Incentives for organ donation? The United Network for Organ Sharing Ad Hoc Donations Committee

Nonprocurement of transplantable organs in a tertiary care hospital: a focus on sociological causes

BACKGROUND

The purpose of this study was to investigate prospectively the medical and organizational causes of nonprocurement of transplantable organs and to provide explicit information on the determining factors of family response to donation request.

METHODS

Medical causes investigated were age, human immunodeficiency virus, human T-cell lymphoma virus and hepatitis C virus status, documented malignancy, and chronic cardiac or renal failure. Organizational aspects investigated were cause and place of death and number of referrals. Sociological aspects were investigated by semidirective interviews with the families of the deceased.

RESULTS

A total of 105 brain-dead patients and 42 families were included. Of the 105 patients, 9 were not eligible for donation because of medical reasons; cardiac arrest occurred before organ procurement in 6 cases. Denial of consent from the coroner occurred in 7 cases. Consent was requested from the families in 82 cases, obtained in 53 cases, and denied in 29 cases. Consent to donation was associated with openness of the process, information about brain death and transplantation, previously stated will of the deceased, favorable attitude of the deceased toward the medical profession, and a generally altruistic attitude of the deceased. Denial of donation was associated with poor understanding of brain death and fear of being deprived of the deceased body.

CONCLUSIONS

Practical implications of this study include encouraging people to state their attitudes toward organ donation and improving the level of information available to the general public on the meaning of brain death and on the medical aspects of organ transplantation.

The admission of Asian patients to intensive therapy units and its implications for kidney donation: a preliminary report from Coventry, UK

OBJECTIVE

To determine the relative admission rates of Asian and non-Asian patients to intensive therapy units (ITUs) in Coventry and to explore the implications of these rates for the transplantation of organs to Asian people.

DESIGN

Examination of 1991 census data and a retrospective review of ITU admissions books. Data were collected on ethnic background, presenting diagnosis, and clinical outcome for each admission.

SETTING

The three ITUs in Coventry.

PATIENTS

All admissions to the ITUs from 1990-93 inclusive.

RESULTS

Asian patients were admitted to ITUs disproportionately to their numbers in the Coventry population. Members of the Asian community were less than half as likely to be admitted to an ITU (p < 0.001) and more likely to die while there (p = 0.007) than members of the non-Asian population in Coventry. The proportions of patients referred to the transplant unit and the rates of subsequent donation do not seem to differ significantly for Asian and non-Asian patients (p = 0.26 in both cases).

CONCLUSIONS

There are clear implications for the availability of cadaveric kidney transplantation to Asian patients, given that few kidneys from non-Asian donors are histocompatible with Asian recipients. Indeed, in Asians, promotion of living related donation may be more effective in countering the organ shortfall than efforts to increase consent to cadaveric transplantation. However, it may be valuable to investigate any patterns of morbidity or social or cultural factors that might explain the initial low admissions rates to ITUs for Asian patients.

Attitudes and beliefs within the Sikh community regarding organ donation: a pilot study

The current shortage of organs for transplantation is a matter of considerable concern in the United Kingdom (U.K.). Whilst issues of histocompatibility create particular problems in this respect for the Asian population in the U.K., it is sometimes suggested that there is also a resistance to the idea of organ transplantation among this community. To explore this issue, a small-scale interview study was conducted in Coventry among members of the Sikh community. A judgemental sample of 22 individuals, from different strata of the local Sikh community, were interviewed either in one-to-one interviews or in a focus group. These interviews had two broad aims: to determine the prevailing attitudes towards organ transplantation, and to gauge the impact and acceptability of the current Department of Health campaign literature. It was found that, whilst there were a number of misgivings to do with notions of mutilation and reincarnation, and anxieties as to technical or clinical aspects of the transplantation process, the prevailing view was supportive of transplantation, and organ donation was seen as a highly appropriate means of exhibiting the altruistic tradition within Sikhism. Such barriers that exist to the idea of transplantation seem to have more to do with knowledge and understanding than with cultural or religious factors. Concerning the campaign literature, informants identified a number of shortcomings, and indicated ways in which the impact of the leaflets and posters might be enhanced. Although the generalizability of these findings is limited, and despite possible threats to the validity of the data collected, this study has produced findings with significant implications for future policy in this area.

