[Ethical and legal issues concerning renal replacement therapy withdrawal or withholding]

Rapid and dynamic increase of the number of patients that need different forms of renal replacement therapy can be noticed in the developed countries. This increase is associated with increased number of patients with 'diseases of modern civilization', such as diabetes and hypertension, which lead to kidney complications (e.g. diabetic and hypertensive nephropathy). Improved long-term care (especially diabetic and cardiologic) allows these patients to survive longer and to reach the stage of end-stage renal disease. This leads to increasing age and morbidity of patients treated with dialysis. In many cases, due to extremely advanced level of co-morbidity patients on dialysis are exposed to extreme level of suffering and unacceptably low quality of life. Persistent continuing of renal replacement therapy under such circumstances (with no hope for recovery or improvement) raises also some economical issues, especially in the context of permanent crisis and shortage of resources in health systems of most countries in the world. In this review the current practice concerning withdrawal or withholding of renal replacement therapy as well as some legal and ethical issues of this practice are discussed.

A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines

Kidney transplant physicians and surgeons met in Amsterdam, The Netherlands, from April 1-4, 2004 for the International Forum on the Care of the Live Kidney Donor. Forum participants included over 100 experts and leaders in transplantation representing more than 40 countries from around the world, including participants from the following continents: Africa, Asia, Australia, Europe, North America, and South America.

Les nouvelles règles de répartition des greffons rénaux en France

The French rules for the attribution of a kidney transplant are regularly evaluated and modified according to scientific progress, evolution of the waiting list and of health policies. Modifications, initiated by the Transplantation Commission of the French-speaking Society of Nephrology, have been introduced in 2004 by the Etablissement français des Greffes and aim at decreasing the number of patients on the waiting list having difficult access to transplantation because of their immunogenetic characteristics (rare ABO or HLA group, HLA immunization). Four points are concerned: 1/ better definition of hyperimmunisation; 2/ introduction of a program based on "acceptable mismatches" as a new priority for hyperimmunized patients; 3/ suppression of the full-match priority to non-immunized patients; 4/ attribution to immunized patients (anti-HLA antibodies=5-80%) who have difficult access to a transplant, of priorities similar to those followed for hyperimmunized patients. This article presents the new rules for the allocation of a kidney transplant and the rationale for the current modifications.

Priority for children in cadaveric kidney sharing: the strategy adopted in Sao Paulo, Brazil

Early kidney transplantation is crucial in order to accomplish both optimal mental development and the best adult height in children with end-stage renal disease. The aim was to evaluate the efficacy of the child priority policy for cadaveric kidney sharing adopted in the State of Sao Paulo (Brazil). We performed a retrospective study of data collected by the Government Transplant Department in São Paulo, involving all patients included in the waiting list from August 13, 1998 to December 31, 2001. During the study period, the child priority policy had been changed giving: period A--from the outset up to March 14, 2001, where the rule was to direct cadaveric kidneys obtained from children <12 yr, to recipients <12 yr; period B--from March 14, 2001 onwards, where the policy had been broadened to include cadaveric donors <18 yr, destined for recipients <18 yr. We performed the analysis of the data comprising 8940 patients, 8622 being adults (mean age = 48.6 +/- 14.1 yr, 3594 females) and 318 children (mean age = 11.9 +/- 5.1 yr, 156 females). Over the 3.5-yr follow-up there were 1964 deaths [1933 adults and 31 children, odds ratio (OR) 0.37; 95% CI 0.25-0.55], 1032 living donor kidney transplants (963 adults and 69 children, OR 2.20; 95% CI 1.66-2.93), and 556 cadaveric kidney transplants (444 adults and 112 children, OR 10.11; 95% CI 7.75-12.94). Three and a half years after being enrolled on the list, 24% of the children and 75% of the adults, respectively, were still awaiting a cadaveric kidney transplant (log rank test = 539, p < 0.00001). The analysis of period A vs. period B, suggests that the raising of the inclusion age upper limit to 18 yr, resulted in a twofold increase in the percentage of children being grafted within 6 months of enrollment. Overall, our data shows a slow rate of cadaveric kidney transplantation activity in Sao Paulo. Children's chances of receiving a living donor kidney almost doubled. Moreover, 19.5% of pediatric recipients had received their kidney within the first year of being enrolled on the waiting list. The scheme adopted in Sao Paulo is encouraging, but the results remain less favorable than those observed in other countries. The adoption of the priority policy did not result in an unacceptable increase of adult waiting time, given that the number of adults on our waiting list outweighs by far the number of children.

