Organ allocation policies according to the UNESCO’s Universal Declaration on Bioethics and Human Rights
On October 19th, 2015 the General Conference of the United Nations Educational, Scientific and Cultural Organisation (UNESCO) adopted the “Universal Declaration on Bioethics and Human Rights”. The Declaration has been signed by representatives of the 191 member states of the Conference. The Declaration is of major importance: it was the first legally binding document approved by a global organisation to address the whole range of subjects covered by bioethics. The UNESCO Declaration and the Universal Declaration of Human Rights are part of an integral whole, which grounds both rights and ethics in the inherent dignity and equality of human beings. Policies concerning the allocation of organs cannot, therefore, disregard the principles affirmed in the Declaration.
Among the principles laid down in the Declaration, those most relevant for the allocation of organs are: benefit and harm (Article 4); equality, justice and equity (Article 10); non-discrimination and non-stigmatization (Article 11); solidarity and cooperation (Article 13); social responsibility and health (including access to quality health care) (Article 14); sharing of benefits (Article 15). Policies concerning the allocation of organs cannot disregard the principles affirmed in the Declaration.
Organ allocation policies rest on the difficult balancing of the need for justice (equity in access) on the one hand and the need for effectiveness (therapeutic benefit) on the other. Different ethical theories attribute priority rating to one or other element.
The principle of justice refers in particular to a patient’s waiting time on the list for an organ and to the equality of opportunity between patients on the waiting list.
Calculation of the benefit factor is based on a number of clinical and non-clinical parameters. If the allocation of organs were intended to favour only the survival probability of the organ and the patient in terms of quality and duration, the choice should fall on the patient with the highest level of compatibility and the most favourable overall health conditions (age, probability of success, etc.). Although this criterion may seem desirable, it conflicts with numerous others. Strictly applied, it would lead to serious discrimination against patients with more complicated clinical conditions or whose chances of a successful outcome are fewer; or it would reduce the chances of a transplant for patients with unfavourable biological features. Thus the criterion of net benefit cannot be applied alone, but must be balanced against other factors.
Among the many other elements to be considered alongside justice and benefit is the seriousness of a patient’s condition: patients with fewer chances of survival without a transplant should be given priority.
The Declaration devotes ample attention to the principle of justice, but beneficence is referred to only in Article 4. In this regard it is worth noting that: i) there is no particular need to elaborate on the concept of beneficence, which has been at the forefront of ethics in the medical profession throughout the centuries; ii) the Declaration should be considered within the context of the whole body of internationally recognised basic human rights (and corresponding duties and prohibitions); iii) Article 26 (“Interrelation and complementarity of the principles”) specifies that “This Declaration is to be understood as a whole and the principles are to be understood as complementary and interrelated. Each principle is to be considered in the context of the other principles, as appropriate and relevant in the circumstances”; iv) there is no order of hierarchy attached to the principles; they complement one another and are interdependent.
The adoption of these principles does not solve the problems, but it does help to do so by providing an ethical framework within which to discuss them.
Head of the Bioethics Unit, Office of the President, National Institute of Health, Rome, Italy
Organ Allocation Policies 10 Years After UNESCO’s Universal Declaration on Bioethics and Human Rights.
Transplant Proc. 2016 Mar