Should all living donors be treated equally?

Navigating Cultural Challenges in Transplant Surgery: Insights from Turkish Surgeons

To achieve expertise, transplant surgeons in Turkiye undergo rigorous training, including medical school, residency, compulsory service, and extensive training in transplant surgery. Despite their high academic and clinical knowledge level, success in transplant surgery heavily depends on cultural competency. Through semi-structured interviews with 21 transplant surgeons specializing in kidney and liver transplants in Ankara, this study reveals how health illiteracy, culture, and folklore create significant barriers. Surgeons navigate these challenges while enduring harsh working conditions. This research highlights the critical role of cultural competency in transplant surgery, emphasizing the necessity for surgeons to understand and address the diverse cultural needs of their patients. Key findings indicate that surgeons must balance medical expertise with cultural sensitivity to deliver effective care. This study identifies four main cultural barriers: spiritual trust, family politics, health illiteracy, and subcultural incompetency. Effective transplant surgery requires a combination of theoretical proficiency and cultural awareness to meet a patient's needs and improve surgical outcomes.

Anonymous Living Liver Donation: Literature Review and Case Series Report

Background

Anonymous living liver donations (ALLDs) raise ethical concerns regarding the donors' motivations. Thus, ALLDs are not as widely accepted as directed donations from friends and family. Literature on ALLDs is limited. Understanding this particular group of individuals is crucial, as they could further help mitigate the shortage of liver grafts worldwide.

Methods

A literature review was performed to identify current definitions, ethical considerations, different approaches, and barriers to ALLD worldwide. Furthermore, we present our current experience after the establishment of a protocol to enable an ALLD program in our center and surveyed potential donors to better understand their motives throughout the process.

Results

Literature regarding ALLD is scarce. Canada leads the experience with the majority of case reports published to date. Survey-based evaluation of this unique group of individuals reflects the selflessness nature of anonymous living donors and shows that most of them experience the donation as a positive and life-changing event. In our experience, 41 individuals initiated the process of ALLD during the study period. Most were lost to follow-up or deemed ineligible. Five candidates fully completed the donation process and successfully underwent living liver donation. Given that 2 candidates have a follow-up period <3 mo from donation, we have only included data on the first 3 donors in this analysis. Eight individuals (19.5%) responded to the survey with respondents sharing similar reasons for initiating ALLD but varied and multifactorial reasons for terminating.

Conclusions

Different institutional protocols can be used to accomplish ALLD, including the one utilized by our institution. Adopting policies to allow for ALLDs and reducing modifiable factors that contribute to ending donation has the potential to increase grafts and decrease wait times.Supplemental Visual Abstract: http://links.lww.com/TP/C251.

Have we reached the limits in altruistic kidney donation?

Altruistic donation (unspecified donation) is an important aspect of living donor kidney transplantation. Although donation to a stranger is lawful and supported in many countries, it remains uncommon and not actively promoted. Herein, we ask the question if we have reached the limit in altruistic donation. In doing so, we examine important ethical questions that define the limits of unspecified donation, such as the appropriate balance between autonomous decision-making and paternalistic protection of the donor, the extent of outcome uncertainty and risk-benefit analyses that donors should be allowed to accept. We also consider the scrutiny and acceptance of donor motives, the potential for commercialization, donation to particular categories of recipients (including those encountered through social media) and the ethical boundaries of active promotion of unspecified kidney donation. We conclude that there is scope to increase the number of living donation kidney transplants further by optimizing existing practices to support and promote unspecified donation. A number of strategies including optimization of the assessment process, innovative approaches to reach potential donors together with reimbursement of expenses and a more specific recognition of unspecified donation are likely to lead to a meaningful increase in this type of donation.

The experiences and impact of being deemed ineligible for living kidney donation: Semi-structured interview study

AIM

We aimed to describe the impact and experience of being deemed ineligible as a living kidney donor.

METHODS

Semi-structured interviews were conducted with 27 ineligible donor candidates. Transcripts were analysed thematically.