Relay kidney transplantation in Korea—legal, ethical and medical aspects

Living kidney transplantations constitute the majority of kidney transplantations in Korea. Recently, relay kidney transplantation, which is a modified form of both 'exchange transplantation' and 'living anonymous donation', has become at issue. After a living anonymous donor makes the initial donation, the next donor, who is related to the first recipient, makes the second donation; the third donor, who is related to the second recipient, makes the third donation; and so on. In relay kidney transplantation, organ trafficking, coercion of donation, assessment order, breach of agreement, and recipient burden should be evaluated with respect to ethical, legal and medical considerations. Despite these problems, a non-governmental body, the Korean Organ and Tissue Donor Program, has been promoting relay kidney transplantations to address the shortage of cadaveric kidney donations. Acceptance of the method of relay kidney transplantation requires the institution of supplementary measures to minimize the related problems.

Jewish medical ethics: monetary compensation for donating kidneys

The Israel Health Ministry is preparing legislation that would allow a person to receive monetary compensation in exchange for donating a kidney for a lifesaving transplant. Such a bill would be the first of its kind, and would seem to establish a policy that is in contrast with both existing international professional ethics and major Christian and Islamic religious ethics. In an attempt to investigate the extent to which such a bill would be consistent with traditional Jewish ethics, we reviewed the opinions of major traditional Jewish ethicists/halakhists, with emphasis on contemporary opinions, and found that compensating an organ donor for his or her time, discomfort, inconvenience, and recovery is fully consistent with traditional Jewish law and ethics. While non-altruistic sale of kidneys might be theoretically ethical from a Jewish perspective, ultimately its ethical status is inextricably connected to solving a series of pragmatic issues, such as creating a system that insures that potential vendors/donors are properly informed and not exploited, controlling and supervising medical screening and support of the donors to insure that their health is not permanently endangered, protecting minors and incompetents, and regulating payments so that they reasonably reflect compensation for pain and suffering.

Kidney transplants from young children and the mentally retarded

Kidney donation by young children and the mentally retarded has been supported by court decisions, arguments based on obligations inherent in family relationships, an array of contextual factors, and the principle of beneficence. These justifications for taking organs from people who cannot protect themselves are problematic and must be weighed against our obligation to protect the vulnerable. A compromise solution is presented that strongly protects young children and the mentally retarded but does not abdicate all responsibility to relieve suffering. Guidelines are proposed that prohibit the retrieval of kidneys from young children and the mentally retarded but permit one exception. They would allow retrieval of a kidney when the consequence to a first order relative with whom the donor has a meaningful and valuable relationship is otherwise imminent death. This would be done in accordance with additional guidelines that minimize harm to the donor. Since most patients with end stage renal disease can be maintained on dialysis the need for a kidney to prevent death should be an uncommon occurrence. This compromise is proposed as a solution to a dilemma that exists because two ethical principles are in conflict and one cannot be honored without violating the other.

[Decision-making capacity and informed consent in living organ donation--difficult constellations in the psychosomatic and medico-ethical assessment of potential donors]

Organ donation from relatives or other persons with a close relationship to the patient has become a fairly routine procedure in many countries. However, donors should be chosen carefully not only to avoid medical or psychosocial risks but also ethically questionable outcomes. Prerequisites for living organ donation are reported together with a short review of the known risks for donors. Under the central maxim of averting harm for the donor, six cases are described to illustrate typical difficulties in the psychosomatic-ethical consultation-liaison service, and our own procedures are discussed. Suggestions are made as to how to approach the information, evaluation and selection of potential donors.

