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ISLAMIC MEDICAL EDUCATION RESOURCES 04

9607-ORGAN TRANSPLANTATION: ANALYSIS OF THE LEGAL AND ETHICAL ISSUES

Dr Omar Hasan Kasule, Sr.;   M B Ch B, M P H, Dr P H (Harvard) Professor of Medicine, Universiti Islam Antarabangsa PO Box 70 Jalan Sultan Petaling Jaya 46700  MALAYSIA Fax 60 3 757 7970 (Incomplete draft of paper written for the International Seminar on Organ Transplantation and Health care Management from an Islamic Perspective 29-30 July 1996 Jakarta Indonesia)

ABSTRACT

 

1. The paper identifies and critically analyzes medical, legal, and ethical issues in the motivation, execution, and after-effects of transplantation of organs and tissues (human and non-human, living and dead) into living humans using the Purposes of the Law (maqasid al sharia)  and Principles of Figh  (al qawaid al fiqhiyyat al kulliyat). II. Under the PURPOSE OF MAINTAINING LIFE (hifdh al nafs) There should be no injury to the health and human dignity of both the donor and the recipient. III. The associated side-effects, complications, and abuses for both the recipient and the donor are treated under 2 Principles of Law: hardship (mashaqqa) and injury (dharar). Under the PRINCIPLE OF HARDSHIP: necessity and hardship legalize what would otherwise be objectionable or risky (al dharuurat tubiihu al mahdhuuraat) , lowering donor risk has precedence over benefit to the recipient (dariu al mafasid muqaddamu ala jalbi al masaalih), the complications and side-effects to the recipient must be a lesser harm than  the original disease (ikhtiyaar ahwan al sharrain). Under the PRINCIPLE OF INJURY: transplantation relieves an injury  to the body (al dharar yuzaal) in as far as is possible (bi qadr al imkaan) but its complications and side-effects should be of lesser degree than the original injury (al dharar la yuzaal bi mithlihi). Abuse of transplantation by abducting or assassinating people for their organs could lead to complete prohibition under the principles of dominance of public over individual interest (al maslahat al aamat muqaddamat ala al maslahat al khhasat),  prevention of harm has priority over getting a benefit (dar’u al mafaasid awla min jalbi al masaalih), and pre-empting evil (dariu al mafasid). IV. The principles of custom and certainty are invoked in the definition of death and thus the earliest time for organ harvesting. Under the PRINCIPLE OF CUSTOM (al aadat),  brain-death does not fulfill the criteria of being a widespread, uniform, and predominant customary definition of death which is considered a valid custom (al aadat muhakkamat). The successes of biotechnology in transplantation and other fields introduces a strong doubt (shakk) in the irreversibility of brain-death. Under the PRINCIPLE OF CERTAINTY (yaqeen), existing customary definition of death should continue in force until there is compelling evidence otherwise (al asl baqau ma kaana ala ma kaana).  V. Selling organs could open the door to criminal commercial exploitation and may be forbidden under the purpose of maintaining life, the principle of preventing injury, the principle of closing the door to evil (sadd al dharia), and the principle of motive.  Protecting innocent people from criminal exploitation is a public interest that has priority over the health interests of the organ recipient. The PRINCIPLE OF MOTIVE (qasd) will have to be invoked to forbid transplantation altogether if it is abused and is commercialized for individual benefit because the purpose will no longer be noble but selfish. Matters are to be judged by the underlying motive and not the outward appearances (al umru bi maqasidiha) VI. The concepts of LEGAL COMPETENCE  (ahliyyat) and FREE CONSENT(‘adam al ikraah) are invoked for organ donors. In order to avoid any doubts, decisions about donation of organs should be made only by those giving the organs not because they own the organs but because, of all the players involved, they are the most intimately concerned and have no conflict of interest. They must however fulfill the conditions of legal competence which are: adulthood, soundness of mind, and no coercion. This practically excludes harvesting organs of minor children, the insane, or the unconscious VII. The paper concludes with the observation that most outstanding ethical and legal problems of transplantation are temporary, they will disappear in the near foreseeable future when medical science advances to use xenografts or artificial organs. The issues of definition of death and the possible abuse of the transplantation process by organized crime are two outstanding issues that could lead to prohibition of  transplantation.

 

1.0 INTRODUCTION

 

1.1 SCOPE OF THE PAPER

In preparation of this paper, an extensive review of published medical literature on transplantation was made: historical evolution (    ), present status (     ), future visions (  ), indications or reasons for transplantation (  ), associated immunosuppressive (    ), neoplastic (     ), infectious(     ), toxic (      ),  graft rejection (     ), and other complications. Literature on outstanding concerns was summarized(  ). Although available writings by Muslims on transplantation are reviewed (   ), the paper relies on the general theories of the Purposes of the Law (maqasid al sharia) (   ) and the Principles of Fiqh (al qawaid al fiqhiyyat) (  )  in its analyses.. Literature on outstanding ethical and legal issues in procurement and allocation of organs (  ), the donor (    ), and the recipient (  ) was studies (  ). The sociological literature on death was reviewed to establish the customary definition or understanding of death (    ). The paper made tentative analyses and discussed tentative conclusions; its main purpose was to clarify the issues involved as a basis for further discussion.

 

1.2 HISTORICAL BACKGROUND (HIST)

From humble beginnings about 3 decades ago, transplantation has grown into a major discipline of medicine. From a few very advanced centers, transplantation is now offered in many centers and many countries.

 

Immunesuppression methods, tissue-matching, organ preservation, surgical technics, and post-operative care have all improved over the past 30 years. Newer surgical techniques have been elaborated and most of the surgical difficulties have been overcome (   ). Supportive medical biotechnology has kept pace with all these developments (  )

 

The earliest transplants were those of the cornea. The range or organs transplanted has grown to include: the kidney, the heart, the liver, the lung and the pancreas. Heart valves are routinely transplantanted now.

 

Azathioprine (imuran) was the first immune suppressant used. Anti-thymocyte or anti-lymphocyte glubulin was introduced in 1966. Other drugs that have been used are: corrcusteroids, cytotoxics, and Anti-metabolites.The introduction of cyclosporin in 1978 increased 1-year survival to 70-75% and is considered a landmark in transplantation. Newer and more effective immunosuppressants have been discovered and used. (  )

 

1.3 PRESENT STATUS (STAT)

Table 1A shows the organs that are most commonly transplanted. (  ) Table 1B shows 1-year survival rates (   )

TABLE 1A: SHOWING COMONLY TRANSPLANTED ORGANS

HEART

KIDNEY

LIVER

LUNG

PANCREAS

 

TABLE 1B: 1-YEAR SURVIVAL RATES FOR VARIOUS TYPES OF TRANSPLANTATION.

HEART                                 80-90.

kIDNEY                                  90

LIVER                                     70-90

PANCREAS                                         55.

BORN MARROW                                40-75

Transplantation is now quite a safe procedure; new surgical technical have been explored and most of the technical difficulties have been overcome (   ). Survival rates are high and are improving (  ).

Transplantation is now a team effort with a multidisciplinary approach (   ). Technology and knowledge in this field are growing rapidly.

 

1.4 INDICATIONS AND CONTRA-INDICATIOND FOR TRANSPLANTATION (IND)

End-organ failure is the main indication for transplantation. Table 1C shows the commonest clinical indications for transplantation. Other less common indications include metabolic diseases (  ).

 

 Developments in medical science are likely to increase the range of indications and decrease the range of contra-indications.

 

Table 1C SHOWING COMMONEST INDICATIONS FOR TRANSPLANTATION

 

                ORGAN                                                                 INDICATIONS

 

1.BORN MARROW                                                             LEUKEMIA

                                                                                                A PLASTIC  ANEMIA

                                                                                                CONGENITAL IMMUNE DEFECTS

2. HEART

 

 

3. LUNGS

 

 

4. LIVER

 

 

5. KIDNEY

 

 

6. PANCREAS                                                      PANCREATIC INSUFFICIENCY

                                                                                                DIABETIS MELLITUS.

 

 

1.5 SIDE-EFFECTS AND COMPLICATIONS OF TRANSPLANTATION

Table #1D shows side-effects and complications of transplantation: immune suppression, infection, neoplastic growth, graft rejection, drug toxicity, and others.

 

Immune suppression is a necessary component of a transplantation procedure yet it is a double-edged sword. Whereas it is needed to induce tolerance to the allograft, it does at the same time weaken the body’s immune defense capability and thus exposes it to infection  and  neoplastic conditions.

 

Infection can be due to infective organisms transferred with the transplanted organs. It is also due to normally apathogenic organisms that become virulent in the situation of depressed immunity or immune incompetence caused by the immune suppressive therapy and the stress of surgery. The extensive invasive and often lengthy procedures increase the opportunities of exposure to infection. Pre-existing infection may be excercabated by the immune suppression of transplantation.

 

Organ rejection is prevented by keeping organ recipients on immunesuppressive drugs perhaps for life and suffer from toxic and other side-effects. Methods have not yet been discovered of inducing permanent clinical tolerance. Shortages of human organs will result into using xenografts that will elicit even more rejection.

 

 

TABLE 1D: SHOWING COMPLICATIONS OF TRANSPLANTATION

 

Complication                                       Type                                                                       References

IMMUNE SUPPRESSION  HUMORAL

                                                                CELLULAR

                                                                BOTH HUMORAL AND CELLULAR

 

INFECTION                                          BACTERIAL

                                                                      mycobacteria 

                                                                VIRAL

                                                                     HIV

                                                                     EBV

                                                                     HBV

                                                                     CMV

                                                                     HCV

                                                                     Influenza

                                                                     Parvovirus

                                                                FUNGAL

                                                                     aspergilluss                                                     

                                                                     candida            

                                                                PARASITES

                                                                     P. carinii

 

NEOPLASMS                                       CARCINOMA

                                                                    squamous cell carcinoma of the skin

                                                                    cancer of the uterus

                                                                    cancer of the vulva         

                                                                               

                                                                LYMPHOMA

                                                                    Non-Hodgkin’s lymphoma

 

                                                                LYMPHOPROLIFERATION

                                                                    EBV-related

                                                                               

GRAFT REJECTION                            ACUTE REJECTION

                                                                LATE REJECTION

 

DRUG TOXICITY                                NEPHROTOXICITY           

 

OTHERS                                                HYPERTENSION

                                                                ABDOMINAL INFLAMMATON

                                                                TRANSPLANT ARTERIOSCLEROSIS

 

 

Table 1E shows that there are many advances in resolving these outstanding problems.

 

TABLE 1E: APPROACHES TO DEALING WITH TRANSPLANTATION COMPLICATIONS

 

Complication                                       Aproaches to resolution                                    Reference

 

IMMUNE SUPPRESSION  NEW IMMUNESUPPRESSANTS

                                                                MONOCLONAL ANTIBODIES

                                                                LOCAL IMMUNE SUPPRESSION

 

INFECTIONS                                        VACCINATION

                                                                EARLY DETECTION

                                                                PROPHYLACTIC/PRE-EMPTIVE TREATMENT          

                                                                SCREENING DONATED ORGANS

                                                                NEW ANTI-INFECTIVE THERAPIES

 

NEOPLASMS                                       MONOCLONAL ANTIBODY

                                                                CANCER SCREENING

                                                                LESS AGGRESSIVE IMMUNESUPPRESSION

                                                                ADOPTIVE TRANSFER OF  CYTOTOXIC T CELLS

 

GRAFT REJECTION                            HLA TISSUE MATCHING

                                                                MONOCLONAL ANTIBODIES

                                                                SELECTIVE IMMUNESUPPRESSION

                                                                SERUM MONITORING TO DETECT REJECTION EARLY

                                                                NEW PROTOCOLS THAT CAUSE                                                                                                  HYPORESPONSE

 

                                                                MODULATE THE T CELL-ALLOANTIGEN

                                                                 INTERACTION

                                                                SPECIFIC ANTAGONISTS OF CYTOKINES

                                                                INTERFERENCE AGAINST METABOLITES

                                                                CHIMERISM

                                                                MONITORING FOR EARLY REJECTION SIGNS

 

DRUG TOXICITY                                CYTOTOXICITY CROSS MATCHES

 

1.5 VISIONS OF THE FUTURE

Transplantation will become a very common procedure in the next 5-10 years being carried out even in peripheral medical facilities. This will be facilitated by success of medical science to overcome medical and technical complications that confine transplantation to only the most sophisticated centers today. The cost of the transplantation procedures will also fail.

 

Demand for transplantation will increase because of 4 trends. Improved health facilities and wealth in many countries will make more people able to afford the procedure and to find a place where it can be carried out. The increased longevity will increase the number of people with damaged organs who will need replacements. The range of transplantable organs will increase. Simultaneous transplantation of more than one organ will become common. Transplantation for reasons other than medical need may arise for example for cosmetic or even criminal change of identity.

 

1.6 CAUSE FOR CONCERN

 

With success will come legal and ethical problems. The ethical problems associated with transplantation still defy an easy solution. The main legal issues that arise are: (a) definition of what is the moment of death such that organs can be harvested (b) the right over body organs (c) respect for human dignity of the dead (d) possible criminal or commercial abuses

 

Transplantation, like other advanced bio-technological feats, has paradoxical consequences. On one hand new advances lead to new ethical problems. On the other hand advances solve some of the ethical problems. An example of the latter is advances that make the procedure very safe such that risk to the donor or the recipient are no longer relevant considerations in the decision on whether to transplant or not. Progress in use of xenografts and artificial organs may solve most of today’s ethical and legal problems but may create new problems of its own.

 

It is conceivable that neural and reproductive tissues and organs that carry permanent defining characteristics of a person and his/her progeny may be transplanted thus creating a novel problem in defining the legal entity of a person.

 

The demand for organs is more than the supply. The supply of organs is constrained by social and ethical objections as well as by medical contra-indications yet the demand in increasing (   ). Inequity and injustice are likely in such a situation; the rich and powerful are given priority in transplantation of the scarce organs. Criminal abduction of persons for their organs and purchase of organs from ignorant poor people by false pretence are likely to be used by criminal syndicates.

 

Use of animal organs or even artificial organs could solve the problem of organ scarcity but that is still in the future. Selling of organs would be the market mechanism to procuring enough organs but there are strong ethical and legal objections to it.

 

The major problem in our view is definition of death. The customary definition of death would preclude transplantation altogether because by the time a person is certified dead, the organs have already started deteriorating. Definition of death as brain death is not yet widespread and is still controversial. The danger is that the criteria for brain death may be fixed arbitrarily in order to increase the number of organ donors. Abuses are likely when living people will be declared brain=dead so that their organs may be harvested. Organized crime may be involved in organ commerce when people are abducted or killed for their organs.

 

2.0 METHODS

 

2.1 ANALYTIC PARADIGM

Review of published (     ) and unpublished (   ) writings by Muslims on transplantation showed that so far ijtihad undertaken in this vital subject is insufficient and more work needs to be done. Use of textual (nass) evidence has had limited success because the issues involved are new and were not dealt with before.  A new approach has therefore become necessary. In its analysis of transplantation, this paper has used 2 general theories derived from the Qur’an, sunnah, and ijma of scholars: General Purposes of the Law (maqasid al sharia) and the General Principles of Fiqh (al qawaid al fiqhiyyat).

 

Islamic law achieved spectacular growth in dealing with specific problems that could be referred to the text of the Qur’an and sunnat directly or indirectly by qiyaas. The advances in dealing with parts (al juz’iyyat) were not matched by advances in dealing with the larger picture (al kulliyaat). Using a larger picture, it is possible to develop general theories of law that can be applied to many new and unprecedented cases without having recourse to the original texts or nass (    ). The social and technological changes of the 15th century AH make use of general theories and underlying purposes of the law imperative.

 

2.2 PURPOSES OF THE LAW (MAQASID AL SHARIAT)

(x) The paper has used the third section on maqasid.

Pioneers in the development of the theory of Purposes of the Law, maqasid al sharia, were al Ghazzali d..... (   ), Ibn Taymiyyah d.....(   ),  al Shatibi d.....(  ). The field of the purposes of the law witnessed little development after the 5th century AH until revived by Imaam Abu Ishaq al Shatibi in the 8th century AH. He was an original and very incisive thinker. He drew attention to the importance of an over-all instead of a partial approach. He argued that the aim of ijtihad was to discover the purpose of the lawgiver in order to reach a legal ruling (hukm shar’i). The law was revealed to fulfil specific underlying purposes that will ensure succes, falah, in this world and the hereafter . The law was specifically promulgated for the interests or benefit (masaalih) of the people.

 

This paper has used al Shatibi’s major work, al Muwafaqaat fi Usuul al Fiqh (    ), as the basis for its analysis of issues of transplantation. al Shatibi divided his book into 5 parts: (a) al muqaddimaat  (b) al ahkaam (c)  maqasid al shar’iat (d) al adilat als shar’iat (e) ahkaam al ijtihad wa al taqliid. This paper has used  the third  section on maqasid.