RESULTS

Seven themes were identified: deriving health and relationship benefits in the process (strengthening emotional connection, identifying problematic health conditions); devastating loss and disappointment (harbouring guilt over personal failings, shattering confidence and hope, undermining relationships with extended family and friends, disrupting home dynamics); constrained within a rigid system (denied autonomy, resorting to other avenues); acknowledging as matter of fact (accepting the clinical decision, reassured by preventing a poor outcome); reluctant to relinquish the donor identity (unable to fulfil family duty, having the donor role stolen, holding onto other opportunities to donate); uncertainty in unpredictability, inconsistency and ambiguities (frustrated by inefficiencies, questioning clinician motivation, suspended donor status, unfairness in changeable eligibility criteria, unresolved concerns and questions of own health); and abandoned in despair (lacking practical support to meet eligibility criteria, ill prepared for rejection, dismissed and discarded by the system).

CONCLUSION

Being deemed unsuitable for donation took an emotional toll on ineligible donor candidates who felt immense guilt for 'failing' the potential recipient. Ineligible donor candidates were frustrated and angry with the perceived lack of support from clinicians and rigidity of the evaluation process. Informing potential donors of available services, including psychological support, communicating the decision sensitively and with sufficient time, and full disclosure of their health status, may contribute to improved adjustment following the ineligibility decision.

Unspoken ambivalence in kinship obligation in living donation

BACKGROUND

Traditionally, living kidney donors were first-degree relatives due to both greater biological compatibility and concerns about extrafamilial motivation. Because familial relationships often entail distinctive experiences of moral obligation, health-care providers must be attentive to potential undue influences on intrafamilial donor decision-making processes to ensure that decisions are voluntary.

METHODS

Qualitative interviews were conducted with 20 individuals who donated kidneys to first-degree relatives and subsequently developed end-stage renal disease themselves.

FINDINGS

We analyze the different influences kinship obligations had on participants' decision-making processes. Although participants described their decision to donate as obvious, an appropriate kin response, and free from external pressure, they indirectly expressed some ambivalence-both by their description of the rapidity of the process and in their concern about exposing an intimate to the risks of living donation.

DISCUSSION

Our data uncovered an asymmetry. Although our participants claimed that they would donate again, none received a living donor kidney. Our data also highlight the moral significance of the interdependence of donor and recipient in intrafamilial kidney donation and its impact on the range of voluntary choices as perceived by the donor. Their decision-making must be understood as embedded within a network of intimate social relations.

Considering Tangible Benefit for Interdependent Donors: Extending a Risk-Benefit Framework in Donor Selection

From its infancy, live donor transplantation has operated within a framework of acceptable risk to donors. Such a framework presumes that risks of living donation are experienced by the donor while all benefits are realized by the recipient, creating an inequitable distribution that demands minimization of donor risk. We suggest that this risk-tolerance framework ignores tangible benefits to the donor. A previously proposed framework more fully considers potential benefits to the donor and argues that risks and benefits must be balanced. We expand on this approach, and posit that donors sharing a household with and/or caring for a potential transplant patient may realize tangible benefits that are absent in a more distantly related donation (e.g. cousin, nondirected). We term these donors, whose well-being is closely tied to their recipient, "interdependent donors." A flexible risk-benefit model that combines risk assessment with benefits to interdependent donors will contribute to donor evaluation and selection that more accurately reflects what is at stake for donors. In so doing, a risk-benefit framework may allow some donors to accept greater risk in donation decisions.

Ethical Analysis of Living Organ Donation

In 2003, the first 3-way living kidney donor-swap was performed at Johns Hopkins Hospital in Baltimore, Md. Three new donor protocols including paired donation now allow unrelated individuals to serve as donors. Some ethicists have suggested that emotionally unrelated individuals not be permitted to donate because they will not experience the same satisfaction that a family member who is a donor experiences. Others who frame living donation as an autonomous choice do not see emotionally unrelated or even nondirected donation as ethically problematic. This article uses an ethical framework of principlism to examine living donation. Principles salient to living donation include autonomy, beneficence, and nonmaleficence. The following criteria are used to evaluate autonomous decision making by living donors, including choices made (1) with understanding, (2) without influence that controls and determines their action, and (3) with intentionality. Empirical work in these areas is encouraged to inform the ethical analysis of the new living donor protocols.

