Iran’s Experience on Living and Brain-Dead Organ Donation: A Critical Review

Fig. 24.1

Hand-written announcements for kidney sale

Exploitation of Poor People Given the choice, nobody wants to sell his or her organs. Therefore, the burden of commercialization of human organs is placed on underprivileged social groups and the poor. It has been reported that many donors are addicts seeking money to buy drugs or sometimes, women forced by their husbands to sell their kidneys. In some cases, in families encountering financial problems, they expect the husband or father to sell his kidney to solve or alleviate the problem.²¹

Although the informed consent is obtained from all donors, nobody can ignore the fact that the main drive behind kidney donation in IMKT is financial. In an attempt to make the donation a consensus within the family, and as a unique feature of the IMKT, informed consent is necessary from both the donor and his or her next of kin (husband or wife in the case of married donors),²² which obviously does not solve the problem of financial coercion.

Stigmatization of Donors Organ donors are considered organ sellers with no honor, therefore, they tend not to disclose their true identity and address to the hospital’s administration, which makes their medical follow-ups very difficult and often impossible.²³ The resulting absence of an effective registration system for donors and the long-term follow-up of donors have been named as significant disadvantages of the IMKT.²⁴

Suppression of Altruistic Donation Since organs for transplant are available in the market for a relatively low price, family members of patients who need organs prefer to buy an organ for their loved ones instead of donating their own organs. Also, the stigmatization surrounding organ donors lowers the rate of altruistic donation in society.²⁵

24.4 Organ Transplantation and Brain Death Act

As an attempt to use organs harvested from brain-dead persons, the Organ Transplantation and Brain Death Act, previously rejected in 1995, was approved by Iran ’s parliament in 2000, permitting organ transplantation using brain-dead donors.²⁶ According to this Act, brain-dead persons’ organs, with the consent of their close relatives, can be transplanted to persons in need provided that doing so is necessary in order to save their lives. Accordingly, only heart transplantation can be considered a legitimate reason for terminating a brain-dead person’s life. Harvesting other organs, like kidneys, pancreas, liver or cornea is permitted only after harvesting the heart, which turns a brain-dead person into a dead person.

Considering that in Iran , legislation is based on Islamic (Shiite) jurisprudence (Fiqh), this Act is based on religious decrees allowing such practice. In Shiite jurisprudence, a brain-dead person is not considered dead but, rather, as being in a stage of life (namely:Hayat-e-Gheyr-e Mustagherreh, which means unstable life) where she or he could only be sacrificed for the sake of saving a stable human life.²⁷

In contrast with living donation , organ donation from brain-dead persons are completely altruistic without any monetary incentive for donors. A virtual network, covering the entire country (encompassing 13 procurement units and 18 brain death identification units), facilitates this sort of organ donation. The declaration of brain death is based on the diagnosis of five physicians (consisting of an internist, a neurologist, a neurosurgeon, an anesthesiologist, and a forensic medicine specialist) and according to neurological tests and after obtaining a confirmatory electroencephalogram.²⁸ The consent for donation should be obtained from the first-degree relative of the donor. Before transplantation, recipients and donors are anonymous to each other. These organs are being allocated based on a first come, first serve policy .

However, because of the availability of better quality organs obtained from live donors, most recipients prefer to receive their organs from a live donor rather than a deceased one. Consequently, in contrast to developed countries, 76 % of kidneys come from living unrelated donors and only 12 % of kidneys are from deceased donors.²⁹ In comparison, consider for example that in the US in 2006, 65 % of transplanted kidneys were from deceased donors and less than 1 % of them were from anonymous living donors. Consequently, the health authorities do not feel any urge to improve the quality of organs obtained from deceased donors or adopt any essential policy aimed at increasing the number of organs obtained in this way.

24.5 Conclusions

In light of the substantial advantages as well as weaknesses of the IMKT, its ethical flaws cannot be ignored. Arguably, despite some notable practical successes and advantages of this model, it should be substituted with another model that is mainly based on altruistic donation. Of course, given long waiting lists and the large number of people who die before getting their transplant in developed countries, one should not fail to appreciate the value of the elimination of these deadly waiting lists. One the other hand, without the act of paying enough money, it is impossible to achieve a sufficient number of unrelated donors to eliminate the waiting list . Thus, while compensatory payment by an NGO could be considered an acceptable incentive for donors, such processes would, quite clearly, not eliminate the waiting list . Accordingly, a model of indirect and regulated payment from recipients to donors can be considered as a possible solution for the future.

Considering the high prevalence of accidents resulting in brain death in Iran , and the positive public attitude towards brain dead organ donation,³⁰the problem of a shortage of organs could be solved by promoting organ donation from brain-dead persons. Consequently, adopting the opt-out approach rather than the opt-in one would be a great step forward.

Acknowledgement

The abstract of this article was first presented at the International Bioethics Workshop for Young Scholars, titled Organ Transplantation in Times of Donor Shortage: Interdisciplinary Challenges and Solutions, held by the Ludwig-Maximilians-University (LMU) Munich, Germany, February 25-March 2, 2012. I would like to express my gratitude to the leaders and organizers of that workshop, especially Prof Dr. Georg Marckmann and PD Dr. Ralf J. Jox for that great and fruitful event. Also, I would like to extend my many thanks to Dr. Galia Assadi for all her assistance and cooperation through the workshop and the process of writing and finalizing this article. Last but not least, I would like to appreciate the helpful and informative comments provided by Dr. Barbro Fröding, the reviewer of this article.

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