 

Two general categories of maqasid al sharia were recognised: the Purposes of the Allah the lawgiver and the Purposes of the Individual (mukallaf). The Purposes of the Lawgiver were divided into 4 types: the original purposes for which the law was revealed (maqasid al sharia ibtidaa’an), the purpose of law as understanding (maqasid al sharia li al ifhaam), law as injuctions and obligations (maqasid al sharia li al takliif), the law as implementation (maqasid al sharia li al imtithaal). The original purposes are at 3 levels: necessities (dharuraat), needs (haajiyaat), and improvements (tahsinaat) and each of the 3 has complements (mukammilaat).  Necessities are the basis on which needs, improvements, and complements depend. There are 5 necessities that are generally referred to as the Purposes of the Law, maqasid al sharia, arranged here in order of importance: religion,diin [D] life, nafs[N], the mind, aql[A], progeny, nasl [N], property , maal [M]. Maintenance of religion includes, inter alia,  faith (iman), the 2 testaments (shahadatain), prayer (salat), fasting(siyaam), pilgrimage (hajj). Maintenance of life includes eating, drinking, etc. Maintenance of the mind includes avoiding doing or consuming what affects the intellect like alcohol. Maintenance of progency includes the regulatins about marriage, family life, and child upbringing. The regulations about property, trade, and inheritance are for the preservation of property rights. The 5 purposes are permanent and are unchangeable (kulliyat abadiyat).

 

TABLE 2A: SHOWING THE PURPOSES OF THE LAW

 

RELIGION (DIIN)

LIFE (NAFS)

THE MIND/INTELLECT (AQL)

PROGENY (NASL)

PROPERTY (MAAL)

 

al Shatibi discussed various situations that guide the use of the 5 Purposes above. On earth, unlike heaven, there is no absolute benefit (maslahat) or harm (mafsadat),  the purpose of the law is therefore to choose the best equilibrium. It is not always true that benefits are permitted (halal) and harms are prohibited (haram). The law alone defines what is a benefit and what is a harm; human intellect and desires are unreliable in this exercise. Exceptions,  branches, or parts (juz’iyaat) that do not fit logically should not detract us from the holistic (kulliyat) understanding the purposes of the law for example tayammum does not fit the description of cleaniliness that is the overall purpose of taharat but does not invalidate the purpose of taharat. Imaam al Shatibi however emphasized that the parts (juz’iyaat) must be preserved if the whole (kulliyaat) are to be maintained.

 

2.3 PRINCIPLES OF THE LAW ( AL QAWAID AL FIQHIYYAT)

 

The principles discussed below are available in most elementary books of usuul al fiqh. A compilation of the princiiples in an unpublished paper by Sono Mustafa Koutoub (  ) has been used as the only source on the Principles. Five principles are recorgonized by most scholars: Qasd, Yaqveen, Dharar, Mashaqgat and Aadat .Each of the 5 Principles is a group of legal rulings or axioms that share a common derivation by analogy (qiyaas). The pioneers in the development of the Principles were al Dabbaas (d...) , al Dabuusi ( d...), Ibn Nujiim (d....), and al Suyuti ( d...). Imaam al Dhariir Abi Dhahir al Dabbaas (d....  ) collected 17 principles  Imaam al Kurakhi who collected 37 principles al Dabuusi in his book Ta’asiis an Nadhar concentrated on principles from a hanafi  perspective. Imaam Zain al Abidiin Ibrahim Ibn Nujiim   in his book al Ashbaahu wa al Nadhairu added a 6th principle that of no reward (thawaab) without intention (al niyyat).  Jalaal al Ddiin al Suyuuti   in his book ..al Ashbahu wa al Nadhairu... tried to link each principle to its origin in the Qur’an and sunnat. Other writers in the field were: al Qaraafi al Maliki in his book al Furuuq, Ibn Rajab in his book Kitaab al Qawaid, and al Khadimi. The Turkish scholar Muhammad Abi Saied al Khadimi collected 154 principles in his book Majamiu al Haqaiq.  The most recent work principle of Figh was the Majallat al Ahkaam al Adliyyat promulgated by the Othman Empire in.....and comprised of 99 principles. Commentaries on this book were written by Sheikh Muhammad Ahmad al Zarqa  his son Mustafa al Zarqa in their book al Madkhal al Aam li al Fiqh al Islami , and al Nadawi in..his book sharh at Qawaid.....

 

TABLE 2B: SHOWING PRINCIPLES OF FIQH

 

Main principle                     sub-principles

MOTIVE (qasd)                    Q1: what matters are intentions and underlying meanings                                                                           Q2: reward in the hereafter depends on the intention

 

CERTAINTY(yaqeen)         Y1: existing assertions continue if no contrary evidence

                                                Y2: innocence is presumed if no contrary evidence

                                                Y3: an event is considered recent if no contrary evidence                                                                           Y4: a new attribute in not accepted without evidence

                                                Y5:  a matter is left as is if no contrary evidence

                                                Y6: original intent takes precedence over the de facto

 

INJURY (dharar) D1: injury should be mitigated as much as possible

                                                D2: injury should be relieved

                                                D3:  injury relief is not by an injury of similar degree                                                                                     D4: an old is the same as a new injury

 

HARDSHIP (mashaqqa)     M1: necessity legalizes the prohibited

                                                M2: the law is permissive where there is no alternative

                                                M3: prevention of harm has priority over assuring a benefit

                                                M4: the lesser of 2 harms is chosen if no other alternative

                                                M5: public has priority over private interest

                                                M6: what is illegal to own,is illegal to sell or donate

                                                M7: an action is illegal even if committed through an agent

 

CUSTOM (aadat)                A1: a custom is uniform, widespread, and predominant

                                                A2: the customary meaning of words is evidence

                                                A3: a custom is like reality

                                                A4: a fact can be left in favor of a custom

                                                A5: the widespread predominant and not the rare is followed

                                                A6: customs change with time and place

 

The Principle of  Motive, qasad [Q] states that each action is judged by the intention behind it (al umuur bi maqasidiha). The following are derived sub-principles: [Q1] what matters are intentions (maqasid) and underlying meanings (ma’aani) and not literal terms (alfaadh) or structures (mabaani). The terms or words used are symbols of the underlying meaning. If there is a contradiction between the term and the meaning, it is the underlying meaning that matters. [Q2] There is no reward in the hereafter for any good act or leaving a prohibited action without a specific intention (la thawaab illa bi al niyyat)

 

The Principle of  Certainty , yaqeen [Y] states that a certainty  can not be voided, changed or modified by an uncertainty (al yaqeen la yazuulu bi al shakk). When an assertion  is an established truth, it should not be changed by a mere doubt being raised about all or some of its components.  Certainty (yaqeen) is a situation when there is no doubt. Doubt (shakk) is a situation in which there are two or more competing options with no sufficient evidence to prove one of them as the most valid. Conjecture (dhann) is a situation in which there is some evidence in favor of one option but that evidence is not strong enough to rule out the other alternatives. The following are derived sub-principles: [Y1] Existing assertions should continue in force until there is compelling evidence to change them (al asl baqau ma kaana ala ma kaana) [Y2] innocence of an individual is presumed until compelling evidence is produced (al asl baraat al dhimma)  [Y3] an event is considered of recent occurrence unless there is evidence to the contrary ( al asl idhafat al haadith ila aqrab waqtihi) [Y4] If an acquired attribute or change is not accepted unless there is compelling evidence (al asl fi al umuur al ‘aaridhat al ‘adam) [Y5]  An existing structure, situation or condition whose origin is not known should be left as is until there is evidence to the contrary (al qadiim yutraku ala qadamihi) [Y6]  What has been accepted as customary over a long time is not considered harmful unless there is evidence to the contrary (al qadiim la yakuun dhararan) [Y7] declaration of original motive takes precedence over what is de facto (la ibrat bi al dalaalat fi muqabalat al tasriih)  

 

 The Principle of Injury, dharar  [D] states that an individual should not harm others or be harmed by others (la dharara wa la dhirar). It has the following derived principles: [D1] injury should be mitigated as much as is possible (al dharar yudfau bi qadr al imkaan).  [D2] injury should be relieved (al dharar yuzaal).  [D3] an injury is not relieved by a similar injury (al dharar la yuzaal bi mithlihi).  [D4] There is no distinction between an event being old or recent in judging its injury. A matter can not be considered no longer harmful just because it is old (al dharar la yakuun qadiiman). This sub-principle restricts sub-principle [Y6] above.

 

The Principle of  Hardship , mashaqqa [M]  states that hardship mitigates easing of the sharia rules and obligations (al mashaqqa tajlibu al tayseer).  The hardships that were considered valid by classical scholars were: travel, illness, coercion, forgetting, general disasters. The  following are derived sub-principles: [M1] necessity legalizes the prohibited (al  dharuraat tubiihu al mahdhuuraat). Necessity is defined as what is required to preserve the 5 Purposes of the Law (ie religion,life property, property, and intellect). If any of these 5 is at risk, permission is given to commit an otherwise legally prohibited action.  Committing the otherwise prohibited action should not extend beyond the limits needed to preserve the Purpose of the Law that is the basis for the legalization (al dharuraat tuqaddar bi qadriha). Necessity however does not permanently abrogate others’ rights which must be restored or recompensed in due course; necessity only legalizes temporary violation of rights (al idhtiraar la yubtilu haqq al ghair). The temporary legalization of the prohibited action ends with the end of the necessity that justified it in the first place (ma jaaza bi ‘udhri batala bi zawaalihi). This can be stated in al alternative way  if the the obstacle ends, enforcement of the prohibited resumes (idha zaala al maniu, aada al mamnuu’u).   [M2] when a hardship situation is restrictive, the law is permissive and eases the situation (al amr idha dhaaqa ittasa’a). Possible abuse of this sub-principle is restricted by the sub-principle:  when a situation is permissive, the law is restrictive (al amr idha ittasa’a dhaaqa). In practical terms this means that the law is permissive only to the extent of the hardhip and no more as explained above (al dharuraat tuqaddar bi qadriha).  [M3] prevention of a harm has priority over pursuit of a benefit of equal worth (dariu an mafasid awla min jalbi al masaalih).  If the benefit has far more importance and worth than the harm, then the pursuit of the benefit has priotity. [M4] the lesser of two harms is selected (ikhtiyaar ahwan al sharrain). If confronted with 2 actions both of which are harmful and there is no way but to choose one of them,  the one with lesser harm is committed in order to block the way for the bigger harm. A lesser harm is committed in order to prevent a bigger harm (al dharar al ashadd yuzaalu bi al dharar al akhaff). This also implies that an individual could suffer in the interest of preventing a public harm.  [M5] public interest has priority over individual interest (al maslahat al aamat muqaddamat ala al maslahat al khaassat). The individual may have to sustain a harm in order to protect public interest (yatahammalu al dharar al khaas li dafiu al dharar al aam)   [M6] What is illegal to get, use or possess is also illegal as a gift or  a trade good (ma haruma akhdhuhu, haruma itauhu). [M7] An action is still illegal even if someone else is made to carry it out (Ma haruma fi’iluhu, haruma talabuhu)

 

The Principle of  custom, aadat [A] states that what is customary is a legal ruling (al aadat muhkkamat).  Unless contradicted specifically by text (nass), custom or precedence is considered a source of law. The customary must also be old and not a recent phenomenon.  It has the following sub-principles: [A1] What is considered customary is what is uniform, wide-spread, and predominant (innama tutabaru al aaadat idha atradat aw ghalabat).  [A2] The way people use words is used as evidence (istimaal al naas hujjat yajibu al amal biha).  [A3] what is objectionable by custom is like what is legally objectionable (al mumtaniu aadat ka al mumtaniu haqiiqat). [A4]  A fact could be abandoned on the basis of a custom  (al haqiiqat tutrak bi dalaalat al aadat). [A5] what is considered is what is predominant, wide-spread, and not what is rare (al ibrat li al ghaalib al shaiu la al naadir). [A6] you can not deny the change of rulings with times, situations, and customs (la yunkiru taghayyur al ahkaam bi taghayyuri al azmaan wa al ahwaal wa al aadaat wa a’raaf)   ie customs eventuary change with time.

 

2.5 DEFINITION OF LEGAL COMPETENCE

Decisions to donate an organ can only be legally binding when  made by an individual recognized by the law as having legal competence (ahliyyat): adult, of sound  mind, and  not under duress of compulsion.

 

2.6 BINDING LEGAL RULINGS (fatwa)

General binding legal rulings (fatwa) can not be made on most issues related to transplantation; each case should be considered on its own merits. The organ donor, who takes a major risk, should make the final informed decisions after clarification of the medical, legal, and ethical issues by physicians and fuqaha. A decision could be made for an organ recipient because transplantation for him or her is predominantly beneficial. The rapid changes in medical science also make a general binding fatwa even more irrelevant because the balance of risks and benefits of transplatation change almost daily with discovery of new drugs and surgical technics.

 

This paper does not pretend to give any legal rulings (fatwa) on the issues raised. It makes analyses that clarify the issues from the law and medical points of view. It asserts that general purpose fatwas are irrelevant in this situation because there are many parameters that go into making a decision including the inclinations and feelings of the donor, conflicts of interests, and psychological factors.   Since these factors are intangibles that are difficult to put into the equation, it is felt that  physicians and fuqaha should confine themselves to clarifying the issues and leaving the final decision to those most concerned: the organ donors.

 

 

3.0 RESULTS

 Tables #3A-3G show the major ethico-legal issues in transplantation and the maqasid  and qawaid that can be used for them.


TABLE #3A: REASONS FOR TRANSPLANTATION

 

Situation                                                                               maqasid and qawaid reference       

Irreversible organ failure                                     Life, Injury, Hardship         

Sub-optimal functioning of the organ                              Life, Injury, Hardship         

Preventive replacement without injury             none

 

In the case of irreversible organ failure, transplantation is carried out to maintain the health of the recipient. The end-organ failure is an injury that has to be relieved as much as is possible. Transplantation must not however lead to complications and side-Effects that are worse than non-transplantation or use alternative treatment. The recipient is in a position of hardship under which the law permits procedures that would otherwise be objectionable.

 

The arguments above also apply to situations in which the organ has not yet failed completely but is functioning sub-optimally. The equation between benefits and potential injury is biased more towards prevention of injury.

 

 

TABLE 3B: COMPLICATIONS AND SIDE EFFECTS OF TRANSPLANTATION

 

COMPLICATION                                                MAQASID AND QAWAID

IMMUNE SUPPRETION                                    LIFE INJURY

INFECTION                                                                          LIFE INJURY

NEOPLASM                                                                         LIFE INJURY

GRAFT REJECTION                                                            LIFE INJURY

DRUG TOXICITY                                                                LIFE INJURY

 

The associated side-effects and complications of immunesuppression, infection, neoplasia, graft rejection, and drug toxicity are treated under 2 principles of the Law: hardship (mashaqqa), injury (dharar). Under the Principle of hardship, necessity to preserve good health  legalize the otherwise prohibited mutilation of the human body  because of the hardship involved  (al al dharuurat tubiihu al mahdhuuraat),  prevention of harm to the donor and the recipient as a result of the transplantation procedures  should take precedence over pursuit of health benefits for the recioeint  (dariu al mafasid muqaddamu ala jalbi al maslahat), and if confrointed with a situation in which transplantation has harms and non-transplantation will lead to health impairement, then the lesser harm is selected (ikhtiyaar ahwan al sharrain). Under the principle of injury, transplantation is justified because impairment of health is an injury that must be relieved (al dharar yuzaal) in as far as is possible (bi qadr al imkaan) but should not be replaced by another injury (al dharar la yuzaal bi mithlihi) in other words the side-effects of transplantation must be less than the original disease.

 

Transplantation just for the sake of getting a new organ when the old one is still functioning well has no basis in law. There is no hardship or injury to be relieved whereas there are associated complications that could affect life and health.

 

1-TABLE #3C: SOURCES OF ORGANS

 

Situation                                                               maqasid and qawaid reference       

Artificial man-made                                              none

Edible animals                                                       none

Inedible animals                                   Hardship

Human organs                                                      Hardship, Injury

Human organs can be obtained in different ways: (a) a living donor who consents to sell or donate one of paired organs (b) a person who, in a legal will, donates or sells all or parts of his or her body to be used in transplantation at death (c) a living or dead person, minor or major, whose organs are used without prior consent.

 

Use of artificial organs and organs from edible animals have no associated legal or ethical problems. The only consideration is the possibility of side-effects and complications that may be worse to the recipient than his or her original condition. Use of organs from humans or edible animals can be justified under the principle of necessity that arises in hardship. The donor human should not suffer major injury in the process of donation. Violation of human dignity by ‘mutilating’ a human body to get organs could be an argument against harvesting organs.

 

TABLE #3D: OBTAINING HUMAN ORGANS VOLUNTARILY

 

Situation                                                                               maqasid and qawaid reference       

Gift or sale by living adult                                 Property, Life, Injury

Will to gift or sell on death                                 Property, Custom, Certainty              

Gift or sale by living condemned                       Property, Certainty

Gift or sale after death by condemned              Property,Custom, Certainty,

 

In all cases of harvesting human organs for transplantation the issue arises whether the body or its parts are property that individuals can dispose of as they like.

 

The life or health of the living donor (by sale or gift) should suffer no major injury due to transplantation. The degree of acceptable risk or injury to life is a matter for ijtihad.