Coercion and choice in parent-child live kidney donation

This paper explores whether donor-parents felt coerced to donate a kidney to their child. There is a paucity of UK literature on parental live kidney donors and the voluntariness of their decision-making. Data were gathered as part of a study exploring parental experiences of consenting for live donation at a UK specialist children's hospital. Parents who donated a kidney to their child between September 2006 and December 2010 and who consented at their child's hospital to be referred to an adult unit for consideration for live donation were invited to participate. Of the 19 eligible parents, seven fathers and three mothers consented to be interviewed. Their primary motivation for donation was being a parent (more specifically, the parent of a sick child). Participants expressed this in terms of parental love and concern. Participants conveyed certainty about their decision and viewed live donation as a positive opportunity. Most participants regarded the decision to donate, or not donate, as one every parent is entitled to make for their own reasons. In discussing our findings, we argue that when parents do not separate their child's interests from their own, this does not necessarily compromise autonomous decision-making: using one's own moral values to constrain one's own choices can be compatible with voluntary decision-making. Indeed, choices may be more constrained when parents are unable to donate, because this reduces the options available to parents to help their child.

What are the harms of refusing to allow living kidney donation? An expanded view of risks and benefits

Recent Organ Procurement and Transplantation Network policies relating to living kidney donation (LKD)warrant renewed attention to the ethics of transplantation from living donors. These policies focus on risks related to potential donor evaluation, informed consent and follow-up. The ethical basis of living donation is a favorable risk/benefit ratio for the donor, but regulations and research have given less attention to the benefits of donation. Relatedly, the transplant field has also failed to consider potential harms from denying patients the opportunity to donate. These harms may be substantial in the setting of directed kidney donation to a spouse/partner, sibling or child.We argue that complete assessment of donor risks and benefits demands consideration of not only the risks and benefits of donation, but also those of refusing a donor. In contrast to the ever-expanding literature on risks of donation, there are no data describing outcomes for individuals who were turned down as kidney donors. We consider factors contributing to this omission in the transplant literature, argue that current regulations may perpetuate a narrow understanding of relevant risks and benefits in LKD, and identify areas for improvement in research and clinical practice.

Transparent vessels?: What organ donors should be allowed to know about their recipients

A live organ donor needs to be informed carefully about the risks and benefits of her donation for both herself and her recipient, but a key ethical question is how much the donor is allowed to know about the recipient. To decide this question, we must first decide whether, out of respect for autonomy, the donor should decide how much she wants to know, or whether the transplant team, as the professionals, should decide what information is relevant to the donor's decision. I argue that the transplant team should control the process. While the donor has the right to know enough about her recipient to assess the risk to herself and the prospects for a successful donation, she is not entitled to any further information, no matter how much she wants it. In particular, I argue that donors are not entitled to information that has not been shown to affect outcomes, but that they should be told if a recipient is HIV or that he has rejected a previous organ due to non-compliance. Donors have a right to make decisions with all the information they need, but recipients need not make their lives completely transparent.

Exploring moral distress in potential sibling stem cell donors

In relation to the phenomenon of moral distress, this article presents two original perspectives. First, the literature to date reflects a focus on moral distress in an occupational context. In this article, however, the impact of moral distress on siblings is explored. Moral distress is considered in a particular context, stem cell donation, but there are clear insights and implications for wider practice, particularly in life-threatening contexts and situations where live donation enhances the potential for survival. Second, the article represents some progress in relation to creating conceptual clarity. It is suggested that in addition to external and internal moral constraints a further classification of constraint emerges, and that this is useful in teasing out the distinction between moral stress and moral distress. The insights drawn from exploring the experiences of these siblings should enhance the ability to pre-empt and ameliorate potential distress and, ultimately, reduce harm.

