[Answered] Gender skew in organ transplantation raises concerns about justice and equality. Examine the ethical and policy frameworks required to ensure equitable access to organs based on need, not gender.

Introduction

Persistent gender disparities in India’s organ transplantation highlight deep-rooted socio-cultural biases, demanding ethical safeguards and policy reforms to ensure that allocation is based on medical need rather than gender.

The Gender Skew: Evidence from India

1. NOTTO data (2013–23): Women form a majority of living donors (63% in 2023) but a minority of recipients—37% in kidney, 30% in liver, and as low as 24% in heart transplants.
2. British Medical Journal (2018–23): Women made 36,038 of 56,509 living donations, but benefited in only 17,041 transplants.
3. Socio-cultural patterns: Patriarchal norms often lead to women sacrificing as donors for male relatives while their own health needs are deprioritised.

Ethical Dimensions

1. Principle of Justice: WHO’s Guiding Principles on Human Cell, Tissue and Organ Transplantation emphasise equitable access irrespective of gender, socio-economic status, or ethnicity. Justice requires that organ allocation reflect clinical urgency and compatibility, not social position.
2. Principle of Autonomy: Women’s consent as donors must be informed, voluntary, and free from family or social coercion.
3. Principle of Non-Maleficence: Preventing harm includes protecting women from becoming repeat donors while being denied timely treatment themselves.
4. Principle of Beneficence: Allocation systems should maximise health benefits while addressing historical disadvantage through transparent corrective mechanisms.

Policy Challenges in Correcting the Skew

1. Legal Constraints: The Transplantation of Human Organs and Tissues Act, 1994 (THOTA) mandates allocation based on medical criteria, making gender-based prioritisation procedurally complex.
2. Operational Ambiguity: Defining “near relatives” for prioritisation may create loopholes for misuse.
3. Risk of Corruption: Fears that special categories could enable out-of-turn allotments in a system already vulnerable to illegal organ trade.
4. Limited Cadaveric Donations: India’s deceased donation rate is ~0.8 per million (Spain: ~46 pmp), increasing competition for scarce resources.

Frameworks for Equitable Access

1. Medical Need–Based Allocation: Continue prioritising clinical urgency, compatibility, and likelihood of survival, as per NOTTO’s standard allocation criteria. Use objective scoring systems like MELD (Model for End-Stage Liver Disease) or LAS (Lung Allocation Score) to minimise bias.
2. Gender-Aware Monitoring without Preferential Shortcuts: Publish annual gender-disaggregated transplantation data to identify disparities. Mandate audit committees to investigate and address systemic bias in referrals and waiting lists.
3. Awareness & Empowerment: Public campaigns challenging the cultural norm of women as default donors. Train healthcare professionals to identify unconscious gender bias in patient referrals.
4. Ethical Review Boards: Strengthen institutional ethics committees to vet all living donation consents, ensuring absence of coercion.
5. Cadaveric Donation Expansion: Scale up opt-in/opt-out systems, green corridors, and ICU-based donor identification to reduce scarcity and hence discriminatory allocation pressures.
6. International Lessons: UK’s NHS Blood and Transplant uses a transparent points system with protected oversight. Israel’s Organ Transplant Law (2008) balances priority incentives for registered donors with medical need criteria.

Conclusion

Gender equity in transplantation demands data transparency, bias-free referral systems, ethical oversight, and stronger cadaveric donation networks—ensuring that medical urgency, not gender, determines access to life-saving organs.