 

Harvesting organs on death is complicated by the definition of death. Under the customary definition organs will have spoiled by the time they are harvested. Brain death is not yet established as a customary widely accepted definition of death. If brain death is used as a definition of death, there is an uncertainty that a ’living’ human is being ‘killed’ for his organs.  

 

The case of a criminal condemned to death is complicated further by the fact that we can never be sure that he is acting under his free will or is under coercion.

 

TABLE #3E: OBTAINING HUMAN ORGANS INVOLUNTARILY

 

Situation                                                                               maqasid and qawaid reference       

Gift or sale by living or dead adult                    Motive

Gift or sale by living or dead minor                   Motive

Gift or sale by living or dead insane                 Motive

Gift or sale by the living / dead condemned    Motive

Corpse or unknown identity                                              Motive

 

Harvesting organs from an individual without his or her free consent is not allowed by the law on the basis of motive. The ‘owner’ of the organs is the only individual whose motive is known with certainty not to be colored by conflict of interest or exploitation that harms him; he is therefore the only one who can decide to donate his organs as a gift or sale. Any other individual or organization that makes the decision on harvesting organs may have motives, interests or considerations that are not in the best interests of the organ donor.

 

In case of the minor child, the unconscious or the insane, the trustee, wali, does not have the right to make the decision on donating their organs because of the potential risk involved and the possibility of wrong motives and conflict of interests. The trustee can make decisions that have only benefits or in which the balance of benefit is clearly predominant over the harm.

 

The absence of a free will to donate is enough to prohibit any harvesting of organs. We could reinforce this with the principles of maintaining the health of the donor and not exposing him to risks and injury, and the certainty of death before organs are harvested,

 

TABLE 3F: THE DONOR OF ORGANS

Situation                                                               maqasid and qawaid reference       

Human dignity of the dead                 Life

Human dignity of the living                               Life

Psychological Effects                                          Life

Long-Term Health Risk.                      Life

 

Judgments on Dignity and Psychological effects and risks are very subjective

 

TABLE 3G: RECIPIENTS OF ORGANS

 

Situation                                                               maqasid and qawaid reference       

Minor or child                                                       Life, Injury, Harship

The insane or legally incompetent    Life, Injury, Harship

Competent adult                                   Life, Injury, Harship, Motive

 

The guiding principles are maintenance of health, lessening injury, and permission given under hardship. The trustee can make decision on behalf of the minor child or the legally incompetent because the benefit from transplantation is predominant over the harm. The free consent of the competent adult is necessary to assure desire to die in dignity without the hussles of transplantation which is included under the Purpose of Life.

 

TABLE 3H: OWNERSHIP/CONTROL OF ORGANS

 

Situation                                                                               maqasid and qawaid reference       

The living donor                                                  Property

Inheritors of deceased donor                                             Property, Motive

Public property controlled by government      Property, Motive

 

There is no agreement that the human corpse or its organs are property that is owned by any body and therefore can be disposed of as willed. The ownership of such organs by inheritors or the government raises the question of motive because abuses and other interests may be involved in both cases.

 

TABLE #3G: DEFINITION AND TIMING OF DEATH

Situation                                                               maqasid and qawaid reference       

Brain death                                                            Certainty, Motive

Cardiac arrest                                                        Certainty,Custom

Respiratory arrest                                                Certainty, Custom

Rigor mortis                                                          Certainty, Custom

Temperature                                                          Certainty, Custom

 

Brain-death as a definition of death is not yet accepted customarily and  has a big element of uncertainty that organs are being harvested from a living person who is thereby killed. The motive behind using brain death as a definition of death is also questionable. It could be argued that the need to harvest organs is behind the adoption of brain-death as a definition of death. The other definitions of death in the table above are quite classical widely accepted by precedent and have no uncertainty associated. They however are too late for organs to be harvested. Organs start deteriorating quite early in the death process.

 

TABLE #3J: ABUSES

Situation                                                                               maqasid and qawaid reference       

Abduction & murder                                                           Life, Injury, Motive

Buy organs from the starving poor                   Life, Injury, Property

Buy/remove organs of the terminally ill           Motive, Certainty

 

Abducting people or murdering them for their organs is a criminal activity that destroys life, causes injury and has a bad motive.

 

The starving poor who sell their organs do so under duress and the sale contract in that case is not legally valid. Their health may be impaired and they may suffer injury in the process. The issue of whether they have property rights to their organs discussed above is raised again here.

 

Buying or removing organs from the terminally ill may be motivated by selfish reasons. The certainty of their condition being ‘terminal’ is also questionable; no human can with certainty declare that death, ajal, is near.

 

Abuses such as murder, coercion of the poor and weak by physical force or money, instigation of violence and wars are likely to increase when transplantation becomes a comon and safe procedure following resolution of outstanding technical and medical problems. Authorities will have to restrict transplantation under 3 principles: dominance of public over individual interest (al maslahat al aamat muqaddamat ala al maslahat al khhasat), prevention of harm has priority over geting a benefit (dar’u al mafaasid awla min jalbi al masaalih), and forestalling harm (dariu al mafasid)

 

4.0 DISCUSSION

4.1 INDICATIONS/REASONS FOR TRANSPLANTATION

 

4.1.1 GENERAL

Transplantation is carried out under the Purpose of preserving good health (hifdh al nafs) of the recipient without impairing the life of the donor

 

4.1.2 INDICATIONS

Irreversible or end-organ failure is the main indication for transplantation. This is a debilitating or potentially fatal condition. It must be clear from the beginning that Islamic paradigms do not permit setting as the purpose of any medical procedure the prevention or prolongation of death. The moment of death, ajal, is the prerogative of Allah and no human being can delay or advance it. All our efforts are directed at maintaining or improving the quality of life remaining until the moment of death. Transplantation can be seen as an effort in this direction because we can not give up since the actual moment of death in unknowable to us as humans.

 

Sub-optimal functioning of the organ is nor as compelling a reason for transplantation as end-organ failure but could be considered a stage towards total failure and transplantation would be more effective before there is further organ deterioration.

 

Preventive replacement without injury is likely to occur when transplantation becomes a widely-available easily-performed procedure. This does not seem to be a convincing reason to risk the health of both the donor and the recipient. In a situation of shortage of organs, preventive replacement will not be ethical.

 

4.1.3  CONTRA-INDICATIONS AND COMPLICATION

 

The progress of medical science will in the foreseeable future overcome many of the  contraindications, complications, and side-effects of transplantation. This will remove them from the legal and ethical debate. We do not know whether a new generation of problems will arise after that.

 

4.2 SOURCE OF ORGANS

 

With greater demand for transplantation services, the available organ pool is far from satisfying the number of people waiting for organs. This situation is not likely to get better with time. There will be no alternative but to look for non-human sources.

 

At the moment human organs are used in most transplantation procedures. It is likely that before this decade is over organs from animals or those artificially made will be available. Organs from non-human living things, dead or alive, can be used under the general Qur’anic concept of taskhiir    which implies that earth and what is on it can be put at the service of humans.

 

Artificial organs do not constitute an ethical or legal problem as far as procurement is concerned. Their side effect are also limited. Artificial Hearts values have been used for a long time.

 

Research to overcome rejection associated with animal organs (xenografts) is quite advanced. Animal organs perhaps produced with the aid of genetic engineering will are likely to replace human organs in all transplantation procedures (   ).  The medical side-effects and complications of allografts and xenografts are essentially the same; differences may be only qualitative or quantitative. Xenografts will not have the associated legal and ethical problems that are associated with allografts. A wide range of animal sources are likely to be used such that the issue of edible (halal) and unedible (haram) animals will not arise. If this issue were to arise it could be resolved under the principle of necessity (dharurat).

 

 

 

4.3 OBTAINING HUMAN ORGANS VOLUNTARILY

 

4.3.1 DONATION BY LIVING ADULT                            

A living adult can freely consent to donate one of paired organs since life can be maintained with only one organ or parts of it. The purpose of maintaining life is invoked here. The transplanted organ enables the recipient to lead a productive and healthy life but it is risk to the donor. The law does not allow causing a harm in order to get a benefit for somebody else. Therefore this donation becomes acceptable if the risk to the donor is understood to be limited.

 

Physicians and fuqaha are not unanimous about organ donation by a living adult. Dr Sharawi argued that donation of an organ or part of an organ by a living person is prohibited on  the basis that the person does not own that organ and therefore can not dispose of it by sale or donation (  ) .

 

Dr Jad al Haqq Ali Jad al Haqq (  ), Sheikh al Azhar,  argued that if a Muslim physician who is trusted declares that the donor will not suffer any injury then donation is allowed because the principle that an injury is not relieved by another injury (al dharar la yuzaalu bi al dharar) is not violated. He however put the condition that the donor should not benefit materially from the donation.(  ).  Dr Tantawi (  ) , Mufti of Egypt,  agreed with Dr Jad al Haqq using the principle that the  greater  injury is relieved by the lesser one (al dharar al ashadd yuzaal bi al dharar al akhaff)(  ).

 

4.3.2 SALE BY LIVING ADULT

Sale of organs generates more controversy than donation. Some scholars reject sale of organs outright. Some accept it under certain restricting conditions. Others appear to allow it by calling it another name.

 

Dr Abu al Futuuh gave two arguments against sale or organs (a) an organ can not be sold because the owner is Allah. And according to the fiqhi principle he who does not own a thing can not give it to another (faaqidu al shay la ya’taiihi li ghairihi’ (b) sale of organs can not be likened to sale of blood or sale of breast milk by a mother or a wet nurse because  with blood  and breast milk are  a renewable

 

Dr Tantawi (  ) saw that sale of any organ under the principle that necessities legalize the prohibited (al dharuuraat tubiihu al mahdhuuraat) was wrong. He argued that the principle should not be used in isolation. It should be considered alongside the following restricting principles: an injury is not relieved by another injury (al dhararu la yuzaalu bi al adharar), the greater injury is relieved by committing alesser injury (al  dharar al ashadd yuzaaku bi al dharar al akhaff) , an individual bears an injury in order top prevent a public injury (tahammul al dharar al khaas li dafui al dharar al aamu), choosing the lesser of two injuries (al akhdh bi akhaff al dhararain), prevention of harms has precedence over obtaining benefits (dariu al mafaasid muqaddamu ala jalbi al massalihi).

 

Dr Faidh llah argued that it is prohibited to sell an organ but the buyer is not at fault if he has necessity and buys the organ; it is the seller who is at fault. The condition of necessity does not apply to the seller. We find this distinction between the seller and the buyer unacceptable  using the analogy of riba in which both the giver and taker are guilty perhaps equally.

 

Dr al Mahdi (  ) saw no harm in a person selling one of paired organs. He even derived the price of one of paired organs as one-half of blood-wit (diyat).

 

In discussing sale of organs, Dr Yasin argued that sale of organs was allowed if there is necessity under the following constraining conditions: the sale does not violate human dignity for example if done for profit and trade, the organ must be sold to be used specifically for the function  it was created for, the seller should not suffer harm, there should be no artificial alternatives, and the sale must be under supervision of a competent authority to prevent abuses.

 

The above-mentioned arguments for and against sale of organs did not, quite surprisingly, question the value of a corpse as a commodity to be sold. The organic part of the human body (al jasad) has no material or moral worth after removal of the ruuh  and is just elements of the earth that will return to the soil and later appear as molecules in another living or non-living thing. It is not property (maal); the PURPOSE OF PRESERVING WEALTH (hifdh al maal), the laws of commercial transaction (ahkaam al buyuu), and the laws of inheritance (ahkam al miraath) can therefore not be applied to situations of buying or selling organs.

 

Using the theory of higher purposes of the law, we can argue that selling and buying using money is the most efficient way to exchange of goods and services among people for mutual benefit and thus fulfils the obligation of mutual social support (takaaful ijtimae). We can therefore envisage a situation in which organs are ‘sold’ but no individual gets financial benefit. The proceeds are put in a trust (waqf) fund that will help the poor (fuqara) or designated relations (aqaarib) get organs or use the money for charitable work (sadaqat jariyat) that will be in the name of the person whose organ was used. This argument becomes more plausible when we consider that voluntary organ donation is not sufficient to cover the demand.

 

In our view the strongest arguments against sale of organs are those based on the fear of criminal abuse and transgressions when transplantation is commercialized.

 

4.3.3 WILL  ( WASIYAT ) TO DONATE ON DEATH

 

A living adult in full possession of his faculties could sign a statement authorizing medical authorities to remove his organs and use them in transplantation in case of death. Scholars have not reached a consensus on this.

 

Dr al Mahdi supported a will to donate organs on death and considered it part of saving someone else’s life( ).

 

Dr  Faidh Llah (  ) made a very interesting analogical comparison by arguing that since in case of necessity a person is allowed to eat flesh of a dead human, then in a case of end-organ failure the organs can be used in life-saving transplantation.

 

Dr  Tantawi  (  ) saw that removing any organ from a dead body violated the respect for the human living or dead that Islam teaches. Dr Sharawi (  ) saw that harvesting organs was not allowed because the person whether living or dead does not own his body and therefore can not donate it.

 

4.3.4 CONTRACT TO SELL ON DEATH

 

The arguments used in 4.3.1 apply here as well.

 

4.3.5 DONATION BY CRIMINAL CONDEMNED TO DEATH

 

A person condemned to death for a crime could voluntarily donate his organs. This is perhaps one situation in which the definition of death does not constitute an ethical or legal problem. Since the prisoner will die anyway, removing the organs even if he is not fully ‘dead’ by classical criteria makes no practical difference.

 

Dr Faidh llah (  ) argued that using part of the body of a person legally condemned to death was valid and used the analogy of permission to eat their flesh in case of necessity. He however put the condition that removal of he parts should not be by mutilation or persecution which was forbidden.

 

 

4.4 OBTAINING HUMAN ORGANS INVOLUNTARILY

 

4.4.1 DONATION BY A LIVING ADULT

It is possible that the judge can under the laws of retribution (qisaas) force a person guilty of criminally destroying an organ of another person, to donate one of his pared organs to the victim.

 

There are however many issues to be explored by fuqaha to answer questions such as the following: can a parent be forced to donate organs to his children and vice versa? what about the wife and husband or the brothers and sisters?

 

4.4.2 SALE BY A LIVING ADULT

Buying organs from the poor and hungry may appear voluntary but is not; they are desperate. Such a sale should be classified as involuntary and therefore illegal.

 

4.4.3 DONATION BY A LIVING MINOR

In our view, a minor cannot be a donor under any circumstances. Although the guardian is allowed to make decisions for the minor, it seems to us that a permanent irreversible matter like solid organ donation should not be among these decisions. This argument does not however apply to the minor receiving an organ because in that case the balance between benefits and risk is clear for a specific individual and his or her best interests are considered without fear of conflict of interest.

 

4.4.4 DONATION BY A CRIMINAL CONDEMNED TO DEATH

We feel that forcing a condemned criminal to donate organs against his will is transgression and violation of his rights (dhulm). The punishment meted out was death and should not include removal or organs.

 

4.4.5 FAMILY DECISION TO DONATE AFTER DEATH

We feel that the family should not have any right to decide on the donation of organs of the deceased if his wish in this matter was not known. Giving the family authority to donate organ could open the door to abuses in which some family members could be killed in order to obtain organs for others.

 

4.4.6 FAMILY DECISION TO SELL AFTER DEATH

The arguments in 4.4.5 above apply here.

 

4.4.6 DEAD BODY OF UNKNOWN IDENTITY

Taking organs from a body of unknown identity should be forbidden under the principle of (sadd al thariiat). Innocent persons could be kidnapped and killed for their organs.

 

4.5 THE DONOR OF ORGANS

 

The final decision to donate an organ should be left to the donor because of intangible considerations known or felt only by him or her and the fact that he or she is the only one who can make a decision in his/her best interests if given the right information. Issues such as human dignity, perceived  long term risk and psychological  often effect one intangibles.

 

An 80-year old grandfather may feel differently about a risky and major transplantation operation from a 25-year old widowed husband and father of 3 young children who have no other relatives. A criminal condemned to death may feel differently about donating his organs than a young healthy person in the prime of his life. A healthy individual living in an industrial country with excellent medical services may find it easier to donate one of paired organs than one living in a country with many infectious diseases and poor medical services such that the risk of surviving with only one organ is considered too high.

 

Transplantation involves many ambiguous issues with great potential for conflict of interest and possible violation of others’ rights (dhulm). The approach of this paper is to let the donor who is most intimately concerned and whose rights and interests are most at stake, make the final decisions. This automatically excludes children and others with deficient legal capacity from being donors. However an individual who is unconscious or is legally incapacitated could have an organ harvested if there is a valid preferably written permission made when he was in perfect health and in full possession of his mental faculties,

 

4.6 THE RECIPIENT OF ORGANS

 

Transplantation is mainly of the benefit of the recipients. The equation of benefits and harm is titled to the side of benefits.

.

4.7 OWNERSHIP OF ORGANS

 

4.5.1 THE CONCEPT OF OWNERSHIP

The concept of ownership of organs is closely related to transplantation. If it is established that an individual is the owner of his organs, he can then dispose of them as he likes either by sale or by donation. Whatever definition of the ownership concept is adopted, it must not be forgotten that the owner of everything is Allah. Whatever ownership a human may have is limited to control and use of organs or any other type of wealth. We will consider 3 possible ownership alternatives: (a) The living donor (b) inheritors of A deceased donor (c) Public property controlled by government. Some things are owned by Allah but the human has a right of ownership over them.