How different conceptions of risk are used in the organ market debate

The success of kidney and liver transplantation is hindered by a shortage of organs available for transplantation. Although currently illegal in nearly all parts of the world, a living 'donor' or 'vendor' kidney market has been proposed as a means to reduce or even end this shortage. Physician members of the American Society of Transplantation, the American Society of Transplant Surgeons and the American Association for the Study of Liver Disease were surveyed regarding organ markets for both living kidney and living liver transplantation. The survey queried respondents about their attitudes toward directed living donation, nondirected living donation, the potential legalization of living donor organ markets and the reasons for their support or opposition to organ markets. Partial or completed surveys were returned by 346 of 697 eligible respondents (50%). While virtually all supported or strongly supported directed living donation (98% and 95% for kidney and liver lobes, respectively), the vast majority disagreed or strongly disagreed with the legalization of living donor organ markets (80% for kidneys and 90% for liver lobes). Both those who support and those who oppose a legalized living donor organ market rate risk to the donor among the most important factors to justify their position.

Elective surgical patients as living organ donors: a clinical and ethical innovation

We propose a new model for living organ donation that would invite elective laparoscopic cholecystectomy patients to become volunteer, unrelated living kidney donors. Such donors would be surgical patients first and living donors second, in contrast to the current system, which 'creates' a surgical patient by operating on a healthy individual. Elective surgery patients have accepted the risks of anesthesia and surgery for their own surgical needs but would face additional surgical risks when a donor nephrectomy is combined with their cholecystectomy procedure. Because these two procedures have never been performed together, the precise level of additional risk entailed in such a combined approach is unknown and will require further study. However, considering the large number of elective cholecystectomies performed each year in the United States, if as few as 5% of elective cholecystectomy patients agreed to also serve as living kidney donors, the number of living kidney donors would increase substantially. If this proposal is accepted by a minority of patients and surgeons, and proves safe and effective in a protocol study, it could be applied to other elective abdominal surgery procedures and used to obtain other abdominal donor organs (e.g. liver and intestinal segments) for transplantation.

Age, gender, race, and associations with kidney failure following living kidney donation

INTRODUCTION

Our previous reports suggested that African Americans (AA) are more likely to develop end-stage renal disease (ESRD) following kidney donation when compared with white counterparts. We sought information on age, gender, and race of kidney donors to determine which groups were over-represented on the kidney transplant waiting list.

METHODS

We queried the United Network for Organ Sharing United Network for Organ Sharing (UNOS) Organ Procurement Transplantation Network (OPTN) database for former donors who were subsequently placed on the kidney transplant waiting list. Information was retrieved on race, gender, age at donation, years between donation and listing, and diagnosis leading to ESRD. Comparisons were made to all kidney donors between 1988 and 2006 using chi-square testing.

RESULTS

In this study, 126 individual kidney donors entered the kidney transplant waiting list. Fifty of the 126 (40%) were AA (P < .0001 compared with all donors, 13% AA). For both AA and whites, male donors and those who donated before age 35 made up a larger proportion of donors on the waiting list than would be expected by their proportion of overall donors.

CONCLUSION

AA, males, and young donors may be at higher risk for kidney failure in the years following kidney donation. Mechanisms of increased risk are unclear but deserve further scrutiny. Our data are limited by the small number of patients developing kidney failure, the lack of complete follow-up on all living kidney donors, and the possibility that older donors with kidney failure were not listed because of death or other medical conditions. We believe that discussion of long-term risks may be different for various subgroups, especially for young AA kidney donors.

Living anonymous liver donation: case report and ethical justification

Most living organ donations are from genetically or emotionally related donors. Although some transplant centers are willing to accept donations from living anonymous kidney donors (LAKDs), very few centers will accept donations from living anonymous liver donors (LALDs). The difference in acceptance rates is primarily due to the greater risk in liver donation, which is estimated to be 10-fold that of the risk in kidney donation. We present a case of donation from a LALD, the first reported in Canada. There are currently no established standards for LALDs. Our criteria for the ethical acceptability of LALDs require such donors to be physically healthy, mentally competent, altruistic, highly motivated, well-informed and able to give voluntary consent to donation. Another major ethical criterion is that the likely psychological benefit to the LALD balances the physical risks. Our case demonstrates that transplants from LALDs are medically successful and ethically justified under certain conditions.

