Differences between organ and blood stem cell transplants
In the context of NRP 63, the philosopher and bioethicist Simone Romagnoli is studying questions related to blood stem cell transplants.
Mr Romagnoli, why is the donation of blood stem cells different from organ donation?
There are major epidemiological and immunological differences which, for instance, have an impact on availability: when a person who has agreed to donate his or her heart dies, this heart would be a suitable transplant for a large number of people. A waiting list as well as allocation criteria are therefore needed for this form of donation. The waiting list gives rise to some tricky questions: how can the organs be distributed fairly? Is it permissible to give preference to younger patients? Such problems do not arise in the same way for blood stem cells.
Why not?
The probability that the donor and the recipient are compatible is much smaller. Generally, there is only one ideal donor for a patient in need of a blood stem cell donation - and the doctors may not even be able to find such a donor in the blood stem cell registry containing 15 million donors worldwide. Hence, the question of a waiting list does not arise here.
What other differences are there?
To name just two: in contrast to organ donation, where organs are taken from deceased persons in many but not in all cases, blood stem cell donors are living people. What is more, blood stem cell donors can donate more than once.
However, the question of how to increase people's willingness to donate is relevant to both forms of transplant.
In this context, a debate is currently underway on whether absolute anonymity is justified. In Switzerland, donors and recipients are not allowed to meet.
This could be risky in practice, though. Theoretically, donors with financial problems might be tempted to confront recipients with the fact that they owe them their lives and should show them some gratitude.
That is why revealing the identity of the donor or of the recipient is not allowed in Switzerland. But nonetheless - is absolute anonymity justified? In certain countries it is permissible for the donor and the recipient to meet once a certain amount of time has passed since the transplant if this is what both parties want. In Germany, for instance, after a period of two years.
Why should the donor and the recipient meet?
Some recipients feel the need to thank their donor personally. The risks involved in the removal of blood stem cells are small, but they are there. The donor accepts these risks in order to help another person. On the other hand, some donors would like to meet the person whose life they have saved. Allowing for such meetings might be a way to increase people's willingness to donate.
Would this be an option for Switzerland?
I think we should at least consider it. However, I would be in favour of waiting longer before a meeting, say five years, because the possibility of medical setbacks for the recipient is greater in the first few years after a transplant. If the recipient needs another transplant, the donor should not be pressurised by this in any way.
Another question with which you have dealt is the conditional donation of blood stem cells. This would be the case, for instance, if a Swiss donor wished to have his or her stem cells given only to a Swiss recipient. Would this be ethical?
A conditional donation is, in principle, problematic because it is discriminatory. For instance, it would be unethical for white donors to specify that their stem cells must not go to persons from Africa or Asia. That said, we must ask ourselves whether a conditional donation is unethical in all cases. Living donations can be conditional if, say, the daughter donates a liver to her sick mother: I will donate my liver if it helps my mother. That is generally accepted because there is a kind of moral commitment to help people one is close to. But how large is this circle? If a woman from Tunisia would like a Tunisian to receive her donation or a member of a religious community would prefer to have someone from within the community as a recipient, then this might be ethical, as long as the donation is made available to everyone if the initial condition is not met. For we must not forget: the different ethnic groups are currently very unevenly represented in the registries. Most of the registered donors are Caucasians, the other groups are underrepresented, some of them quite severely.
What consequences does this have?
It means that Africans, for instance, who are strongly underrepresented in the registries will find it much harder to find a donor than someone from Europe.
What are the possible benefits of such conditional donations?
Different studies have shown: the closer the donor and the recipient are, the greater the motivation to donate. This is most obvious when a child falls ill. In such cases the family is highly motivated to donate. This thinking could be extended to larger groups, such as people with the same nationality.
But such conditional donations would also have some disadvantages.
Correct. And therefore we do not regard this in principle as a viable path. In addition to the problem of discrimination we have already discussed, a conditional donation would put into question one of the basic tenets of medical ethics, to help all patients regardless of their background.