 

The human organic body and its parts (al jasad) are not the essence of the person (al insaan) and atrer just elements of the earth without much significance after removal of the soul (ruuh). The body or its organs are not property (maal) therefore the Purpose of preserving wealth (hifdh al maal), the laws of commercial transaction (ahkaam al buyuu), and the laws of inheritance (ahkam al miraath) can not be applied to situations of donating or selling organs

 

4.5.2 OWNERSHIP BY A LIVING DONOR

Dr Mukhtar al Mahdi (  ) argued that organs are owned by the donor and used analogical reasoning, qiyaas, without mentioning the technical term. He argued that if an organ is injured, the victim can claim compensation from the person who caused the injury and can benefit from the proceeds of that compensation; proof of ownership. He argued that he saw no problem in donating or selling ORGANS. Abu al Futuuh (  ) did not agree with this argument and explained that blood-wit (diyat) was a punitive measure and not an exchange value for the injured organ ( ).

 

4.5.3 ORGANS ARE OWNED BY THE INHERITORS

The discussion of ownership of the body by the inheritors depends on the conclusions of 4.5.2 above. If the deceased did not own his body in life, then his inheritors can not be said to be owners after his death.

 

 

4.5.4 GOVERNMENT HAS CONTROL OF ORGANS

Dr Muhamad Sayied Tantawi, Mufti of Egypt argued that the human body belongs to Allah and quoted verses of the Qur’an preventing a human from killing oneself (Nisa:29-30, Baqara:195). If the human has no rights of ownership of his body, then it can be legitimate to claim that the government has that right as long as it upholds the sharia. This argument is derived from the analogy of a person who dies with no inheritors to own his property. That property reverts to the treasury of Muslims.

 

4.5.5  CONCLUSION

The debate on ownership of the body or its parts could be laid to rest by the observation that the body without the soul is worth nothing, it is just elements of the earth that will soon return to their origin and may end up into another body of a plant of an animal. Selling a worthless thing is not logical but its donation could be understood only if the donated gift does not cause injury to the recipient. The argument about respect for the dignity of the human being in death could be settled by the observation that it is the manner in which the organ is removed and the way the rest of

the body is disposed of that could be respect or disrespect.

 

4.8 DEFINITION AND TIMING OF DEATH

 

Table...shows classical definition of death for a person not on sedatives.The customary definition of death has not been very rigorous because there was no urgency in determining that a person died. Therefore cardiac arrest, respiratory arrest and other very obvious and perhaps quite late indicators of death have been used. Transplantation created a novel situation because death had to be declared before organs start deteriorating. Cadaveric kidneys must be removed within  100 minutes of cardiac arrest The concept of grain death evolved to solve this problem but it gave  rise to new problems.

 

Table...... Definition of death

No response to external stimuli

No Spontaneous respiratory movement for 3 minutes

No reflexes

Bilateral fixed dilated pupils

EEG flat on all channels.

 

There is now a doubt whether brain death is actually a terminal event and can not be reversed by yet an undiscovered procedure. The success of transplantation is its own worst enemy. By making it possible for patients with end-organ failure to survive, transplantation creates enough doubt about the finality of brain death. medical technology may soon discover a way of reviving persons who are brain dead to normal physiological functioning. This possibility makes the harvesting of organs from such patients a very doubtful matter legally. Where there is a doubt, we have to proceed very carefully.

 

The principles of custom and certainty are invoked in the definition of death and thus the earliest time for organ harvesting. Under the PRINCIPLE OF CUSTOM ( al aaadat),  brain-death does not fulfill the criteria of being a widespread, uniform, and predominant customary definition of death which is considered a valid precedent (al aaadat muhakamat). The successes of biotechnology in transplantation and other fields introduces a strong doubt (shakk) that brain-death could be reversed. Under the principle of certainty, existing customary definition of death should continue in force until there is compelling evidence otherwise (al asl baqau ma kaan ala ma kaana).

4.9 HUMAN DIGINITY

Respect for dignity of the person (ikraam bani Adam) in life and death is the reason for doubting whether transplantation involving mutilation and burial without all the parts is appropriate. Human dignity, derived from the Purpose of preserving life, is invoked in cases of a dead or dying unconscious donor. Being buried with all body parts is part of respect for the human even in death. Only the deceased, and not his family, can be the best judge of that as expressed in a valid will made when in perfect health

 

4.10 POTENTIAL ABUSES

Restricting transplantation on the ground that it will be abused is logical enough but the underlying reasoning is flawed. If every good or legal things that can potentially be abused by un---------- persons were to be prohibited. There would be very few things  that humans can do.

 

5.0 CONCLUSIONS

This paper has reviewed all issues pertaining to the transplantation orocess and fiound that there are only 2 outstanding issues that cast doubt on the legality of transplantation: (a) definition of death as brain death (b) organizede crim getting involved in procurement and sale of human organs (c) harvesting organs from minors and legally incompetetent persons.

 

The paper concludes with the observation that most outstanding ethical and legal problems of transplantation are temporary, they will disappear in the near foreseeable future when medical science advances to use xenografts or artificial organs.

 

 

 


NOTES

 

HISTORICAL EVOLUTION (HIST)

Calne-R . The history and development of organ transplantation: biology and rejection. Baillieres-Clin-Gastroenterol. 1994 Sep; 8(3): 389-97

To a large extent the surgical problems of transplantation have now been solved but rejection remains the main stumbling block to long-term survival of organ allografts... Work in progress world wide is directed to the eventual establishment of tolerance in the clinic so that recipients of organ grafts will not have to submit to a lifetime of potentially toxic drug dosage. A shortage of organs for transplantation and the ethical dilemmas make organ transplantation an unusual and worrying field of medicine. Perhaps we will find salvation in transplanting organs from animals, although this achievement would seem to be some way off.]

Starzl-TE  The early days of transplantation. JAMA. 1994 Dec 7; 272(21): 1705

 

Fox-MD  The transplantation success story [editorial] JAMA. 1994 Dec 7; 272(21): 1704

 

 

Brannigan-MC  A chronicle of organ transplant progress in Japan. Transpl-Int. 1992 Jul; 5(3): 180-6 [

This study reviews developments in five areas: actual transplant legislation; landmark cases notably affecting public impressions of organ transplants; efforts to establish brain death criteria; action on the part of the Japan Medical Association; and current attempts to legislate on brain death. The account demonstrates how the notions of both brain death and heart transplantation have met with strong resistance. The first and only heart transplant occurred in 1968. Through its historical emphasis, this report reveals that, although opposition has not impeded transplant research, the determination of death and the idea of heart transplants remain highly controversial due to specific religious, philosophical, and cultural factors]

 

High techinical medical Miracles publications. United States: s.n,1985 [PVS 2.1] Human transplantation / edited by Folix T. Rapaport and Jean Dausset. NewYork : Grune and station, 1968 [RD 120.7 Rap]

 

Warshofsky,Fred. The rebuild man: the story of spare-parts surgery New York: Thomas Y.Crowell, 1965 [RD 126 War]

 

Randal-J.  Discovery may improve transplant success [news]. J-Natl-Cancer-Inst. 1995 Mar 15; 87(6): 404-6

 

Neuhaus-P; Platz-KP . Liver transplantation: newer surgical approaches. Baillieres-Clin-Gastroenterol. 1994 Sep; 8(3): 481-93

 

 Groth-CG [The future of transplantation surgery (editorial)

 

Clean-K; Kneteman-N; Taylor-G  Comparative risk of bloodstream infection in organ transplant recipients. Infect-Control-Hosp-Epidemiol. 1994 Sep; 15(9): 582-. Liver recipients experienced a higher rate (28%) than either kidney (5%) or heart, heart-lung (10%). Primary infections (60% overall) caused by gram-positive bacteria (59% overall) predominated at all three sites.]

 

Rublee-DA  Medical technology in Canada, Germany, and the United States: an update. SO Health-Aff-Millwood. 1994 Fall; 13(4): 113-7 [ This study compares the proliferation of six complex medical technologies in Canada and Germany with that in the United States, the traditional high-tech leader. The technologies--open-heart surgery, cardiac catheterization, organ transplantation, radiation therapy, extracorporeal shock wave lithotripsy, and magnetic resonance imaging--are more prevalent in the United States, on a per capita basis, than in the other two countries. This was the case five years ago, too]

 

Shmueli-D; Lustig-S; Nakache-R; Yussim-A; Bar-Nathan-N; Shaharabani-E; Shapira-Z  Renal transplantation in patients with amyloidosis due to familial Mediterranean fever. Transplant-Proc. 1992 Oct; 24(5): 1783-4

 

 Faltin-DL; Jeannet-M; Suter-PM The decrease in organ donations from 1985 to 1990 caused by increasing medical contraindications and refusals by relatives. Transplantation. 1992 Jul; 54(1): 85-8

 

 

PRESENT STATUS (STAT)

 

 Mignon-M; Delmont-JP  Current status of liver transplantation (LT) in France and specificities of French ethical attitudes concerning LT. Gastroenterol-Jpn. 1993 Jul; 28 Suppl 6: 28-32; discussion 33

[Legal dispositions stipulating the presumed consent of the donor and accrediting the notion of "cerebral death" have eased the development of liver transplantation in France. Despite these measures shortage in liver available for grafts results in still too large. There is, in France, a strong consensus for a strict sticking to the absolute principles of gratuity of organ donation and non-marketing of excised organs available for graft]

 

[1st Francophile Congress on Organ Transplantation in Children. Lyon, France, 10-11 December 1993. Abstracts]. Pediatrie. 1993; 48 Suppl 1: 5S-126S

 

 Barone-GW; Ketel-BL; Tobler-HG  An update of solid organ transplantation at UAMS.

SO J-Ark-Med-Soc. 1993 May; 89(12): 601-3 [The one year survival for solid organ transplants is 70 to 90%. Encouraged by this success. The limiting factor in transplants continues to be a shortage of Donor organs and the need for increased referral of potential donors]

 

 Sala-P  Simultaneous transplantation. Todays-OR-Nurse. 1993 Mar-Apr; 15(2): 23-6

.

Organ transportation 1990 / edited by G.M. Abouna, M.S.A Kumar, A.G. White. Dordrecht; Boston: Kluwer Academic publishers, 1991. [WO 660 Org ]

 

Transplantation society, International congress. (4th: 1972: San Francisco ) Tranplantation today: proceedings of the fouth international congress of the transplantation society, september 24-29, 1972 San Francisco, California / editors; Felix T. Rapaport, Hans Balner {and } Samuel L. Kountz. NewYork: Grune and Stratton,1973. [RD 120.7 Ts]

 

Shaheen-FA. Transplantation in Saudi Arabia. Transplant-Proc. 1995 Feb; 27(1): 1470-1

 

Ota-K; Teraoka-S; Kawai-T . Transplantation in Asia: organ transplantation in Japan. Transplant-Proc. 1995 Feb; 27(1): 1463-5

 

Cooper-DK; Samara-EN; Mieles-L; Merhav-H; Imes-N; Van-Thiel-D; Zuhdi-N Survival following organ transplantation in an Oklahoma institution, 1985-1993. J Okl State Med Ass. 1994 Nov; 87(11): 506-8

. The current actuarial one-year survival rate of patients undergoing heart, kidney, lung, or liver transplantation at our center is 94%, 90%, 87%, and 91%, respectively. Five-year survival of heart and kidney recipients is 80% and 75%, respectively.

 

INDICATIONS/REASONS FOR TRANSPLANTATION (IND)

 

Ikehara-S  Intractable diseases and bone marrow transplantation. Pathol-Int. 1994 Dec; 44(12): 817-26

[Of the 86 intractable diseases recognized by the Ministry of Health and Welfare of Japan, half are thought to be curable by bone marrow transplantation (BMT)]

 

Kelly-DAI Organ transplantation for inherited metabolic disease. Arch-Dis-Child. 1994 Sep; 71(3): 181-3

[Liver transplantation for inherited metabolic disease is a therapeutic reality in the 1990s. The rapid expansion of molecular genetics and the development of effective gene therapy may well displace liver transplantation as appropriate treatment of these disorders in the future].

 

 Shmueli-D; Lustig-S; Nakache-R; Yussim-A; Bar-Nathan-N; Shaharabani-E; Shapira-Z  Renal transplantation in patients with amyloidosis due to familial Mediterranean fever.

SO Transplant-Proc. 1992 Oct; 24(5): 1783-4

 

 

 Santamauro-JT; Stover-DE; Jules-Elysee-K; Maurer-JR  Lung transplantation for chemotherapy-induced pulmonary fibrosis. Chest. 1994 Jan; 105(1): 310-2

 

Lesions and transplantation / edited by P.Micheal Conn. San Diego,Calif: Academic press, 1991.[QP 361 Les]

 

IMMUNE SUPPRESSION (IMM)

 

Lutz-E; Ward-KN; Gray-JJ Maturation of antibody avidity after primary human cytomegalovirus infection is delayed in immunosuppressed solid organ transplant patients. J-Med-Virol. 1994 Dec; 44(4): 317-22

[This finding provides evidence that immunosuppression has subtle, hitherto unsuspected, effects on humoral immunity to CMV in addition to the well-known depression of cell-mediated responses].

 

Zeevi-A; Pavlick-M; Lombardozzi-S; Banas-R; Pappo-O; Rao-AS; Fontes-P; Demetris-J; Shapiro-R; Dodson-F; et-al  Immune status of recipients following bone marrow-augmented solid organ transplantation. Transplantation. 1995 Feb 27; 59(4): 616-20

[It has been postulated that the resident "passenger" leukocytes of hematolymphoid origin that migrate from whole organ grafts and subsequently establish systemic chimerism are essential for graft acceptance and the induction of donor-specific nonreactivity. This phenomenon was augmented by infusing 3 x 10(8) unmodified donor bone-marrow cells into 40 patients at the time of organ transplantation].

 

Bertolatus-JA  Clinical immunosuppressive regimens and clinical results in renal transplantation. Semin-Nephrol. 1992 Jul; 12(4): 332-42

 

Kahan-BD; Welsh-M; Knight-R; Katz-S; Lewis-R; Grevel-J; Van-Buren-CT. Pharmacokinetic strategies for cyclosporin therapy in organ transplantation. J-Autoimmun. 1992 Apr; 5 Suppl A: 333-41

. In an attempt to eliminate marked deviations of insufficient or excessive CsA concentrations consequent to the administration of uniform drug doses, test dose pharmacokinetics were performed on each potential organ transplant candidate]

 

Huynh-LA; Min-DI  Outcomes of pregnancy and the management of immunosuppressive agents to minimize fetal risks in organ transplant patients. Ann-Pharmacother. 1994 Dec; 28(12): 1355-7

 

Audra-P  [Pregnancy in women who underwent organ transplantation (editorial)]  Arch-Pediatr. 1994 Aug; 1(8): 699-702

 

Haydon-GH; Hayes-PC  New immunosuppressive treatment in transplantation medicine.

SO Baillieres-Clin-Gastroenterol. 1994 Sep; 8(3): 455-64

[Currently, the standard immunosuppressive regimen in organ transplantation is centred around cyclosporin. However, despite the use of this drug, rejection is not uncommon and it is associated with significant side-effects. Novel drugs and regimens have been developed to combat allograft rejection. FK506. Sodium brequinar rapamycin. Mycophenolate mofetil, has monoclonal antibodies against the T-cell receptor, the IL-2 receptor, CD4 T cells and specific adhesion molecules such as ICAM-1

 

Gruber-SA. Local immunosuppressive therapy in organ transplantation. Transplant-Proc. 1994 Dec; 26(6): 3214-6

 

Boussiotis-VA; Freeman-GJ; Griffin-JD; Gray-GS; Gribben-JG; Nadler-LM. CD2 is involved in maintenance and reversal of human alloantigen-specific clonal anergy]. SO J-Exp-Med. 1994 Nov 1; 180(5): 1665-7

 

Twentyman-PR  Cyclosporins as drug resistance modifiers. Biochem-Pharmacol. 1992 Jan 9; 43(1): 109-17

[Cyclosporin A (CsA, is the principle drug used for immunosuppression in organ transplant patients. It is known to have a very specific effect on T-cell proliferation although the precise mechanism remains unclear. PSC-833. a non-immunosuppressive analogues of CsA has resistance modifier activity and is are more potent than the parent compound.