Current trends in live liver donation

The introduction of living donor liver transplantation (LDLT) has been one of the most remarkable steps in the field of liver transplantation (LT), able to significantly expand the scarce donor pool in countries in which the growing demands of organs are not met by the shortage of available cadaveric grafts. Although the benefits of this procedure are enormous, the physical and psychological sacrifice of the donors is immense, and the expectations for a good outcome for themselves, as well as for the recipients, are high. We report a current overview of the latest trends in live liver donation in its different aspects (i.e. donor's selection, evaluation, operation, morbidity, mortality, ethics and psychology). This review is based on our center's personal experience with almost 200 LDLTs and a detailed analysis of the international literature of the last 7 years about this topic. Knowing in detail how to approach to the different aspects of living liver donation may be helpful in further improve donor's safety and even recipient's outcome.

Experience with an organ procurement organization-based non-directed living kidney donation programme

The organ procurement organization (OPO)-based non-directed living kidney donation programme was developed to decrease wait times for kidney transplants, and to meet the community's desire for altruistic living donation. Community awareness was encouraged through information about non-directed living kidney donation on the state donor registry Web site, and through the media. The OPO received all inquiries and responded with phone calls, e-mails, printed information, medical/social history questionnaires, interviews, and referrals to the transplant centres. Kidneys were allocated according to the United Network for Organ Sharing (UNOS) wait list for the evaluating transplant centre. Between March 2002 and 23 September 2005, there were 608 inquiries to the OPO about non-directed living kidney donation. In 41 months, 20 transplants occurred with kidneys from non-directed donors. The donor registry and OPO-sponsored publicity led to 578 of the 608 inquiries and 15 of the 20 transplants. OPO screening saved transplant centre resources by ruling out 523 inquiries, referring 76 to transplant centres for complete evaluations. Optional donor/recipient meetings appeared to be beneficial to those participating. OPO-based non-directed living donor programmes can be effective and efficient. Standardization of evaluation, allocation, and follow-up will allow for better data collection and more widespread implementation.

The impact of accepting living kidney donors with mild hypertension or proteinuria on transplantation rates

BACKGROUND

As waiting times for kidney transplantation increase, individuals with hypertension or proteinuria may be considered as eligible living donors. We set out to determine how frequently donors are excluded because of hypertension or proteinuria and to what extent accepting such donors would increase transplantation rates.

METHODS

Wait lists from 4 Canadian transplantation centers were examined for causes of living kidney donor exclusion. Donors with hypertension (clinic blood pressure >140/90 mm Hg or requiring antihypertensive medication) or proteinuria historically have been excluded at these centers. We define potentially acceptable hypertension as a clinic blood pressure less than 150/100 mm Hg or less than 140/90 mm Hg if administered a single antihypertensive medication and define acceptable proteinuria as protein of 0.15 to 0.3 g/d.

RESULTS

Only 35% (124 of 352 patients) of wait-listed patients had a living donor evaluated (n = 180 potential donors). Primary reasons for donor exclusion were immunologic: a positive cross-match (32%; n = 59) or blood group type incompatibility (22%; n = 40). Hypertension or proteinuria were less common (17%; n = 31). Of 31 donors excluded for hypertension or proteinuria, only 13 had results in the acceptable range. Acceptance of these donors would have resulted in transplantation of 3% (12 of 352 patients) of the wait-list population.

CONCLUSION

Accepting living donors with mild hypertension and proteinuria will lead to a slight increase in transplantation rates. Efforts to improve living donor awareness and overcome immunologic barriers to transplantation may have a greater impact.

Motivation for Living-Donor Liver Transplantation from the Donor’s Perspective: An In-Depth Qualitative Research Study

BACKGROUND

There has been a lack of systematic in-depth research on the motives of living liver donors before transplantation that could contribute to an advanced understanding of their situation and to a more precise psychosocial evaluation, to protect the autonomy for decision, and to prevent psychosocial complications.

