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New Developments in Transplant Ethics

Linda Wright and David Rodriguez-Arias Vailhen
Linda Wright and David Rodriguez-Arias Vailhen

Should elective surgery patients be offered the opportunity to donate a kidney to a patient on the waiting list? If only 3% of patients scheduled for laparoscopic cholecystectomy agreed to donate, the waiting list would disappear. Since the risks of anesthesia and incisions have already been accepted, the only incremental risk is loss of a kidney by laparoscopic nephrectomy. Should the donor meet the potential recipient? Should the donor be reimbursed?

These questions, recently debated at the University of Chicago MacLean Center for Clinical Medical Ethics, are typical of the high voltage transplant ethics issues and complex quandaries that Assistant Professor of Surgery Linda Wright addresses routinely in her role as UHN Director of Bioethics. A widely acknowledged authority on transplant ethics, Linda receives calls from across Canada, the US, and abroad. Should an anonymous donor be allowed to donate against the wishes or without the knowledge of her spouse? How should public solicitation and internet based donation be managed ethically? How should domino transplants be managed to maintain confidentiality and avoid the potential problem of donors backing out once their spouse has secured a kidney? Should altruistic liver donors be reimbursed? Linda and her colleagues wrote the guidelines for living organ donors (1).

Linda began her career as a social worker in nephrology in Montreal, gaining a large experience with the ethical and social issues related to decisions about dialysis and transplantation. She then began working in the heart transplant program at the Royal Victoria Hospital. She came to Toronto and completed her masters degree in bioethics at the Joint Centre for Bioethics. Following a clinical fellowship, she was appointed to the bioethics program at the University Health Network. In addition to her work on transplantation, the bioethics programme works with all of the other services, teaching, developing policy, and dealing with a wide range of issues from innovation and research to neurosurgical interventions to treat depression. Her work has been substantially facilitated by the addition of Kyle Anstey, a PhD ethics scholar trained in Australia, (http://www.jointcentreforbioethics.ca/people/anstey.shtml) and the recent arrival from Spain of David Rodriguez-Arias Vailhen, PhD, as an ethics postdoctoral fellow.

David finished his PhD in philosophy at the University of Paris-Descartes in December of 2008. He received a scholarship from the Spanish government offered to post-doctoral candidates to go anywhere in the world to study. The plan was to reduce the inbreeding in multiple fields. David's goal is to strengthen his already excellent English, and to gain clinical exposure. The University of Toronto Joint Centre for Bioethics was well-known to him by reputation. Abdallah Daar put him in contact with Linda, a bioethicist with practical expertise in clinical transplantation. David's thesis was a scholarly, largely abstract work on brain death and transplantation. David learned about Linda while studying in Cleveland; he visited the Joint Centre after an overnight bus trip and was attracted to the learning opportunity. He finds their skill-sets complementary. Linda is an expert on living donors and David on deceased donors, Linda on practical issues and David on theoretical frameworks. He hopes to participate as an observer in clinical consultations and operations.

He is interested in conceptual boundaries between animal and human, male and female, life and death, all of which are partly objective, and partially constructed by social factors and institutions. His philosophical interests are in constructivism, pragmatism, and utilitarianism - all relevant frameworks for transplantation ethics. In the U.S. last year there was a presidential council white paper that questioned the appropriateness of brain death and suggested that this definition of death might be abandoned.

The brain death construct was developed by a committee at Harvard University that led to a bifurcated definition of death. Cardiorespiratory death is the irreversible loss of circulation, while brain death is the irreversible loss of the functions of the entire brain. The committee cited two reasons for defining brain death: 1. the burden on the patient, family, and institution of keeping such patients alive; 2. obsolete criteria for the definition of death that led to controversy in obtaining organs for transplantation. [After performing Japan's first heart transplant, cardiac surgeon Juro Wada was arrested for murder when he removed the heart from a "brain dead donor", a western concept not yet accepted in Japan.]

David finds Toronto a model of integration of cultures, far beyond anything he saw during his five years in Paris where "there are many people from many countries, but they are more segregated." He loves the mosaic of Toronto where 107 languages are spoken and the people are genuinely friendly, polite and helpful. On his return, David will go back to teach at the University of Salamanca, the third oldest university in the world after Bologna and Paris. His goal is to strengthen the connection between the University of Toronto and his university as he has done in connecting the University of Paris with Salamanca.


1. Wright L, et al. Ethical guidelines for the evaluation of living organ donors. Can J Surg. Dec. 2004;47(6):408- 413.

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