 

 

Talaat-KM; Tyden-G; Bjorkman-U; Groth-CG. Thirty successful pregnancies in organ transplant recipients: a single-center experience. Transplant-Proc. 1994 Jun; 26(3): 1773

 

Thomas-FT; Tepper-MA; Thomas-JM; Haisch-CE  15-Deoxyspergualin: a novel immunosuppressive drug with clinical potential. Ann-N-Y-Acad-Sci. 1993 Jun 23; 685: 175-92

[The studies discussed in this review suggest that DSG is a potent immunosuppressive agent, The initial advance in immunosuppression which made the first organ transplants possible was the finding of the immunosuppressive capabilities of azathioprine (Imuran) and the ability to reverse acute rejection crisis with prednisone. Anti-thymocyte or anti-lymphocyte globulin, introduced in 1966, achieved variable results, with some groups reporting excellent patient and graft survival using this agent.. By the mid-1970s, transplant results had improved at a number of units, with graft survivals of kidney and heart recipients in the 70 percent range at 1 to 2 years. No major progress was reported in most units, however, until the introduction in 1978 of cyclosporine. A major effect of cyclosporine was to create a universal improvement in graft survival in all units surveyed around the world with a 70 to 75 percent one-year cadaver kidney graft survival, representing the basic standard for clinical results]

 

NEOPLASM (NEO)

Khauli-RB  Genitourinary malignancies in organ transplant recipients. Semin-Urol. 1994 Aug; 12(3): 224-32.

 

Leblond-V; Sutton-L; Dorent-R; Davi-F; Bitker-MO; Gabarre-J; Charlotte-F; Ghoussoub-JJ; Fourcade-C; Fischer-A; et-al  Lymphoproliferative disorders after organ transplantation: a report of 24 cases observed in a single center. J-Clin-Oncol. 1995 Apr; 13(4): 961-8

Organ recipients are at a high risk of post-transplant lymphoproliferative disorders (PTLDs) as a complication of immunosuppressive therapy. Anti-B-cell monoclonal antibody therapy seems to be effective in PTLD, even in monoclonal B-cell forms, but other approaches will be necessary to improve survival further].

 

McClean-K; Kneteman-N; Taylor-G  Comparative risk of bloodstream infection in organ transplant recipients. Infect-Control-Hosp-Epidemiol. 1994 Sep; 15(9): 582-4

. Liver recipients experienced a higher rate (28%) than either kidney (5%) or heart, heart-lung (10%). Primary infections (60% overall) caused by gram-positive bacteria (59% overall) predominated at all three sites]

 

Frank-D; Cesarman-E; Liu-YF; Michler-RE; Knowles-DM  Posttransplantation lymphoproliferative disorders frequently contain type A and not type B Epstein-Barr virus. Blood. 1995 Mar 1; 85(5): 1396-403

 

Burtin-P; Boman-F; Pinelli-G; Mattei-MF; Dopff-C; Villemo  Cancers following thoracic organ transplantation: a single center study. Transplant-Proc. 1995 Apr; 27(2): 1765-6

 

Penn-I  The problem of cancer in organ transplant recipients: an overview. Transplant-Sci. 1994 Sep; 4(1): 23-32

 

Lee-ES; Locker-J; Nalesnik-M; Reyes-J; Jaffe-R; Alashari-M; Nour-B; Tzakis-A; Dickman-PS.  The association of Epstein-Barr virus with smooth-muscle tumors occurring after organ transplantation [see comments]. N-Engl-J-Med. 1995 Jan 5; 332(1): 19-25

 

Penn-I  Depressed immunity and the development of cancer. Cancer-Detect-Prev. 1994; 18(4): 241-52

[The most common tumors in patients with primary immunodeficiency states are NHLs (49%), leukemias (13%), various carcinomas (9%), and Hodgkin's disease (7%).]

 

AU Philit-F; Mornex-JF; Dureau-G; Chuzel-M; Euvrard-S; Ecochard-D; Brune-J. Cutaneous Kaposi's sarcoma with pulmonary carcinomatous lymphangitis in patient with transplantation. Rev-Mal-Respir. 1994; 11(4): 421-3

[We report a case of cutaneous Kaposi's sarcoma developing some six months after a cardiac transplant.

 

Namyslowski-G; Religa-Z; Steszewska-U; Misiollek-M; Czecior-E.  [A case of laryngeal carcinoma as a result of immunosuppressive therapy with cyclosporin A following heart transplantation]

SO Otolaryngol-Pol. 1994; 48(1): 72-4

[case of the larynx cancer of 38 year old woman, two years after heart transplantation, during Cyclosporine A therapy]

 

Lacha-J; Jirka-J; Nouza-M; Chadimova-M; Rossmann-P. [Kidney transplantation and tumors]. Cas-Lek-Cesk. 1994 Sep 26; 133(18): 562-5

[The prevalence of tumours of various organs in patients after transplantations of the kidneys are not a frequent but a very serious complication. Its causes are multifactorial.

 

Berg-LC; Copenhaver-CM; Morrison-VA; Gruber-SA; Dunn-DL; Gajl-Peczalska-K; Strickler-JG. B-cell lymphoproliferative disorders in solid-organ transplant patients: detection of Epstein-Barr virus by in situ hybridization. Hum-Pathol. 1992 Feb; 23(2): 159-63

[These data provide further support for the etiologic role of EBV in the pathogenesis of

posttransplantation lymphoproliferative disorders].

 

Kolb-HJ; Guenther-W; Duell-T; Socie-G; Schaeffer-E; Holler-E; Schumm-M; Horowitz-MM; Gale-RP; Fliedner-TM.  Cancer after bone marrow transplantation. IBMTR and EBMT/EULEP Study Group on Late Effects. Bone-Marrow-Transplant. 1992; 10 Suppl 1: 135-8

[Radiation, chemotherapy, immunosuppression and the original disease for which transplantation was performed may predispose to the development of cancer.

 

Dodd-GD 3d; Greenler-DP; Confer-SR . Thoracic and abdominal manifestations of lymphoma occurring in the immunocompromised patient. Radiol-Clin-North-Am. 1992 May; 30(3): 597-610

[Organ transplant and AIDS patients are at a much higher risk for developing non-Hodgkin's lymphoma than is the general population. This increased risk is directly related to chronic immunosuppression and often is associated with viral infections. In contrast to lymphomas occurring in nonimmunocompromised patients, these tumors typically are of higher grade, are more aggressive, have a worse prognosis, and exhibit a higher frequency of extranodal disease. The most frequent organs involved are the head and neck, bowel, liver, and lungs]

 

Filipovich-AH; Mathur-A; Kamat-D; Kersey-JH; Shapiro-RS. Lymphoproliferative disorders and other tumors complicating immunodeficiencies. Immunodeficiency. 1994; 5(2): 91-112

[The incidence rates of these cancers vary from 1% to as high as 25% among specific groups of persons with primary (genetically-determined) immunodeficiencies as well as acquired immunodeficiencies, including immunosuppressed organ transplant recipients and individuals infected with HIV].

 

Morrison-VA; Dunn-DL; Manivel-JC; Gajl-Peczalska-KJ; Peterson-BA. Clinical characteristics of post-transplant lymphoproliferative disorders. Am-J-Med. 1994 Jul; 97(1): 14-24

[The outcome of patients with post-solid organ transplant lymphoproliferative disorders is poor, and the optimal approach to therapy is not clear. Newer therapeutic approaches are thus needed to improve the outcome of these patients].

 

Penn-I.  De novo malignancy in pediatric organ transplant recipients. J-Pediatr-Surg. 1994 Feb; 29(2): 221-6; discussion 227-8

malignancies that developed in pediatric recipients was very different from that of the general pediatric population and that of adult recipients

 

Mathur-A; Kamat-DM; Filipovich-AH; Steinbuch-M; Shapiro-RS. Immunoregulatory abnormalities in patients with Epstein-Barr virus-associated B cell lymphoproliferative disorders. Transplantation. 1994 Apr 15; 57(7): 1042-5

[These results suggest that imbalance in the proportions of circulating cytokines favoring B cell proliferation may be contributing to the development of EBV-associated BLPD].

 

Gruber-SA; Matas-AJ. Etiology and pathogenesis of tumors occurring after organ transplantation. Transplant-Sci. 1994 Sep; 4(1): 87-104

 

Nalesnik-MA; Starzl-TE.  Epstein-Barr virus, infectious mononucleosis, and posttransplant lymphoproliferative disorders. Transplant-Sci. 1994 Sep; 4(1): 61-79

[PTLD may be considered as an "opportunistic cancer" in which the immunodeficiency state of the host plays a key role in fostering the environment necessary for abnormal lymphoproliferation.]

 

Opelz-G; Henderson-R TI: Incidence of non-Hodgkin lymphoma in kidney and heart transplant recipients. Lancet. 1993.

that the risk of NHL is related to the aggressiveness of the immunosuppressive regimen.]

 

 

Farge-D. Kaposi's sarcoma in organ transplant recipients. The Collaborative Transplantation Research Group of Ile de France. Eur-J-Med. 1993 Jun-Jul; 2(6): 339-43

[True prevalence of Kaposi's sarcoma among European transplant recipients is high (0.52%) and appeared significantly higher in liver compared with other organ transplant recipients. Cyclosporine seems to increase severity of the disease among kidney transplant recipient].

 

Euvrard-S; Chardonnet-Y; Pouteil-Noble-C; Kanitakis-J; Chignol-MC; Thivolet-J; Touraine-JL TI: Association of skin malignancies with various and multiple carcinogenic and noncarcinogenic human papillomaviruses in renal transplant recipients. Cancer. 1993 Oct 1; 72(7): 2198-206

[Our results show that oncogenic and benign HPV often are detected within premalignant keratoses and SCC in organ transplant recipients, which suggests that HPV may play a role in the development of cutaneous malignancies].

 

Cen-H; Williams-PA; McWilliams-HP; Breinig-MC; Ho-M; McKnight-JL . Evidence for restricted Epstein-Barr virus latent gene expression and anti-EBNA antibody response in solid organ transplant recipients with posttransplant lymphoproliferative disorders. Blood. 1993 Mar 1; 81(5): 1393-403

 

Penn-I. Tumors after renal and cardiac transplantation.  Hematol-Oncol-Clin-North-Am. 1993 Apr; 7(2): 431-45

[Organ transplant recipients treated with immunosuppressive therapy are prone to develop malignancies particularly squamous cell carcinomas of the skin, non-Hodgkin's lymphomas, Kaposi's sarcomas, carcinomas of the vulva and perineum, in situ carcinomas of the uterine cervix, renal carcinomas, hepatomas, and various sarcomas. The earliest tumors to appear are the Kaposi's sarcoma at an average of 21 months after transplantation, and the latest are carcinomas of the vulva and perineum, at an average of 112 months after transplantation. The tumors that develop in cardiac allograft recipients compared with renal transplant recipients are predominantly non-Hodgkin's lymphomas and more rarely, skin, uterine cervical and vulvar tumors. Major factors accounting for these differences are the intensity of immunosuppressive therapy given to the cardiac patients and the much longer follow-up of the renal allograft recipients].

 

Burtin-P; Boman-F; Pinelli-G; Mattei-MF; Dopff-C; Villemot-JP . Cancers following thoracic organ transplantation: a single center study. Transplant-Proc. 1995 Apr; 27(2): 1765-6.

 

Noel-JC; Heenen-M. [ Posttransplant skin cancer: a possible role for p53 gene mutation but not for oncogenic human papillomaviruses [letter]. J-Am-Acad-Dermatol. 1995 May; 32(5 Pt 1): 819-20

 

Penn-I; Porat-G . Central nervous system lymphomas in organ allograft recipients. Transplantation. 1995 Jan 27; 59(2): 240-4.

[Central nervous system (CNS) involvement occurred in 289 of 1332 patients (22%) with posttransplant non-Hodgkins lymphomas].

 

 

Rea-D; Fourcade-C; Leblond-V; Rowe-M; Joab-I; Edelman-L; Bitker-MO; Gandjbakhch-I; Suberbielle-C; Farcet-JP; et-al . Patterns of Epstein-Barr virus latent and replicative gene expression in Epstein-Barr virus B cell lymphoproliferative disorders after organ transplantation. Transplantation. 1994 Aug 15; 58(3): 317-24.

[We demonstrated that EBV-related B cell PTLD exhibited varying patterns of latent viral gene expression]

 

Espana-A; Redondo-P; Fernandez-AL; Zabala-M; Herreros-J; Llorens-R; Quintanilla-E  Skin cancer in heart transplant recipients. J-Am-Acad-Dermatol. 1995 Mar; 32(3): 458-65

[CONCLUSION: We found an increased progressive cumulative incidence of skin cancer in heart transplant recipients for two reasons: (1) immunosuppression and increased exposure to ultraviolet radiation in some patients, and (2) the skin type of certain patients. We emphasize the need for photoprotection in this group of patients and regular skin cancer screening examinations].

 

 

Lazarovits-AI; Tibbles-LA; Grant-DR; Ghent-CN; Wall-WJ; White-MJ; Joncas-JH TI: Anti-B cell antibodies for the treatment of monoclonal Epstein-Barr virus-induced lymphoproliferative syndrome after multivisceral transplantation. Clin-Invest-Med. 1994 Dec; 17(6): 621-5

[We conclude that CD21 and CD24 monoclonal antibodies may be of value in the therapy of oigoclonal EBV-LPS, and merit further study]

 

AU Riddler-SA; Breinig-MC; McKnight-JL. Increased levels of circulating Epstein-Barr virus (EBV)-infected lymphocytes and decreased EBV nuclear antigen antibody responses are associated with the development of posttransplant lymphoproliferative disease in solid-organ transplant recipients. Blood. 1994 Aug 1; 84(3): 972-84

[a quantitative difference in circulating EBV viral load and EBNA antibody levels is evident between transplant recipients with and without PTLD and may be useful as a noninvasive prognostic marker with which to monitor and/or predict the development of PTLD]

 

Boyle-TJ; Berend-KR; DiMaio-JM; Coles-RE; Via-DF; Lyerly-HK. Adoptive transfer of cytotoxic T lymphocytes for the treatment of transplant-associated lymphoma. Surgery. 1993 Aug; 114(2): 218-25; discussion 226

[This study showed the role of EBV-CTL in inhibiting the development of BCL.

 

Shaver-TR; Swanson-SJ 3d; Fernandez-Bueno-C; Kocandrle-V. The optimal treatment of lymphoceles following renal transplantation. Transpl-Int. 1993 Mar; 6(2): 108-10

[Our results confirm that internal marsupialization is the procedure of choice for most post-transplant lymphoceles. Internal marsupialization through laparoscopy should be used in patients who meet the standard criteria for laparoscopy].

 

 

Leblond-V; Sutton-L; Dorent-R; Davi-F; Bitker-MO; Gabarre-J; Charlotte-F; Ghoussoub-JJ; Fourcade-C; Fischer-A; et-al . Lymphoproliferative disorders after organ transplantation: a report of 24 cases observed in a single center. J-Clin-Oncol. 1995 Apr; 13(4): 961-8

[Twenty-four (1.7%) of 1,385 organ transplant recipients developed PTLDs.: Anti-B-cell monoclonal antibody therapy seems to be effective in PTLD, even in monoclonal B-cell forms, but other approaches will be necessary to improve survival further].

 

INFECTION (INF)

 

Patel-R; Roberts-GD; Keating-MR; Paya-CV . Infections due to nontuberculous mycobacteria in kidney, heart, and liver transplant recipients. Clin-Infect-Dis. 1994 Aug; 19(2): 263-73

[Infections due to nontuberculous mycobacteria (NTM) in solid-organ transplant recipients are infrequent but may be a major cause of morbidity]

 

Wolinsky-E . Mycobacterial diseases other than tuberculosis. Clin-Infect-Dis. 1992 Jul; 15(1): 1-10

[Since 1986 disseminated disease has become not only more common, especially in association with opportunistic infections in patients with AIDS, but also attributable in part to the growing population of patients who are immunocompromised because of malignancy, receipt of an organ transplant, and administration of steroids].

 

Ezzedine-H; Mourad-M; Van-Ossel-C; Logghe-C; Squifflet-JP; Renault-F; Wauters-G; Gigi-J; Wilmotte-L; Haxhe-JJ. An outbreak of Ochrobactrum anthropi bacteraemia in five organ transplant patients. J-Hosp-Infect. 1994 May; 27(1): 35-42.

[Nosocomial bacteraemia caused by Ochrobactrum anthropi occurred over a 1-month period in five organ transplant recipients, four of whom were in the same renal and pancreatic transplant unit. Bacteraemia]

 

Straus-WL; Ostroff-SM; Jernigan-DB; Kiehn-TE; Sordillo-EM; Armstrong-D; Boone-N; Schneider-N; Kilburn-JO; Silcox-VA; et-al . Clinical and epidemiologic characteristics of Mycobacterium haemophilum, an emerging pathogen in immunocompromised patients. Ann-Intern-Med. 1994 Jan 15; 120(2): 118-25

 

Gerrard-JG . Pneumocystis carinii pneumonia in HIV-negative immunocompromised adults.

Med-J-Aust. 1995 Mar 6; 162(5): 233-5

[Solid organ transplant recipients and individuals receiving treatment for Wegener's granulomatosis have a significant risk of developing PCP. Given the high mortality associated with this disease in HIV-negative patients, primary PCP chemoprophylaxis should be considered during the first six months of immunosuppression]

 

The-TH; Grefte-JM; van-der-Bij-W; van-Son-WJ; van-den-Berg-AP. CMV infection after organ transplantation: immunopathological and clinical aspects. Neth-J-Med. 1994 Dec; 45(6): 309-18

[Cytomegalovirus (CMV), a member of the Herpes virus family, is a seemingly harmless infectious agent for healthy individuals. However, it is one of the most important opportunistic pathogens in immunosuppressed patients, particularly in organ transplant recipients].

