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Kulkarni S, Flescher A, Ahmad M, Bayliss G, Bearl D, Biondi L, Davis E, George R, Gordon E, Lyons T, Wightman A, Ladin K. Ethical analysis examining the prioritisation of living donor transplantation in times of healthcare rationing. JOURNAL OF MEDICAL ETHICS 2023; 49:389-392. [PMID: 34983855 PMCID: PMC10314075 DOI: 10.1136/medethics-2021-107574] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 12/17/2021] [Indexed: 05/20/2023]
Abstract
The transplant community has faced unprecedented challenges balancing risks of performing living donor transplants during the COVID-19 pandemic with harms of temporarily suspending these procedures. Decisions regarding postponement of living donation stem from its designation as an elective procedure, this despite that the Centers for Medicare and Medicaid Services categorise transplant procedures as tier 3b (high medical urgency-do not postpone). In times of severe resource constraints, health systems may be operating under crisis or contingency standards of care. In this manuscript, the United Network for Organ Sharing Ethics Workgroup explores prioritisation of living donation where health systems operate under contingency standards of care and provide a framework with recommendations to the transplant community on how to approach living donation in these circumstances.To guide the transplant community in future decisions, this analysis suggests that: (1) living donor transplants represent an important option for individuals with end-stage liver and kidney disease and should not be suspended uniformly under contingency standards, (2) exposure risk to SARS-CoV-2 should be balanced with other risks, such as exposure risks at dialysis centres. Because many of these risks are not quantifiable, donors and recipients should be included in discussions on what constitutes acceptable risk, (3) transplant hospitals should strive to maintain a critical transplant workforce and avoid diverting expertise, which could negatively impact patient preparedness for transplant, (4) transplant hospitals should consider implementing protocols to ensure early detection of SARS-CoV-2 infections and discuss these measures with donors and recipients in a process of shared decision-making.
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Affiliation(s)
- Sanjay Kulkarni
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew Flescher
- Department of English, Stony Brook University, Stony Brook, New York, USA
| | - Mahwish Ahmad
- Center for Bioethics, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - George Bayliss
- Department of Medicine, Brown Univeristy School of Medicine, Providence, Rhode Island, USA
| | - David Bearl
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lynsey Biondi
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | | | - Roshan George
- Department of Pediatrics, Emory Univeristy School of Medicine, Atlanta, Georgia, USA
| | - Elisa Gordon
- Department of Surgery, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Tania Lyons
- UNOS Ethics Committee, Richmond, Virginia, USA
| | - Aaron Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Keren Ladin
- Department of Community Health, Tufts University, Medford, Massachusetts, USA
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