Harvard Medical School Class of 2027
Ever since the first successful kidney transplant at Brigham and Women's Hospital in 1954, organ transplantation has served as a cornerstone of modern medicine, offering life-saving solutions for individuals with end-stage organ failure (1). It stands at the forefront of innovation and scientific discovery, and we, as future physicians and surgeons, hold a responsibility to better the system and improve outcomes for patients.
No system is perfect, as many in the medical field know. With any system that exists, there coexists the need for systemic reforms, technological advancements, and improved public understanding to ensure the continued success and ethical integrity, including in transplantation practices.
When I first started to write this essay, I wanted to focus on the future of transplantation medicine as it relates to technological advancements, including methods to improve the viability of donor organs and innovative partial transplantation approaches such as the partial heart transplantation program currently being trialled at our very own Boston Children's Hospital.
Far more pressing in the next 25 years, however, are issues surrounding the ethics of transplantation. I would be remiss to write an article about the future of transplantation without addressing the recent article from The New York Times which highlights rare yet disturbing instances in which the first steps in the process of organ donation were initiated while patients were still alive or showing signs of recovery, particularly under donation-after-circulatory-death (DCD) protocols (2).
This article in particular has understandably shaken public confidence in the organ donation system; additional negative media stories further risk erosion of that trust. But it is important to first emphasize that organ donations save lives. There are over 100,000 people on the national transplant waiting list, with 13 people dying each day waiting for a transplant (3). Every donor can save up to 8 lives and improve the quality of over 75 other lives with tissue donations (3).
Organ donations save lives.
The New York Times article highlights a miniscule percentage of all organ recoveries performed in the United States, and there are countless protections and safeguards in place to prevent such occurrences (4-6). These protections are of course imperfect, as these instances highlight. In the next 25 years, we must improve upon these to mend public trust and to bolster protection for patients.
Let us first examine current protocols. First, physicians involved in patient care do not know about a patient's donor status during treatment and act independently from the organ procurement team. This safeguards against any potential conflicts of interest, ensuring that patient care decisions are made solely based on medical necessity.
Within the organ procurement team, there are highly subspecialized roles. At New England Donor Services, for example, a family resource coordinator who specializes in difficult conversations is the initial and primary contact with the family. With every organ from every donor, a separate match list is run to make sure that the recipient is compatible from a medical perspective (4,7). When a match list is run, medical institutions are informed of the organ offer so they can provide preliminary acceptance or rejection of the organ (7). The surgeons who procure the organs are not in the room at the time of extubation or the time of death to prevent conflicts of interest. Aftercare specialists provide services for donor families to help with the grieving process. The system is one made of many gears, with multiple necessary roles to help it run smoothly.
Finally, the organ procurement system that interacts with organ donors and their families is entirely separate from the transplant surgeons performing the transplant itself (7). There is little to no overlap, other than the organ procurement organization making the offer to institutions (7). Out-of-order allocations are rare and only occur when the organ is unlikely to be allocated in time to prevent organ non-utilization (7-8).
Future public education campaigns should focus on dismantling misinformation and highlighting the ethical safeguards inherent in the system as we take steps to rebuild this trust. Transparency is crucial. Institutions must openly communicate the steps taken to prevent such incidents, including the implementation of enhanced training for medical staff, the adoption of monitoring technologies, and the establishment of independent oversight committees. By fostering an environment of openness and accountability, the medical community can work towards restoring public confidence in the organ donation process and exciting advancements being made to increase the number of lives saved each year.
The future of organ transplantation holds immense promise, driven by technological innovations and a restoration of public trust. Embracing advancements allows the medical community to continue offering hope and improved quality of life to individuals in need of organ transplants. Each organ donor and donor family are heroes. Even at one of the most emotionally devastating moments in their lives, they chose to be compassionate to others and generous enough to give an incredible gift to save and improve the lives of others. With their last moments, they chose to donate life.
Correspondence: vnguyen@hms.harvard.edu