 

Morales-JM; Campistol-JM; Bruguera-M; Andres-A; Oppenheimer-F; Rodicio-JL . HCV and organ transplantation [letter]. Lancet. 1995 May 6; 345(8958): 1174-5

 

Morrissey-PE; Lorber-KM; Marcarelli-M; Bia-MJ; Kliger-AS; Lorber-MI. Posttransplant Epstein-Barr virus infection is associated with elevated levels of CD19+ B lymphocytes. Transplantation. 1995 Feb 27; 59(4): 637-40

 

Maple-PA; McKee-T; Desselberger-U; Wreghitt-TG. Hepatitis C virus infections in transplant patients: serological and virological investigations. J-Med-Virol. 1994 Sep; 44(1): 43-8

[ABSTRACT: Hepatitis C virus (HCV) is transmitted by organs of HCV antibody-positive donors to transplant recipients.. For detection of HCV infection in transplant recipients it is essential that testing for HCV RNA by RT-PCR is carried out].

 

Weber-B; Braun-W; Tyralla-B; Hamann-A; Doerr-HW. Human cytomegalovirus (HCMV)-specific immunoglobulin E as a serologic marker for HCMV infection in immunocompromised patients. Clin-Investig. 1992 Jun; 70(6): 497-502

IgE against HCMV is a more reliable serologic marker for primary and secondary HCMV infection than IgM in immunocompromised individuals, especially in organ transplant recipients, since it is not affected by the prophylactic application of HCMV hyperimmune globulin preparations].

 

Kangro-HO; Osman-HK; Lau-YL; Heath-RB; Yeung-CY; Ng-MH. Seroprevalence of antibodies to human herpesviruses in England and Hong Kong. J-Med-Virol. 1994 May; 43(1): 91-6

[The high prevalence of CMV in particular may have implications for the management of young pregnant women and organ transplant recipients in Hong Kong]

 

 

Nour-B; Green-M; Michaels-M; Reyes-J; Tzakis-A; Gartner-JC; McLoughlin-L; Starzl-TE . Parvovirus B19 infection in pediatric transplant patients. Transplantation. 1993 Oct; 56(4): 835-8

[Parvovirus infection should be included in the differential diagnosis of solid-organ transplant recipients presenting with severe anemia associated with low or absent reticulocytes].

 

Starr-SE . Cytomegalovirus vaccines: current status. Infect-Agents-Dis. 1992 Jun; 1(3): 146-8

[In a double-blind, placebo-controlled trial in renal transplant recipients, administration of Towne vaccine was associated with significant reduction in the incidence of severe CMV disease.]

 

Avery-RK . Infections and immunizations in organ transplant recipients: a preventive approach. Cleve-Clin-J-Med. 1994 Sep-Oct; 61(5): 386-92

[The best preventive approach encompasses awareness of epidemiologic risk, early detection of infection, appropriate prophylactic or preemptive therapy for specific infections, and close collaboration between the infectious-disease clinician and the transplant team].

 

Burchard-GD. [Transmission of parasites by blood transfusions and organ transplantation]. Infusionsther-Transfusionsmed. 1994 Aug; 21 Suppl 1: 40-8

[guidelines for prevention of transfusion malaria should be modified and that a donor selection should also take place concerning Chagas' disease].

 

Pereira-BJ; Wright-TL; Schmid-CH; Bryan-CF; Cheung-RC; Cooper-ES; Hsu-H; Heyn-Lamb-R; Light-JA; Norman-DJ; et-al . Screening and confirmatory testing of cadaver organ donors for hepatitis C virus infection: a U.S. National Collaborative Study. Kidney-Int. 1994 Sep; 46(3): 886-92

[Hepatitis C virus (HCV) can be transmitted by organ transplantation. Cadaver organ donors are screened for HCV infection by testing for antibodies to HCV (anti-HCV).. Discarding organs from ELISA2 positive donors would eliminate transmission, but organs from 1.88 percent of donors would be wasted]

 

Tollemar-J; Andersson-S; Ringden-O; Tyden-G . A retrospective clinical comparison between antifungal treatment with liposomal amphotericin B (AmBisome) and conventional amphotericin B in transplant recipients. Mycoses. 1992 Sep-Oct; 35(9-10): 215-20

[Treatment with amphotericin B, the drug of choice for these infections, is however often limited by toxicity.

 

Barenbrock-M; Spieker-C; Buchholz-B; Zidek-W; Rahn-KH . Pentamidine inhalation in prevention of pneumocystis carinii pneumonia in treatment of rejection with monoclonal antibody Orthoclone (OKT-3)]. Med-Klin. 1992 Oct; 87 Suppl 1: 53-5

[a prophylactic inhalation of pentamidine in severely immunosuppressed solid organ transplant recipients can prevent pneumocystis carinii pneumonia]

 

Knabe-SL; West-J. Asepsis--transplant infection control in the OR [published erratum appears in Todays OR Nurse 1992 May;14(5):356]. Todays-OR-Nurse. 1992 Feb; 14(2): 19-25

[1.. Transplant recipients are susceptible because normal defense mechanisms are undermined by cytotoxic agents and steroids to prevent rejection of the allograft. 2. The specific type of organ transplant affects the site and type of infection. The stress of surgery and the duration of the operative procedure are important risk factors. The more the patient is subjected to invasive procedures, the greater the risk for infection]

 

Denning-DW; Lee-JY; Hostetler-JS; Pappas-P; Kauffman-CA; Dewsnup-DH; Galgiani-JN; Graybill-JR; Sugar-AM; Catanzaro-A; et-al .  NIAID Mycoses Study Group Multicenter Trial of Oral Itraconazole Therapy for Invasive Aspergillosis. Am-J-Med. 1994 Aug; 97(2): 135-44

[Oral itraconazole is a useful alternative therapy for invasive aspergillosis with response rates apparently comparable to amphotericin B. Relapse in immunocompromised patients may be a problem.

 

Mauch-TJ; Bratton-S; Myers-T; Krane-E; Gentry-SR; Kashtan-CE.  Influenza B virus infection in pediatric solid organ transplant recipients. Pediatrics. 1994 Aug; 94(2 Pt 1): 225-9

[Influenza B infection is potentially life-threatening in pediatric SOT recipients. We recommend annual immunization of pediatric SOT recipients, their household contacts, and health care workers. Prospective studies are needed to evaluate the efficacy of influenza vaccination in pediatric SOT recipients]

 

Bailey-TC. Prevention of cytomegalovirus disease.  Semin-Respir-Infect. 1993 Sep; 8(3): 225-32

[A patient-survival benefit has been shown for preemptive therapy with ganciclovir initiated on the basis of a positive CMV surveillance culture, the basic question of whether prophylaxis is more beneficial than treatment of symptomatic infection goes unanswered]

 

Lowry-RW; Adam-E; Hu-C; Kleiman-NS; Cocanougher-B; Windsor-N; Bitar-JN; Melnick-JL; Young-JB.  What are the implications of cardiac infection with cytomegalovirus before heart transplantation? J-Heart-Lung-Transplant. 1994 Jan-Feb; 13(1 Pt 1): 122-8

[The presence of both early and late antigens in explant tissue strongly predicted allograft virus status during the follow-up periods.. These are the first prospective data to correlate pretransplantation serum antibodies and explant polymerase chain reaction status with the development of future allograft infections and overall clinical outcome].

 

Glowacki-LS; Smaill-FM. Use of immune globulin to prevent symptomatic cytomegalovirus disease in transplant recipients--a meta-analysis. Clin-Transplant. 1994 Feb; 8(1): 10-8

use of immune globulin as passive immunization for the prevention of symptomatic cytomegalovirus disease in the transplant population is supported by this meta-analysis].

 

Freymuth-F; Petitjean-J; Eugene-Ruelland-G; Daon-F; Galateau-F. [Cytomegalovirus infection after transplantation. Virological diagnosis, antiviral treatment]. Pathol-Biol-Paris. 1993 Oct; 41(8): 724-30

[CMV antigen detection within leucocytes, by immunofluorescence with the aid of monoclonal antibodies to CMV phosphoprotein PP-65, appears to be as specific, more sensitive, and allows a more rapid diagnosis than virus isolation techniques].

 

van-den-Berg-AP; van-Son-WJ; Haagsma-EB; Klompmaker-IJ; Tegzess-AM; Schirm-J; Dijkstra-G; van-der-Giessen-M; Slooff-MJ; The-TH . Prediction of recurrent cytomegalovirus disease after treatment with ganciclovir in solid-organ transplant recipients. Transplantation. 1993 Apr; 55(4): 847-51

[These data show that patients with a high risk of relapse of CMV disease can be identified at the end of antiviral therapy].

 

Hibberd-PL; Rubin-RH. Clinical aspects of fungal infection in organ transplant recipients.

Clin-Infect-Dis. 1994 Aug; 19 Suppl 1: S33-40

[Fungal infections following solid organ transplantation remain a major cause of morbidity and mortality. Candida species and Aspergillus fumigatus continue to account for the majority of these infections, although the attack rate is higher among recipients of organs other than kidneys because those patients receive more immunosuppressive therapy. "preemptive therapy," or prophylaxis, for patients at greatest risk of developing infection--may assist in attainment of this goal].

 

Torre-Cisneros-J; Lopez-OL; Kusne-S; Martinez-AJ; Starzl-TE; Simmons-RL; Martin-M. CNS aspergillosis in organ transplantation: a clinicopathological study.  J-Neurol-Neurosurg-Psychiatry. 1993 Feb; 56(2): 188-93

[The most frequent neurological symptoms were alteration of mental status (86%), seizures (41%) and focal neurological deficits (32%). Meningeal signs were less common (19%). Aspergillus spp invasion of the blood vessels with subsequent ischaemic or haemorrhagic infarcts, and solitary or multiple abscesses were the predominant neuropathological findings].

 

Reents-S; Goodwin-SD; Singh-V. Antifungal prophylaxis in immunocompromised hosts. Ann-Pharmacother. 1993 Jan; 27(1): 53-60

[azole agents are currently the most effective and best-tolerated drugs for antifungal prophylaxis in immunocompromised hosts].

 

Benedict-LM; Kusne-S; Torre-Cisneros-J; Hunt-SJ. Primary cutaneous fungal infection after solid-organ transplantation: report of five cases and review [see comments].  Clin-Infect-Dis. 1992 Jul; 15(1): 17-21

[cases of five liver transplant recipients who developed primary cutaneous opportunistic fungal infections that remained localized to the skin].

 

McClean-K; Kneteman-N; Taylor-G. Comparative risk of bloodstream infection in organ transplant recipients. Infect-Control-Hosp-Epidemiol. 1994 Sep; 15(9): 582-4

[on 277 consecutive patients were reviewed. Twenty-eight patients developed 40 infections. Liver recipients experienced a higher rate (28%) than either kidney (5%) or heart, heart-lung (10%). Primary infections (60% overall) caused by gram-positive bacteria (59% overall) predominated at all three sites.]

 

Simonds-RJ. HIV transmission by organ and tissue transplantation. AIDS. 1993 Nov; 7 Suppl 2: S35-8

[With current screening practices, HIV transmission by transplantation is rare].

 

McCarthy-JM; Karim-MA; Krueger-H; Keown-PA. The cost impact of cytomegalovirus disease in renal transplant recipients. Transplantation. 1993 Jun; 55(6): 1277-82

[CMV disease has significant economic impact on renal transplantation as a result of extended hospitalization. In order to develop a cost effective management approach to CMV infection, this impact must be considered when assessing therapeutic and prophylactic regimens and protocols of organ allocation].

 

Crompton-CH; Cheung-RK; Donjon-C; Miyazaki-I; Feinmesser-R; Hebert-D; Dosch-HM . Epstein-Barr virus surveillance after renal transplantation. Transplantation. 1994 Apr 27; 57(8): 1182-9

[We conclude that a 100-1000-fold expansion of circulating EBV+ B cell pools occurs frequently after organ transplantation and that it is balanced by effective EBV immunosurveillant functions resistant to immunosuppression. The mere detection of EBV genomic material was not predictive of lymphoma development].

 

Randal-J.  TITLE: Discovery may improve transplant success [news]. J-Natl-Cancer-Inst. 1995 Mar 15; 87(6): 404-6

 

GRAFT REJECTION (REJ)

Stepkowski-SM; Tu-Y; Condon-TP; Bennett-CF. Blocking of heart allograft rejection by intercellular adhesion molecule-1 antisense oligonucleotides alone or in combination with other immunosuppressive modalities. J-Immunol. 1994 Dec 1; 153(11): 5336-46

[Thus, antisense oligonucleotides may proffer a selective gene-targeted immunosuppressive therapy for organ transplantation.]

 

 

DeVito-Haynes-LD; Jankowska-Gan-E; Sollinger-HW; Knechtle-SJ; Burlingham-WJ

SO Hum-Immunol. 1994 Jul; 40(3): 191-201. Monitoring of kidney and simultaneous pancreas-kidney transplantation rejection by release of donor-specific, soluble HLA class.

[the release of donor sHLA class I proteins by transplanted organs might be a systemic indication of rejection in both pancreas and kidney allografts. The detection of donor sHLA in recipient sera could be an important noninvasive monitor of rejection, especially in the pancreas, which is currently difficult to monitor as a single-organ transplant].

 

Tavora-ER; Lasmar-EP; Vilaca-SS; Figueiro-JV; Bamberg-A; Rocha-LM; Costa-MM; Bicalbo-O; Souza-E; Machado-R. Strategy for improvement of graft survival in kidney recipients of nonrelated living donors. Transplant-Proc. 1995 Apr; 27(2): 1819-20

 

Tchervenkov-JI; Cofer-BR; Davies-C; Alexander-JW.  Indefinite allograft survival induced by the combination of multiple donor-specific transfusions, cyclosporine, and an anti-T cell monoclonal antibody in a protocol relevant to cadaveric organ transplantation. The importance of prolonged posttransplant cyclosporine coverage. Transplantation. 1995 Mar 27; 59(6): 821-4

[This beneficial interaction between CsA, DST, and an anti-T cell MoAb offers a clinically applicable protocol for both living donor and cadaveric organ transplantation in inducing donor-specific hyporesponsiveness, and further investigations are warranted]

 

Washburn-WK; Shaffer-D; Conway-P; Madras-PN; Monaco-AP. A single-center experience with six-antigen-matched kidney transplants.  Arch-Surg. 1995 Mar; 130(3): 277-82

[Identical HLA matching for cadaver recipients provides superior results for graft and patient survival.]

 

Ghobrial-R; Hamashima-T; Stepkowski-SM; Kahan-BD. Induction of transplantation tolerance by perioperative injection of "quasi-self" chimeric class I MHC antigen combined with a short cyclosporine course. Transplant-Proc. 1995 Feb; 27(1): 239-40

 

 

Blakely-ML; Shaffer-D; Ohzato-H; Gottschalk-R; Van-der-Werf-WJ; Monaco-AP. Indefinite survival following small intestinal transplantation after intrathymic injection of the donor with recipient-type splenocytes in a rat model. Transplantation. 1995 Jan 27; 59(2): 309-11

 

Caillat-Zucman-S; Legendre-C; Suberbielle-C; Bodemer-C; Noel-LH; Kreis-H; Bach-JF. Microchimerism frequency two to thirty years after cadaveric kidney transplantation. Hum-Immunol. 1994 Sep; 41(1): 91-5

[This low frequency of microchimerism raises doubts about a major role of chimerism in development of long-lasting specific tolerance following kidney allografting].

 

Masroor-S; Schroeder-TJ; Michler-RE; Alexander-JW; First-MR . Monoclonal antibodies in organ transplantation: an overview. Transpl-Immunol. 1994 Sep; 2(3): 176-89

 

Leffell-MS; Steinberg-AG; Bias-WB; Machan-CH; Zachary-AA. The distribution of HLA antigens and phenotypes among donors and patients in the UNOS registry. Transplantation. 1994 Nov 27; 58(10): 1119-30

[the likelihood of achieving a good match is low, regardless of race. These data explain the observations that, with the exception of the phenotypically identical match, HLA matching does not influence organ distribution significantly].

 

Mannon-RB; Coffman-TM. Immunologic mechanisms of transplant rejection. Curr-Opin-Nephrol-Hypertens. 1992 Dec; 1(2): 230-5

[Rejection can be prevented by interfering with the interaction of recipient T cells with alloantigens using interventions such as antibodies against major histocompatibility complex proteins or accessory adhesion molecules,. In addition, specific antagonists of individual cytokines show promise as antirejection treatments].

 

Narciso-HR; Bordin-JO; Silva-Junior-HT; Ajzen-H; Ramos-OL; Pestana-JO. [ABO incompatibility in organ transplant. Report of case and review of the literature]. Rev-Assoc-Med-Bras. 1992 Apr-Jun; 38(2): 101-5

[preparation of the receptor with plasmapheresis and splenectomy, before the transplantation may prevent the hyperacute rejection on ABO incompatible organs allografts].

