21-year-old drowned college student and transplanted it into an 18-year-old male patient with severe heart failure.

Wada was accused of manslaughter over the brain-death diagnosis of the donor, but the case was eventually dropped because of insufficient evidence. This prompted discussion of the ethical and technical issues of organ transplants, delaying organ transplantation in Japan for 29 years until the 1997 enforcement of the Organ Transplant Law.

Many years after this, Wada told me that the transplant was the only way to save the patient, echoing Shakespeare’s line about desperate diseases needing desperate remedies. It is also another painful truth in transplantation that patients die while waiting for a replacement organ, with demand for organs outstripping supply, and this is likely to increase dramatically in the future.

When is a person dead? As someone commented, defining the exact period of death is like determining the exact time when night turns into day or when hot coffee becomes cold. Even getting organs from anencephalic babies has been proposed. Should the family of the cadaver organ donor be compensated for burial and medical expenses? How about prisoners as organ donors? Then there is the issue of gender. In India, 85 percent of living-donor organ transplants are women, the reason being economic—men work and most women don’t.

Transplant surgeons have devised other techniques to get organs from live donors, like getting just part of the liver or lung. Scientists are continuing research on the use of animal organs, or xenotransplantation, to address the organ shortage, but cross-species transplantation results in hyperacute rejection, where the transplanted animal organ literally withers and dies before the surgeon’s eyes.

Another mentor, the heart surgeon Sir John Wallwork, who helped perform the world’s first combined heart and lung transplantation at Stanford University in 1981, started experiments on implanting human genes in pig hearts to trick the human recipient into recognizing the pig heart as human and therefore compatible. Why the pig? It is because pig organs anatomically resemble human organs. The downside is that viruses from pigs may be transferred to the human recipient—think African swine fever.

In the future, building organs from human stem cells, or the 3-D bioprinting of organs, may eliminate the need for organ donation with all its ethical issues and gray areas. Meanwhile, as the donor campaign slogan says, “Don’t take your organs to heaven; heaven knows we need them here.” Or “Recycle yourself: Be an organ donor.”

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Dr. Jose Luis J. Dañguilan, a thoracic surgeon, is the former executive director of the Lung Center of the Philippines.