A nondirected kidney donation and its consequences: personal experience of a transplant surgeon

Until 1996, living kidney donation had been neglected in Germany. To encourage potential donors and to convince them that nephrectomy is not too risky for a healthy person, the author decided to set an example with a personal nondirected donation. This donation, controversially discussed in the public domain, nevertheless succeeded in raising the percentage of living donors in Germany from 4% to 20% of renal transplants. In 1997, the new German Transplant Act prohibited nondirected donation. With the aim of allowing nondirected donation as an act of Christian charity, a plaint had been submitted to the Constitutional Court against that law on the basis that it violated several fundamental rights, but it was dismissed because of strong medical opposition. The author experienced some unpleasant professional consequences of his act but, nevertheless, is convinced that he had taken the right step when deciding to give a kidney to a stranger.

Heterotransplantation of kidney: medical and legal issues

Since 1905, various attempts were made to transplant kidney from rabbit, pig or goat. But the attempts failed due to strong immune reaction-response. Heterotransplantation or xenotransplantation is a process to transplant kidney between various species. Allotransplantation is costly and needs lifelong immunosuppression associated with high risk rate of infection and other complications. Moreover legal and social issues involved in the process should be taken into account. So xenotransplantation is definitely an improved process.

A proposal for an anonymous living organ donation in Germany

In Germany, living organ donation of paired and usually not regenerating organs is restricted by law to related individuals, as well as persons who 'obviously entertain an especially intimate personal relationship'. When this law was adopted in 1997, the intention of the legislator was to guarantee the free will of the donor and to exclude any trade of organs. Since then the transplantation of cadaveric organs has not increased. Additional organs were donated from living donors. However, for a number of reasons only a limited array of transplantation centers use living organ donation as a supply facing a steadily increasing number of patients with chronic renal failure. Living organ donation raises a variety of medical, ethical and legal questions. Although transplantation is a generally accepted therapeutic approach for impaired organ function, doctors do not promote it actively. Prospective donor-recipient pairs use the information obtained via internet and other sources before they contact the clinician. Doctors are hesitant to operate a healthy individual for allowing her or him to profit from this organ loss only emotionally or in an altruistic sense. Often a complex relationship between donor and recipient, as well as tissue incompatibility (ABO, HLA) may be additional reasons to restrain from carrying out living organ transplantation. To improve the chances for good organ function and better life quality of the patients we here propose a model for anonymous living organ donation with special reference to kidney transplantation.

Estudo bioético dos transplantes renais com doadores vivos não-parentes no Brasil: a ineficácia da legislação no impedimento do comércio de órgãos

OBJECTIVE

This study aimed to know the opinion of five different social segments (public prosecutors, judges, general population, recipients of the awaiting list for kidney transplants and the crew involved in the organ transplantation process of a hospital in Brasília--Hospital de Base) about the present organ transplant legislation, with an emphasis on the donation of kidney by unrelated living donors, and the new determination given by Law #10.211, in March 23rd, 2001, specifically in its article 9, that enlarges the criteria for donation of organs between unrelated living people.

METHODS

A questionnaire with six objective questions was used in order to know the opinion of five groups of people of the Federal District about the present organ transplant legislation in Brazil.

RESULTS

For 80% of the people interviewed, when Brazilian legislation allows donation of organs between unrelated living people, it makes possible the existence of rewarded donation and 81% of them consider that the requirement for judicial authorization is not an effective instrument to prevent organ commercialism.

CONCLUSIONS

The present research indicates that Brazilian legislation fails concerning the utilization of kidneys for transplantation from unrelated living donors, making possible the commerce of organs in the country. Considering that poor people are the most vulnerable ones in this context, the authors suggest changes in the legislation in force, aiming to protect them and, therefore, attain more justice.