 

 

Gia-HP. Methodological problems relating to the evaluation of anti-rejection treatments. Therapie. 1992 Jul-Aug; 47(4): 261-3

[The evaluation of anti-rejection treatments raises a variety of methodological problems depending on the clinical phase of development].

 

Brayman-KL; Sutherland-DE . Factors leading to improved outcome following pancreas transplantation--the influence of immunosuppression and HLA matching. Transplant-Proc. 1992 Aug; 24(4 Suppl 2): 91-5

[As the success rate of pancreas transplantation continues to improve, this treatment should be considered as a means for restoring a normal glucose level in type I diabetic patients before the development of advanced, disabling complications of the disease].

 

Orloff-MS; Fallon-MA; DeMara-E; Coppage-ML; Leong-N; Cerilli-J. TITLE: Induction of specific tolerance to small-bowel allografts. Surgery. 1994 Aug; 116(2): 222-8

[Bone marrow cells share tissue-specific antigens with small-bowel cells to permit induction of tolerance.]

 

Starzl-TE; Demetris-AJ. Transplantation milestones. Viewed with one- and two-way paradigms of tolerance. JAMA. 1995 Mar 15; 273(11): 876-9

 

Schuurman-HJ. Molecular mechanisms of transplant rejection. Clin-Investig. 1994 Sep; 72(9): 715-8

 

Wetzsteon-PJ; Head-MA; Fletcher-LM; Lye-WC; Norman-DJ. Cytotoxic flow-cytometric crossmatches (flow-tox): a comparison with conventional cytotoxicity crossmatch techniques. Hum-Immunol. 1992 Oct; 35(2): 93-9

[Flow-Tox crossmatches demonstrate an increase in both sensitivity and specificity over conventional cytotoxicity crossmatches].

 

Lengerova, Alena. Immunogenetics of tissue transplantation. Amsterdam: North-Holland publication Co., 1969 [QH 431 Len ]

 

OTHERS (OTH)

 

Cocanougher-B; Ballantyne-CM; Pollack-MS; Payton-Ross-C; Lowry-R; Kleiman-NS; Farmer-JA; Noon-GP; Short-HD; Young-JB. Degree of HLA mismatch as a predictor of death from allograft arteriopathy after heart transplant. Transplant-Proc. 1993 Feb; 25(1 Pt 1): 233-6

 

Laine-J; Jalanko-H; Krogerus-L; Fyhrquist-F; Ronnholm-K; Leijala-M; Hockerstedt-K; Holmberg-C . Functional and histopathological cyclosporine A nephrotoxicity in children after organ transplantation. Transplant-Proc. 1995 Feb; 27(1): 1131-3

 

Bennett-WM; Burdmann-E; Andoh-T; Elzinga-L; Franceschini-N. Nephrotoxicity of immunosuppressive drugs. Miner-Electrolyte-Metab. 1994; 20(4): 214-20

[ABSTRACT: Drugs used to modify the immune response in solid organ transplantation or autoimmune disease may cause dose-related nephrotoxicity. This paper summarizes this literature using data from clinically relevant animal models]

 

Dimeny-E . Metabolic factors and outcome of organ transplantation. Scand-J-Urol-Nephrol-Suppl. 1994; 159: 1-74

[Chronic vascular rejection (CVR)--transplant atherosclerosis--is a major problem in organ transplantation and a leading cause of late graft failure. The purpose of the present investigation was to examine the impact of metabolic factors on the outcome of experimental and clinical transplantation. In an experimental model of CVR. It can be anticipated that intervention directed against lipid abnormalities or other metabolic risk factors may improve the long-term success rate in organ transplantation].

 

Patchell-RA. Neurological complications of organ transplantation. Ann-Neurol. 1994 Nov; 36(5): 688-703

[30 to 60% of transplant recipients experience neurological problems].

 

Young-JB. Cardiac allograft arteriopathy: an ischemic burden of a different sort. Am-J-Cardiol. 1992 Nov 16; 70(16): 9F-13F

[cardiac allograft arteriopathy may be detected in as many as 90% of heart transplant recipients after 5 years]

 

First-MR; Neylan-JF; Rocher-LL; Tejani-. Hypertension after renal transplantation.

J-Am-Soc-Nephrol. 1994 Feb; 4(8 Suppl): S30-6

[Hypertension is a frequent complication after organ transplantation in both children and adults and is a significant risk factor for the development of cardiovascular disease and graft dysfunction. Hypertension needs to be treated aggressively in all transplant recipients in an attempt to minimize allograft and cardiovascular damage].

 

Frost-AE; Keller-CA. Anemia and erythropoietin levels in recipients of solid organ transplants. The Multi-Organ Transplant Group. Transplantation. 1993 Oct; 56(4): 1008-11

 

Halpert-RD; Goodman-P; Caroline-DF. Abdominal complications in organ transplant recipients.

Radiol-Clin-North-Am. 1993 Nov; 31(6): 1345-57

These include inflammatory changes involving the bowel, liver, and pancreas and range from technical complications associated with the surgery to organ rejection, opportunistic infections, and an increased risk of de novo malignancy in transplantation patients].

 

Trzepacz-PT; DiMartini-A; Tringali-RD. Psychopharmacologic issues in organ transplantation. Part 2: Psychopharmacologic medications. Psychosomatics. 1993 Jul-Aug; 34(4): 290-8

[The side effects of psychotropic drugs need to be distinguished from those of immunosuppressants]

 

Greenson-JK; Trinidad-SB; Pfeil-SA; Brainard-JA; McBride-PT; Colijn-HO; Tesi-RJ; Lucas-JG .  Gastric mucosal calcinosis. Calcified aluminum phosphate deposits secondary to aluminum-containing antacids or sucralfate therapy in organ transplant patients. Am-J-Surg-Pathol. 1993 Jan; 17(1): 45-50

[accelerated bone demineralization via loss of phosphates and absorption of aluminum in the gastrointestinal tract may be a consequence of long-term aluminum-containing antacid or sucralfate therapy].

 

CONCERNS (CONC)

 

Watanabe-Y. Why do I stand against the movement for cardiac transplantation in Japan? Jpn-Heart-J. 1994 Nov; 35(6): 701-14

[crucial differences between death judged by the classical criteria and so-called brain death transplantation involves prejudice and inequality, since the number of potential organ recipients far exceeds that of donors once organ transplantation from brain dead patients is allowed, numerous ethical and social problems would arise including an arbitrary expansion of the criteria for brain death, selection of donors and recipients by taking non-medial factors into consideration, development of organ commerce leading to the involvement of organized crime, and the birth of a trend in transplant candidates to wish for an early death of histocompatible donors. Finally, it is pointed out that we must give serious thought to the danger of "from neck down" transplantation creating a new person from two bodies (which is a brain transplant in actuality) in the future, since the difference between such a procedure and the multiorgan transplantation presently practiced in many developed countries is only quantitative and one cannot find a logical reason to ban the former while retaining the latter].

 

Sheil-AG. Ethics in organ transplantation: the major issues. Transplant-Proc. 1995 Feb; 27(1): 87-9

 

Starzomski-R. Ethical issues in palliative care: the case of dialysis and organ transplantation. J-Palliat-Care. 1994 Autumn; 10(3): 27-34

 

Olweny-C. Bioethics in developing countries: ethics of scarcity and sacrifice. J-Med-Ethics. 1994 Sep; 20(3): 169-74

[Health care reform in developing countries must not merely re-echo what is being done in the industrialized countries, but must respond to societal needs and be relevant to the community in question].

 

Caplan-AL . Current ethical issues in organ procurement and transplantation. JAMA. 1994 Dec 7; 272(21): 1708-9

 

Carter-JM. Reform organ-tissue transplantation [letter]. J-Natl-Med-Assoc. 1994 Sep; 86(9): 647, 666, 685

 

Metcalf-MP. Ethicist's role on the transplant team [letter]. Clin-Transplant. 1994 Aug; 8(4): 418

 

Koyanagi-H; Hachida-M. [The strategy how to restart heart transplantation in Japan from the viewpoint of cardiovascular surgeons]. Nippon-Kyobu-Shikkan-Gakkai-Zasshi. 1993 Dec; 31 Suppl: 86-9

[Japan is still in the midst of confusion the ethical, social and legal standpoints of organ transplantation. We have paid attention and effort to negotiate and reorganize the heart transplantation environment. This paper discusses several problems concerning the criteria, standardization, assessment, evaluation committee and authorization of medical centers to initiate heart transplantation in this country].

 

Fernandes-FV. [The ethics of organ donation for transplantation]. Acta-Med-Port. 1994 Jan; 7(1): 51-3

[The new law 12/93, which regulates organ donation for transplantation in Portugal, is reviewed. The author emphasizes the importance of some legal improvements to allow a better fulfillment of the first principles of ethics that will rule the conflicts of interest between living and dead donors and recipients. Criticism is made of the interference that the Ministry of Health will have in the decision of doctors' and Medical Centres' competence. The importance given to economic reasons which stimulate political promotion and minimise ethical and professional reasons would become future factors of obstruction and backwardness].

 

Hara-M; Kai-K; Suzuki-T; Nose-Y. [Organ transplantation and inspection from medico-legal aspects]. Nippon-Hoigaku-Zasshi. 1993 Dec; 47(6): 456-65

 

Thomasma-DC. Ethical issues and transplantation technology. Camb-Q-Healthc-Ethics. 1992 Fall; 1(4): 333-43

 

Tichtchenko-PD; Yudin-BG. Toward a bioethics in post-communist Russia. Camb-Q-Healthc-Ethics. 1992 Fall; 1(4): 295-303

 

Huang,Lui. Legal aspects:Organ translantation. Singapore: Faculty of Law, University of Singapore, 1971. [ Wo 690 Hua ]

 

Demikhov, Vladmir petrovich. Experimental transplantation of vital organs /authorized transplantation from the Russian by Basil Haigh. NewYork: Consultants Byreau, 1962 [RD126 Dem ]

Wolstenhlme, G.E.W (Gordon Ethelbert ward ) Law and ethics of transplantation. London: J & A .Churchill,1968. [K 91 S & Wol ]

 

Legislative responses to organ transplantation./ edited by world Health Organization. The Hague: Martinus Nijhoff,1993.  [ k 91 s 7 Leg ]

 

Farndale,william . Law on human transplants and bequests of bodies. Beckenham, Kent: White publisher,1970. [K19 S & Far]

 

MUSLIM WRITINGS (SOURCES) ON TRANSPLANTATION

al Mahdi, Mukhtar al Hadi. A’dhau al insaan bayna al hibat wa al bayiu wa al akhdh bila wasiyyat in: al Ru’iyat al islamiyat li baadhi al mumaarasaat al tibiyyat: proceedings of the seminar held 0n 20 Sha’baan 1407AH/18 April 1987 AD. Islamic Medicine Organization, Kuwait 1987

 

Tantawi, Muhammadf Said. Hukm bayiu al insaan li udhuwi min a’dhaihi aw al tabarru’u bihi in: al Ru’iyat al islamiyat li baadhi al mumaarasaat al tibiyyat: proceedings of the seminar held 0n 20 Sha’baan 1407AH/18 April 1987 AD. Islamic Medicine Organaization, Kuwait 1987

 

Tantawi, Muhammadf Said. Mas’ulliyat al atibau kama yaraaha al fuqaha in: al Ru’iyat al islamiyat li baadhi al mumaarasaat al tibiyyat: proceedings of the seminar held 0n 20 Sha’baan 1407AH/18 April 1987 AD. Islamic Medicine Organaization, Kuwait 1987

 

Faidhallah, Muhammad Fawzi. al tasarruf fi a’adhai al insaan  in: al Ru’iyat al islamiyat li baadhi al mumaarasaat al tibiyyat: proceedings of the seminar held 0n 20 Sha’baan 1407AH/18 April 1987 AD. Islamic Medicine Organaization, Kuwait 1987

 

Yaasiiin, Muhammad Naem. Bayiu al a’adhau al aadamiyya in: al Ru’iyat al islamiyat li baadhi al mumaarasaat al tibiyyat: proceedings of the seminar held 0n 20 Sha’baan 1407AH/18 April 1987 AD. Islamic Medicine Organaization, Kuwait 1987

 

Abu Futuuh, Muhammad Yahya. Bayiu al a’adhai al bashariyyat fi mizaan al amshru’iyyat in: al Ru’iyat al islamiyat li baadhi al mumaarasaat al tibiyyat: proceedings of the seminar held 0n 20 Sha’baan 1407AH/18 April 1987 AD. Islamic Medicine Organaization, Kuwait 1987

 

WRITINGS ON MAQASID

al Shatibi,Abu Ishaq: Al muwafaqat fi usul Al Sharia Vol.2 : Kitaab Al Maqasid. Dar Al fikr Al Arab. No date

 

WRITINGS ON QAWAID AL FIQH.

Koutuub is a lecture in Usul al Figh at the IIU Malaysia. His paper is in possession of the author

 

PROCUREMENT AND ALLOCATION OF ORGANS (SOUR)

 

Woo-KT. Social and cultural aspects of organ donation in Asia. Ann-Acad-Med-Singapore. 1992 May; 21(3): 421-7

[In Asian countries, it is more difficult to obtain cadaver kidneys for renal transplantation because of certain socio-cultural beliefs and customs. The issues affecting living related kidney donation are more social than cultural. This is due to the web of family pressures and personal conflicts for both donor and recipient surrounding the donation. Important misconceptions and fears are: fear of death, the belief that removal of organ violates sanctity of decreased, concern about being cut up after death, desire to be buried whole, dislike of idea of kidneys inside another person, wrong concept of brain death, and the idea of donation being against religious conviction. In Singapore, with the introduction of the Human Organ Transplant Act (HOTA) in 1988, the number of cadaveric transplants have increased, including those from the Medical Therapy Act (MTA). HOTA and education have played pivotal roles in bringing about an increased yield of cadaveric kidneys. With the availability of living unrelated donor (LUD) transplants in India, our living related donor (LRD) transplant programme has suffered, because patients would rather buy a kidney from overseas than get a relative to donate one. Patients are also going to China for overseas cadaveric transplants where the kidneys come from executed convicts. People in countries like Hong Kong, Japan and the Philippines share the same Asian tradition of not parting with their organs after death. Muslim countries like Malaysia require the deceased to have earlier pledged his kidneys for donation prior to death before they can be harvested for transplantation at death].

 

Starzl-TE; Valdivia-LA; Murase-N; Demetris-AJ; Fontes-P; Rao-AS; Manez-R; Marino-IR; Todo-S; Thomson-AW; et-al . The biological basis of and strategies for clinical xenotransplantation. Immunol-Rev. 1994 Oct; 141: 213-44

[Recent discoveries have suggested that the exchange of multiple leukocyte lineages between grafts and host and subsequent long-term chimerism in both is the seminal mechanism of the acceptance of organs transplanted from the same (allografts) or different species (xenografts). This insight suggests new strategies which may allow xenotransplantation, the principal obstacle to which has been humoral rejection].

 

Sachs-DH. The pig as a potential xenograft donor. Vet-Immunol-Immunopathol. 1994 Oct; 43(1-3): 185-91

[Miniature swine have several advantages over other potential donor species as a xenograft donor for clinical use. Among these advantages are: (1) unlimited availability; (2) size (similar to human beings); (3) breeding characteristics; (4) physiologic and immunologic similarities to humans. Because of the genetic disparity between these two species, routine immunosuppression will probably not suffice for the long-term survival of pig to primate xenografts. Studies are therefore underway to induce tolerance across this species barrier, utilizing a mixed chimerism approach which has previously been successful for allogeneic and concordant xenogeneic combinations. Hyperacute rejection has been eliminated by an absorption technique and pig kidney xenograft survivals up to 13 days have been achieved]

 

Kenmochi-T; Mullen-Y; Miyamoto-M; Stein-E. Swine as an allotransplantation model. Vet-Immunol-Immunopathol. 1994 Oct; 43(1-3): 177-83

[Because of their anatomical and physiological similarities to humans, pigs are well suited for solving technical problems associated with clinical transplantation. The availability of genetically defined strains of miniature swine is unique with this species, and has permitted the investigation, in a large animal model, of immunological and genetic aspects of allograft rejection, clinical manifestations associated with bone marrow transplantation, and the feasibility of various approaches for induction of transplantation tolerance. Immunological assays and various reagents are also available in order to pursue these studies].

 

Halliday-NP. Provision of transplant services. Baillieres-Clin-Gastroenterol. 1994 Sep; 8(3): 399-410

[The availability of the key resource for the programme, namely organs, depends on the willingness of the public to donate, and on the co-operation of other health-care professionals, not directly involved in transplantation, in identifying potential donors, encouraging relatives to consent and ensuring that the donor is maintained in an optimal condition.

 

Lamm-LU; Madsen-M. [Scandiatransplant]. Nord-Med. 1994; 109(12): 317-8, 328

[Scandiatransplant is an organ exchange organisation serving a population of about 23 million inhabitants in the five Nordic countries, Iceland, Finland, Sweden, Norway and Denmark. Scandiatransplant maintains a central waiting list for Scandinavian patients scheduled for cadaver organ transplantation. Since its establishment in 1969, more than 13,000 cadaver renal transplants have been performed, and the numbers of liver, heart and lung transplantations are steadily increasing].

