Commentary: The WHO Resolution on Human Organ and Tissue Transplantation

The World Health Organization (WHO) resolution on human organ and tissue transplantation is a comprehensive and timely document that embraces the current and future practice of transplantation. This 2004 resolution is an updated set of guidelines from a 1991 iteration that was principled in its time, but would not be relevant to today’s practice. The revised WHO resolution was needed to address the realities of a modern day experience that has placed a heavy burden of transplantation on the live organ donor. The development of this current resolution follows an extensive fact finding effort by the 2003 WHO meeting in Madrid, compelled by a global shortage of deceased donor organs. It is important to note three fundamental precepts of the 1991 guiding principles to contrast the change in current experience and to understand the rationale for the revisions in the 2004 WHO resolution. In 1991, the WHO recommended that: 1) organs should be preferably obtained from the deceased; 2) living donors should be genetically related to recipients; and 3) no payment for donor organs should be given or received. Each of these historical principles has become obsolete in contemporary practice. Organs Are No Longer Preferably Obtained from the Deceased The pioneer surgeon Dr. Francis Moore predicted many years ago that the pressures of successful transplantation would alter our ethical assumptions about the most basic tenet of the medical profession: to first do no harm (1). Because “the living human donor provides by far the best tissue,” Moore anticipated that live organ donation might become the predominant occurrence (2). The continuing shortage of deceased donor organs and the awareness of patients that live donor organs provide the best opportunity of success has necessitated the WHO resolution to “extend the use of living kidney donations when possible, in addition to donations from deceased donors.” No other WHO conclusion at this time was feasible, but the expansion of live donor kidney transplantation since the millennium spans all regions and all cultures throughout the world. Living Donors Are Not Required to be Genetically Related to Recipients Organ transplantation from live donors is no longer restricted by the relationship of the donor to the recipient or the degree of human leukocyte antigen (HLA) match (3). Successful kidney transplantation is now regularly achieved, even if the donor is completely HLA mismatched to the recipient. The most recent report from the Scientific Registry of Transplant Recipients (SRTR) reveals the graft survival of a kidney transplant from a spouse or friend (HLA mismatched with the recipient) to be the same as that accomplished from a haploidentical parent or sibling (4). In several locations around the world, programs of live donor exchanges have been initiated and are commendable examples of donor altruism, ethical propriety, and good medical care (5, 6). These live donor exchanges even defy political and social constraints. In the Middle East, members of Palestinian and Israeli families have undergone exchange kidney transplant procedures from donors in two regional hospitals (7). In this exchange, a 45-year-old Arab truck driver received a kidney from a 38-year-old male Jewish donor, and this Jewish donor’s 10-year-old son received a kidney transplanted from the truck driver’s wife. Kidney transplantation preemptive of dialysis has become the preferred treatment for end stage renal failure, propelling candidates to turn to their families or friends to donate a kidney, or to brokers to arrange for a vendor to sell a kidney. Payment for Donor Organs Occurs Over 15,000 renal transplants have been performed in Iran via a government sanctioned system of organ vending (8). However, this Iranian experience is unique because elsewhere in the world black markets have developed that are illegal and a major concern for WHO (and the Transplantation Society). Thus, the 2004 WHO resolution has appropriately called for the international transplant community “to take measures to protect the poorest and vulnerable groups from ‘transplant tourism’” and to bring “attention to the wider problem of international trafficking in human tissues and organs.” This is not a readily accomplishable goal; for the trafficking to subside, WHO will have to influence member states to curtail illegal practices. In the interval, the Transplantation Society and WHO have established important links of collaboration to achieve mutual goals espoused in the WHO resolution. In Madrid, members of the Transplantation Society provided leadership for WHO as it crafted its resolution. In Amsterdam, WHO provided its endorsement and its contact resources to bring an international representation of physicians to address the safety and well being of the live kidney donor. The future of this collaboration between WHO and the Transplantation Society is filled with a vision for accomplishment. The agenda is to bring the guidelines of the Amsterdam Forum and the resolution of WHO to a worldwide audience—at regional meetings of transplantation, and to the ministries of health from Member States of WHO. The Future and the Necessity of Xenotransplantation Perhaps this period of medical history will be reviewed by future leaders with an understanding of the ethical dilemma that was encountered—an insufficient supply of human organs. Our predicament has necessitated an arduous remedy that rationalizes the potential harm to a well individual becoming a living organ donor. However, the current reliance on the live human donor as the major source of organs, especially kidneys, should not be projected as the final solution (nor is it the approach that the some of the pioneers intended) (9). Science must eventually bring a reliable line of pig organs that sets aside human donor hazard and vendor sales. WHO is now urging Member States to allow xenogeneic transplantation, but is cautious to declare “only when effective national regulatory control and surveillance mechanisms overseen by national health authorities are in place.” That WHO admonition is appropriate, but the research advances that can bring xenotransplantation to a clinical reality can’t come soon enough! Until then, we hope that the WHO resolution regarding allogeneic transplantation becomes a vibrant testimony to what immediately occurs. The safety and well being of the live human donor is going to be dependent upon an adherence of Member States to this seminal WHO resolution.