Corneal Donation: Bioethical Issues and Barriers

Introduction

The cornea is the transparent outer layer of the eye that allows entry and proper focusing of the light. Corneal transplants showed a high success rate because of the avascular nature of the cornea, and graft rejection is rare. The process of corneal transplantation should be made fairly and ethically. Various guidelines are implemented to make sure that ethical principles are followed for the organ transplantation.

What Is Corneal Donation?

Corneal donation, also called corneal transplant, is a surgical procedure that uses donor tissue to replace damaged corneal tissue. The operation is also called keratoplasty. The cornea is the transparent front part of the eye that allows the entry of light. It plays an important role in vision.

The cornea transplant is done

• To restore vision.

• Reduce pain.

• Improve the appearance of a damaged cornea.

How to Find a Donor Cornea?

Corneas used for transplants are taken from people who have died. In certain conditions, corneas are not used if

• The person died from an unknown cause.

• The person had previous eye surgery, eye diseases, or certain diseases that are passed from one person to the next.

• The patient had infectious diseases like Hepatitis B and C, AIDS, and Septicemia.

• The person died due to blood cancer.

What Are the Steps in the Eye Donation Process?

The process of cornea donation starts when an individual decides to donate his/her cornea.

• Call to the Eye Bank - The eye bank is primarily responsible for the processes related to corneal donation. An eye bank will receive calls from hospitals, organ procurement organizations, or any third-party individual informing that an individual passed away and meets all the criteria for the donation of the cornea. Eye bank, in short contact with close relatives, gets a consent letter, recovers the corneal tissue, and stores it. Eye bank completes the procedures within 12 hours from the time of death.

• Medical Consent and Review- If the deceased individual is a registered eye donor, the eye bank can proceed immediately. If not the eye bank members should contact their close family members or relatives to get consent. The medical and social history of the donor is recorded to match the eligibility criteria. The eye bank will take relevant documents from the hospital to know the cause of death if needed.

• Physical Examination of the Donor - If the medical consent and review match the eligibility criteria the eye bank can proceed to the recovery of their corneas. The eye bank technician can go to the donor's location and the cornea is taken. The technician also draws blood samples from the donor.

• Evaluation of the Corneal Tissue- The corneal tissue is examined under a microscope and checked for any damage or deformities. The blood sample from the donor is tested for HIV, Hepatitis, syphilis, or other blood-borne diseases.

• Release of Corneal Tissue - If the corneal tissue meets all the eligibility criteria for transplant, the cornea is sealed and packed in a container of wet ice. The corneal tissue is labeled and stored. When needed the cornea is transported to the receiver's place.

• Post-Donation Gratitude - Eye bank, sharing gratitude to the donor's families. The donor's sacrifice is honored.

What Are the Bioethical Issues Related to Corneal Transplantation?

Corneal tissue is the most successfully transplanted tissue worldwide. For each of the 70 required corneas in the world, there is only one available for transplantation. This large number of shortages in corneal tissue has led to increased unethical practices.

Informed Consent for Corneal Donation- Informed consent is an important legality in organ donation, and it ensures the patient's right to make his/her choice. Informed consent means an individual gives authorization by free will, without pressure or any reward for the donation of the organ. The two types of informed consent are expressed and presumed

• Expressed Consent- It is signed either by the donor during his/her lifetime or by the donor's family after the death.

• Presumed Consent - It assumes that a person does want to donate the organs after death unless specifically indicated that do not wish to donate the organs. And an individual is considered a donor by default.

Both types of consent can be considered for corneal donation. In some families, presumed consent can be problematic and needs a soft approach.

Corneal Tissue Allocation - Considering the worldwide need for corneal transplant tissue, it is challenging to prioritize certain conditions. For organ transplantation, each country has its own regulations and priorities.

• Based on the principles each country regulates organ donation.

• Prioritizing is justified by the proven urgency or acute condition of the patient, who is on the waiting list for a long time.

• Another issue regarding tissue allocation arises when the recipient is not a resident of the country.

• In general, the permanent residents of the country have priority over foreigners. It is done to achieve self-sufficiency for a country.

• This may help to prevent unethical practices like transport tourism and organ tissue trafficking.

Transplant Tourism - It refers to a condition where the obtained donor tissue used in the transplant surgery is illegal and against the organ donation policies of the country.

When the tissue is obtained illegally, without consent, it is called tissue trafficking and is added as a crime.

Corneal Tissue Exportation and Importation - The import and export of organs between countries should satisfy the legal aspects of the respective countries. Since countries have different economic and cultural variations, that needs to be respected.

• The added cost for import and export of the corneal tissue is to be paid by the recipient, causing financial inequality in organ transplantation. To achieve self-sufficiency in a country the organs are first available to the residents of the same country.

• The donor tissue should come from the eye bank, to ensure the quality and safety of the corneal tissue.

• While signing informed consent, it should be made clear that the donor tissue should go to a person from the same country.

Profit Eye Banking - Eye banks are non-profit organizations that collect, medically evaluate, and transplant corneal tissue to the recipient

Recently, many non-profit organizations have changed to become profit eye banks. This created widespread criticism of this act. These eye bank practices are said to be unethical as corneal transplantation has become a process more dependent on financial status. Such profit-eye banks may do unethical practices in need of money rather than humanitarian values. Monitoring of such profit eye banks is necessary to avoid unethical practices.

What Are the Steps to Be Taken to Avoid Unethical Practices?

• Each country has to establish consent, according to the cultural principles of the population. This enables avoiding the jeopardization of cultural values.

• The self-sufficiency of each country should be met first. Allocation of the corneal tissue to the residents of the same country should be ensured.

• Transplant tourism and organ trafficking should be made illegal and must be punished by law.

• The import and export of corneal tissue should be evaluated and done after achieving self-sufficiency in the country.

• The profit eye bank model may do unethical practices to make a profit. The countries should make proper guidelines for the working of eye banks and make the working eye banks, through ethical practices and in a non-profit way.

Conclusion

Organ donation processes should follow the bioethical principles of each country to ensure that no unethical practices are reported. All the processes from getting informed consent to transplanting the donor tissue need to follow all steps given by the governing bodies. The organ donation process is done through non-profit organizations under the government.