Ethical issues in organ procurement: a review for intensivists

The current state of organ procurement and the ethical issues raised by the procurement process are reviewed in this article. After an examination of the legislative framework governing organ procurement, the intensivist's role in donation is discussed, including (1) donor identification, (2) asking the family to donate, and (3) obtaining consent. Recent proposals for changing the organ procurement system are analyzed, including increasing family donation or increasing the donor pool.

Donor card registration system in Japan: an obstacle to procuring kidneys for transplantation

Donor cards are a simple and effective way to give a consent to organ donation in cases of unexpected death. In Japan the prevalence of donor cards is low (0.4%) compared to the United States (24.6%), although about 50% of Japanese people are reported to be willing to donate their organs after death, a figure equivalent to the United States. We hypothesized that the donor card registration system can explain the low prevalence, and an introduction of a free delivery system will increase the prevalence. From April 1992 to April 1993, 402 high school students and 3391 workers in the Tokyo metropolitan area were requested to answer questionnaires; all the questionnaires were returned. Few respondents (15.5%) knew the way in which to be registered as a donor card holder. If donor cards were delivered freely and registration to carry a donor card was not required, 48.8% replied that they would be willing to carry donor cards. The most commonly cited reason for not carrying a donor card was 'I had no opportunity to get a donor card'. This study indicates that the introduction of free delivery of donor cards will increase the prevalence dramatically if a sufficient number of opportunities are offered. We recommend that a free delivery system should be introduced in order to increase the prevalence and secure the will of the deceased rather than the will of the family.

Some contemporary ethical considerations related to organ transplantation

With the increasing number of transplantable organs and tissues, as well as improvements in transplantation results, has come a severe shortage of organ donors. Consequently, new ethical dilemmas, related to the fair allocation of available organs and the use of alternative sources of donor organs, are of growing concern. Establishing fair allocation priorities is a serious problem in organ transplantation. Ethically, they should be defined by society as a whole rather than exclusively by the medical profession. Proposed solutions for the organ donor shortage, each with their unique ethical constraints, include the use of related donors, partial organ transplantation, cell transplantation using fetal tissue, and the use of animal organs "xenotransplantation ". Commercial trading in donor organs must be regarded as an unethical activity rather than an ethical dilemma since the donors are motivated by monetary rather than by humanitarian reasons. These ethical dilemmas could be largely avoided by an effective reduction in the severe shortage of postmortal organ donations.

Ethical issues in transplantation

The transplantation of gastrointestinal organs has relied on cadaver donors for its successful development. The fact that success has been achieved is largely due to the certainty with which brain death can be diagnosed, and the acceptance of these criteria as signifying actual death by doctors, in particular, intensivists. If continuing goodwill leads to further co-operative effort, cadaveric liver, pancreas and eventually, small bowel transplants, should become more frequent. At present the numbers of recipients requiring these operations are considerably less than those in need of kidneys. There are grounds for believing therefore that the pressure to subvert good ethical standards in acquiring these organs (that pressure imposed by long waiting lists and a high death rate on those waiting lists) should be avoidable. The solution to the problem of deficits in cadaveric liver and pancreatic grafts will be achieved only by better education of nurses and doctors, professionalization and expansion of co-ordinator organizations, legal reform, and cultural change. Only by such progress, achieved at medical, governmental, and societal levels can we avoid the insidious tendency to commercialism which we have witnessed with disquiet in renal transplantation.

Transplantation--a new dimension for paediatrics

Amazing advances have been achieved over the last 20 years in transplantation. As well as the problems of rejection and its control there are other difficulties which have to be confronted. There are shortages of donors, problems of selection for treatment and the problems of funding this expensive form of therapy. The need to make choices has to be considered and the criteria in determining choice have to be determined. Of particular concern in paediatrics are the problems that arise in relation to rehabilitation and the need to provide a multi-disciplinary approach to care. Finally, we have to remember that our enthusiasm for the possibilities of saving life and new treatments must not interfere with the basic responsibility to prevent suffering; at times the preservation of life at all costs is not justified, but in such circumstances doctors and other health care professionals have a responsibility for providing support both to the patient and to the family.