Transplantation Ethics

Transplantation Ethics. Second edition. Robert M. Veatch and Lainie F. Ross. Washington, DC: Georgetown University Press, 2015. 434 pp. Transplantation Ethics comes 15 years after the first edition, authored by Robert M. Veatch. The latest edition adds coauthor Lainie F. Ross from the University of Chicago. The book is intended as a broad and systematic overview of the ethics of transplantation and targets a wide audience including students and policy makers and assumes no advanced knowledge of transplantation. Transplantation Ethics is logically divided into three parts: defining death, ethics of organ procurement and principles of organ allocation. Part one provides a comprehensive and thoughtful overview of the challenges of defining death in the context of organ donation. Topics include the dead donor rule, whole brain death, circulatory death, somatic death and higher brain death. The authors’ conclude part one by proposing three alternative definitions of death to be chosen by the individual or next of kin. This broadened definition reflects the authors’ strong preference to prioritize autonomy, as demonstrated throughout the topics reviewed in Transplantation Ethics. Part two discusses organ procurement including the donation model, organ salvaging and presumed consent, and markets for organs (including an international overview of markets). The authors then discuss live donor transplantation, with a special emphasis on strategies to increase living donation including kidney paired donation. This section also includes a discussion of high-risk donors including those with infections and cancer. A review of xenotransplantation highlights five issues: violation of natural law; animal rights; nontherapeutic interventions; scarcity of resources; and the risk of infection, including third party infections. This section also includes an important new chapter on the positive and negative impact of the media on donation and transplantation. Part three discusses organ allocation. This section reviews fundamental concepts including considerations of both utility and justice and the roles of the clinician and nonclinician stakeholders in establishing organ allocation policy. The authors also cover more controversial subjects such as the transplantation of patients with end-organ failure as a result of high-risk behaviors or lifestyle choices, the role of patient status in gaining access to organ transplantation, socially directed donations and disparities in access to transplantation related to geography. This section also critiques the new kidney allocation system in the United States and proposes an alternative approach, Equal Opportunity and Fair Innings (EOFI). Finally, this section broaches new territory with a chapter devoted to vascularized composite allografts. The second edition nicely updates Veatch’s first edition by including contemporary topics in transplantation. The writing is accessible, and the inclusion of real-life cases brings immediate relevance to the subject matter. Although the authors often prioritize considerations of autonomy, an effort is made to counterbalance those opinions with considerations of equity and efficiency. This edition strays from the format of a classical textbook. The effort to include references to public policy documents, anecdotes and personal interpretations adds to the contemporary feel of the book but also renders it U.S. centric, prone to becoming outdated, and reveals some bias in content coverage. The exclusion of the Declaration of Istanbul from the review of markets for organs is a notable example. The advancement of the authors’ own work including the EOFI is somewhat unorthodox for a textbook. In an effort to reach a broad audience, the book may not meet the specific needs of all readers. The book may be too abstract for clinicians seeking guidance on ethical challenges in day-to-day practice. The chapter on multiorgan, split-organ and repeat transplants, for example, provides an overview of the utilitarian and deontologist views but fails to provide specific guidance relevant to the clinical setting. Similarly, ethicists and students of ethics may find the coverage of ethical theory lacking for some topics. Transplantation Ethics is a broad, readable, and engaging overview of the contemporary ethical issues in transplantation. The second edition adds important new material, and the book should appeal to a variety of readers interested in obtaining a general understanding of this field. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

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