 

Kaihara-S. [A proposal for the Japanese Organ Transplantation Network System]. Jpn-Circ-J. 1993; 57 Suppl 4: 1266-9

 

Shafer-T; Schkade-LL; Warner-HE; Eakin-M; O'Connor-K; Springer-J; Jankiewicz-T; Reitsma-W; Steele-J; Keen-Denton-K. Impact of medical examiner/coroner practices on organ recovery in the United States.  JAMA. 1994 Nov 23-30; 272(20): 1607-13

loss of human life from denials is not needed to protect the judicial process. Increased cooperation between medical examiner offices and OPOs could significantly increase the availability of transplantable organs].

 

Keogh-AM; Kaan-A. The Australian and New Zealand Cardiothoracic Organ Transplant Registry: first report 1984-1992 [see comments]. Aust-N-Z-J-Med. 1992 Dec; 22(6): 712-7

[This initial report of the Australian and New Zealand Cardiothoracic Organ Transplant Registry summarises the results of all cardiothoracic transplants performed between February 1984 and April 1992. A total of 549 first cardiothoracic transplant procedures and six cardiac retransplant operations were performed in five transplant units throughout Australia and New Zealand. There were 466 orthotopic cardiac transplants and one heterotopic transplant with overall survival 86% at one year and 80% at five years. Two of six patients who underwent cardiac retransplantation are alive. Fifty-three heart-lung transplants were performed with 72% one year and 42% five year survival. Twenty-nine single lung transplant procedures were undertaken, with actuarial survival 72% at 12 months. Factors influencing waiting period and post-transplant survival for each type of procedure are detailed. The relative lack of donors compared with recipient demand has produced increased waiting times for every type of cardiothoracic organ transplant]

 

Schaeffer-MJ; Alexander-DC. U.S. system for organ procurement and transplantation. Am-J-Hosp-Pharm. 1992 Jul; 49(7): 1733-40

[The National Organ Transplant Act of 1984 provided for a federally funded network for organ procurement and transplantation, which would function as a private, non-profit organization. This organization is the United Network for Organ Sharing (UNOS). UNOS monitors the activities of and provides service to transplant centers and organ procurement organizations (OPOs). The names of all candidates awaiting cadaveric organ transplants are placed on a central waiting list maintained by UNOS; UNOS also is responsible for maintaining a scientific registry to collect relevant data from transplant centers on the recipients of organ transplants. Although there is a national list of more than 25,000 persons waiting at any given time for a cadaveric organ, there are far fewer actual organ donors (less than 5000 in 1991). The hospital's best resource with respect to the donation process is the local OPO, which provides services related to organ donor referral, evaluation, and surgical recovery. The organ donation process consists of eight components: donor identification, referral, evaluation, consent, management, recovery of organs, allocation, and follow-up. An organ recovery coordinator from the local OPO helps the hospital staff in determining donation potential, seeking consent from the next of kin, and managing the donor after consent has been obtained. The OPO--never the donor's family or their insurer--is billed for charges relating to the donation. The OPO then bills the costs associated with the donation to the transplant centers receiving each organ for implantation].

 

Martin-DK; Meslin-E. The give and take of organ procurement. J-Med-Philos. 1994 Feb; 19(1): 61-78

[Scientific developments of the last 20 years have made the transplantation of cadaveric solid organs a viable and expected treatment alternative for patients suffering from various forms of End Stage Organ Disease. Of the number of organs that could be utilized for this, only a small percentage of them are actually made available. North American legislation explicitly categorizes the transfer of cadaveric organs as an anatomical or tissue "gift". The concept of the gift is mediated by transculturally consistent unwritten, but powerfully felt, rules of conduct. Among the most profound elements of the concept is the obligatory gift-exchange which is central to the gift-relationship. Obviously, neither of these are permitted by the organ transplant scenario. As a result, dissonance is created within the thought process of the individual which cannot be easily resolved, paralyzing many into inaction. We maintain that the present legal framework, designed to facilitate the transfer of organs, clashes with the human phenomenon of giving, and may actually prevent organs from being made available. In a search for a solution to this gift-relationship dilemma, giving organs is contrasted with taking organs as a basis upon which to ground ethically sound public policy. Liberty-limiting principles and the concept of harm are considered within this context].

 

Coelho-JC; Fontan-RS; Pereira-JC; Wiederkehr-JC; Campos-AC; Zeni-Neto-C . [Organ donation: opinion and knowledge of intensive care unit physicians in the city of Curitiba]. Rev-Assoc-Med-Bras. 1994 Jan-Mar; 40(1): 36-8

[It is concluded that almost all intensive care unit physicians in Curitiba are favorable to organ donation and are willing to participate actively in obtaining consent of family members for donation. The basic knowledge of Brazilian law and several medical subjects on organ transplantation is unsatisfactory].

 

Gabel-H; Ahonen-J; Sodal-G; Lamm-L. Cadaveric organ donation in Scandinavia, 1992.

Transplant-Proc. 1994 Jun; 26(3): 1715-6

[Major imbalances in the number of donors and also in the number of patients waiting for a transplantation may result in the supply of organ allografts for one country or region being met by the population of another region. With confidence we are looking forward to the impact of intensified public information and education of hospital personnel on the gap between demand and supply of organ allografts].

 

Mignon-M; Delmont-JP. Current status of liver transplantation (LT) in France and specificities of French ethical attitudes concerning LT. Gastroenterol-Jpn. 1993 Jul; 28 Suppl 6: 28-32; discussion 33

[Legal dispositions stipulating the presumed consent of the donor and accrediting the notion of "cerebral death" have eased the development of liver transplantation in France. Despite these measures shortage in liver available for grafts results in still too large waiting list and fosters nation-wide campaign to encourage organ donation. There is, in France, a strong consensus for a strict sticking to the absolute principles of gratuity of organ donation and non-marketing of excised organs available for graft].

 

DEFINITION AND TIMING OF DEATH (DEA)

Youngner-SJ. Brain death and organ transplantation: confusion and its consequences. Minerva-Anestesiol. 1994 Oct; 60(10): 611-3

 

Strong-RW. Selection and management of the brain dead donor for liver and kidney transplantation. Natl-Med-J-India. 1995 Jan-Feb; 8(1): 33-5

[The passing of brain death legislation by the Indian Parliament in June 1994 has paved the way for the commencement of cadaveric organ transplant programmes in India. The medical profession must develop a code of practice that is legally, medically and ethically acceptable. Once established, adherence to the policy and procedures is mandatory or transplantation in India will fall into disrepute at home and abroad. Donor selection and management is an integral part of the transplant process. The final result of transplantation can only be as good as the quality of the organ transplanted. The key elements of the selection criteria and management of the donor after the determination of brain death are outlined in this article].

 

Hardacre-H. Response of Buddhism and Shinto to the issue of brain death and organ transplant. Camb-Q-Healthc-Ethics. 1994 Fall; 3(4): 585-601

 

Qureshi-MJ. Muslim customs surrounding death [letter]. BMJ. 1995 Mar 11; 310(6980): 669

 

Jorns-KP. Theological theses on the ethics of organ transplantation and on a law concerning the transplantation. Forensic-Sci-Int. 1994 Dec 16; 69(3): 279-83

[The message of the resurrection from the dead is relevant to human beings living and dying in the unity of body and soul. The personality of man is inseparable connected with this unit--even beyond death. Brain death only marks a (decisive) point during the process of dying, and it cannot be defined as the death of a human being (in general). Theological ethics object to this definition and to a new dualism of brain and body as well as of body and personality (i.e. soul), because this dualism socialises the organs of individuals and denies the personal dignity of disappearing life. Therefore, the explantation of organs must depend on a personal declaration of consent given by the adult sponsor himself. Each information given on organ transplants must clarify that the explanation of organs means an interruption of dying].

 

Hardacre-H. Response of Buddhism and Shinto to the issue of brain death and organ transplant. Camb-Q-Healthc-Ethics. 1994 Fall; 3(4): 585-601

 

in-der-Schmitten-J; Hoff-J. [Response to Prof. U. Korner: Brain death and organ transplantation--the controversial control of dying (letter)]. Z-Arztl-Fortbild-Jena. 1994 Aug; 88(7-8): 629-31

 

Staak-M. [Methodology of brain death determination]. Nippon-Hoigaku-Zasshi. 1994 Aug; 48(4): 240-52

 

Easson, William M. 1931 The dying child: the  management of the child or adolescent who is dying / by William M.Eason. Spring field,111.: c.c. Thoms 1970. [WS440 Eas]

 

Karunaivell,Arumugam. Death in Kuala Terenganu Districts-1977; being an explanatory study into the death regestration system currently sperating and the factors influencing the occurance of death/Arumugam Karunaivell. 1979/ [WA 54 Kar ]

 

Boehm, Hans Gero, 1906- Das Todesproblem bei Hegel and Holderlin (1797-1800 ) Marburg: H.schiinkus,1932. [Microfilm 1020.4]

 

Fieldler, Leslie Aaron, 1917. Love and death in American novel. .New york: Criteron Books ,1960.[PS 374-L6 fie]

 

Langer, Lawrence L. The age of atrocity: death in modern  literature Bston ,Mass; Beacon press 1978.[PN 56 D4 Lan]

 

Spencer, Theodere, Death and Elizabethan tragedy: a study of convetion and opinion in the Elizabethan Drama . New york; Pageant Books 1960 [ PR 658 T 7 Spe ]

 

Spilka, Mark Virginia Woolf,s quarrel with qrieving  Lincon , Neb. ; University of Nebraska press, 1980 [PR 6045 072 Z Psi]

 

Todd Janet M., 1942- Gender art and death. New York : Continum, 1993.[PR 119 TOD ]

 

Hull,Terenco. H. Prospects for rapid decline of martality rates in Java; a study of policy in intervation for mortalit control.Yogyakarta: Population studies centre,1980.[HB 1478 J 38 Hul]

 

Anthonony, Helen Sylivia, 1898-The discovery of death in childhood and after. Harmondsworth, Middlesex: Penguin Education, 1971 [BF 723 D3ANT]

 

Banker, John Charles, 1924- Scared to death; an examination of four, its cause and effects . London : F. Muller 1968 [BF 789 D4 Bar] 

 

Corr, Charles A. Death and dying, life and living. Pacific Grove, Calif : Brooks /cole 1994.[BF 789 D4 Cor]

 

Death and dereavement  edited by Austin H. Kutscher, in collaboration with 49 contributors and 24 consultant- respondents. Spring Field, 111.: c.c Thomas, 1969 [B 789 D4 Kut]

 

Leonard Pearson. Death and dying; current issues in the treatment of the dying persons Cleveland, Ohio; case Western Reserve University, 1969. [BF 789 D4 Pea]

 

Elisabeth Kubler-Ross. (Ed.) Death: The Final Stage of Growth. Englewood Cliffs, N.J. Prentice-Hall,1975 [BF789 D4 Deg]

 

Glaser,Barney G.and Anselm l. strauses  Awareness of dying. London: Weiden fold and Nicolsn, 1965. [BF 789 D4 Gla]

 

Glaser,Barney G.and Anselm l. strauses. Time fof Dying .Chicago: Aldine Publishing

 

Juniper,Dean Francis. Man  against mortality: or  “seven essays on the engineering of man’s divinity” London : Pitman publication, 1973. [QP85 Jun]

 

Handbook of bereavement: theory,research, and intervention/edited by margaret s. stroebe, wolf gang strobe, Robert o. Hansson. Cambridge: Cambridge University Press. 1993. [B575 G7HAN]

 

Hardt Dale V. 1946. Death, the Final Frontier. Engle Wood Cliffs, N.J. -Hall,c1979.[B789 D4 Hae]

 

Hil, J. Patrck. A Good Death: Talking more control at the end of your Life/ Choice in Dying,Inc. the

 

National Councial for the Right to Die,  Reading, Mass. Addison- Wesley Pub. Co. 1992.

 

Meyer, Joachim E. Death and Neurosis. NewYork. International Universities Press, [1975] [BF 789 D4 Mey]

 

Schulz, Richard. The Psychology of Death, Dying, and Bereavement/ Richard Schulz. London: Addison-Wesley, 1978.[B789 D4 Schu ]

 

Shneidman, Edwin s. Death of Man . (forewarded by Arnold Toynbee. New York : Quadrangle, 1973 [BF 789 D4 Shn ]

 

Boros, Ladislaus, 1927- The Mystery of Death (translation by Gregory Bain -bridge) New York: Seabury Press, 1973, c 1965.

 

 

Lemaitre,Source: Le Mysrere Deld mord Dans les relio dias  librairie diameriuse et orient paris 1963. (Different socienties have different cuncepts of death)

 

Metcalfe peter. A Burneo Turrney into death. S. abdul Mjeed and co Kuala- lumpur. [conscepts of death census roated to muslim and customs]

 

DONOR (DON)

Bardenheuer-HJ; Kupatt-C; Anselm-R . [Organ transplantation and human dignity. Editorial]. Anaesthesist. 1994 Aug; 43(8): 494-9

[Modern medicine has succeeded in achieving enormous technical developments. One recent highlight has been the introduction of postmortem organ transplantation. At the same time, serious objections have been raised concerning the radical changes in the cultural conception of the inviolable body. One major objection arises from the conflict of considering a brain-dead person as dead. The presence of brain death is a prerequisite for post-mortem organ donation, because only during this phase of dying does the individual quality as dead while the organs, other than the brain, remain viable. The objection implies scepticism as to the physician's ability to distinguish a dead from a living person. On the other hand, even the critics must rely on the physician's ability to discriminate, e.g., when to discontinue resuscitation. The medical community has not found reasons to restrict the definition of irreversible coma 25 years after its first formulation. It must be clearly recognised that reasons other than medical ones can be decisive for refusing organ donation. One ethical problem is the therapeutic benefit of organ transplantation. The beneficiary of the treatment is not the donor, but another person, the recipient. The concept of human dignity does not allow the use of a person for purposes other than the ones he/she consents to, as Immanual Kant stated. Although the human corpse is not a person in the full sense, even if it is protected by the thought of respect for the former person, the life-interest of the organ recipient had to be considered legitimate]

 

RECIPIENT (REC)

Issue of organ donor families meeting transplant recipients [letter]. J-Neurosci-Nurs. 1994 Dec; 26(6): 329

 

Corley-MC; Sneed-G. Criteria in the selection of organ transplant recipients. Heart-Lung. 1994 Nov-Dec; 23(6): 446-57

[The conclusions are that criteria used for organ transplant recipient selection (other than medical criteria related to the diseased organ) vary from setting to setting, organ to organ, and are modified over time. No universal system has been adopted to guide recipient selection].

 

Schaub-S.  [Social justice in public health--the example of transplantation medicine]. Anaesthesist. 1994 Nov; 43(11): 756-8

 

Ethical considerations in the allocation of organs and other scarce medical resources among patients. Council on Ethical and Judicial Affairs, American Medical Association.. Arch-Intern-Med. 1995 Jan 9; 155(1): 29-40

[Physicians' efforts on behalf of patients often involve the use of resources that, because of naturally limited supply or economic constraints, are not readily available to all who need them. The dilemma in such cases is how physicians may fulfill their ethical duties to "do all that [they] can for the benefit of the individual patient" when the care that they can provide is constrained by the scarcity of needed resources]

 

Bromberg-JS; Grossman-RA. Care of the organ transplant recipient. J-Am-Board-Fam-Pract. 1993 Nov-Dec; 6(6): 563-76

[Organ and tissue allografting is now a commonly performed procedure. Patients receiving allografts and immunosuppressive medication are no longer restricted to a few specialized centers and areas of the country. Because transplant recipients are leading longer and healthier lives]

 

Levenson-JL; Olbrisch-ME . Psychosocial evaluation of organ transplant candidates. A comparative survey of process, criteria, and outcomes in heart, liver, and kidney transplantation. Psychosomatics. 1993 Jul-Aug; 34(4): 314-23

[Psychosocial selection criteria are widely used by transplant programs. Cardiac programs are the most stringent, both in criteria and in rate of refusals].

 

 

Twillman-RK; Manetto-C; Wellisch-DK; Wolcott-DL. The Transplant Evaluation Rating Scale. A revision of the psychosocial levels system for evaluating organ transplant candidates. Psychosomatics. 1993 Mar-Apr; 34(2): 144-53

[ratings. Results showed significant correlations between TERS scores and visual analogue scale ratings of five outcome variables at 1-3 years posttransplant. Significant interrater reliability was also found. The TERS represents a promising instrument for transplant candidate selection as well as a valuable tool for further research].

 

ABUSES (ABUS)

Congress looking at tightening organ allocation to foreigners. Waxman Bill part of new Organ Transplant Act [news]. Nephrol-News-Issues. 1993 Aug; 7(8): 24

 

WHERE ?

Interests in goods / Edited by Norman Palmer and Ewan Makendrick London: Lyolds of London 1993. [KD 123 Int]

 

Robert D.C . Research using transplanted tumours of labaratory animals /a cross-referenced bibiliography London: Rogistry and information service for experimental. Tumours: Imperial Cancer Research Fund, 1964 [T 93 Rob ]

Professor Omar Hasan Kasule July 1996