METHODS

Twenty-eight living liver donors were assessed preoperatively through a semistructured clinical interview. The taped and transcribed interviews were analyzed using a combination of grounded theory and empirically grounded type construction.

RESULTS

Various factors contribute to the donor's motivation for donation: the relationship to the recipient, the personal attitude of the donor, his or her personal history, family dynamics, the donor's personal profit, and the exceptional situation of the recipient's life-threatening disease combined with the life-rescuing possibility of living-donor liver transplantation (LDLT). In reference to this, five "ideal types" of living donors emerged from the authors' data.

CONCLUSIONS

A complete absence of coercion on the decision to donate seems unrealistic because of the dynamics initiated by the life-threatening condition of the recipient. It is important that donors feel they are gaining something by donation to be sufficiently motivated and that their profit is of an emotional or moral nature (i.e., the donation being set in an emotionally meaningful context). A mature relationship with the recipient usually provides such a context. The role of the clinician as a part of LDLT dynamics has a decisive influence.

The essence of living parental liver donation--donors' lived experiences of donation to their children

The use of living parental liver donors will continue and probably increase because of lack of cadaveric livers for paediatric transplantation and the excellent graft survival of parental livers. Therefore, it is important for the health care professionals involved in living parental liver donation to understand the experience of being a liver donor. The aim of this study was to investigate the expressed deeper feelings of parents who donated a part of their liver to their own child. The study took the form of in-depth interviews with 11 donors. All donors were biological parents of the recipient, nine fathers and two mothers. The interpretive phenomenology method was used, and interpretive analysis was carried out in three interrelated processes in line with Benner. Data collection was guided by the researcher's preliminary understanding of the donor experience from being involved in the surgery and care of the donors as well as the paediatric recipients. However, the research question was approached from the perspective of holistic care for the donor. In this study, the essence of living parental liver donation was found to be the struggle for holistic confirmation. There were three categories leading to this central theme; the total lack of choice, facing the fear of death and the transition from health to illness. There was total agreement among the respondents that there is no choice when it comes to the question of donation. The findings in this study stress the importance of organizing the parental liver donation programme with as much focus on the donor as on the child. Based on the results of this study, several clinical implications are suggested for the formation of guidelines for living parental liver donation.

Is this live-organ donor your patient?

The transplant community is in the midst of an ethical reflection regarding the manner in which live-organ transplantation should be practiced. There is a fundamental aspect to be addressed and reaffirmed. It is the doctor-patient relationship between the transplant surgeon and the live-organ donor. This relationship brings a mutual responsibility to the physician and the donor patient to each other, which should not be abrogated by the claim of donor autonomy nor the obligation fostered by the recipient's needs. If equipoise is not affirmatively achieved in the risk-benefit calculation for the donor and the recipient, then sound medical judgment should override all other concerns.

Role of living liver donation in the United Kingdom

Patients who need a new liver usually face a long wait. Some die before a suitable donor is found. Living liver donation is offered routinely in some countries. Should the United Kingdom follow suit?

Solid organ donation between strangers

In August 2000, Arthur Matas and his colleagues de scribed a protocol in which their institution began to accept as potential donors, individuals who came to the University of Minnesota hospital offering to donate a kidney to any patient on the waiting list. Matas and his colleagues refer to these donors as nondirected donors by which is meant that the donors are altruistic and that they give their organs to an unspecified pool of recipients with whom they have no emotional relationship. This paper represents an ethical and policy critique of the nondirected donation protocol that was implemented at the University of Minnesota in August 1999. Specifically, I address the ethical questions: Whether altruistic living solid organ donations by strangers (nondirected donations) should be permitted? And if so, What are appropriate ethical guidelines for such donations?

All donations should not be treated equally: a response to Jeffrey Kahn's commentary

Jeffrey Kahn and I agree that organ donation by altruistic strangers is acceptable, and that the organ procured this way ought to be allocated equitably. Our agreement in principle, however, is challenged in the details of its application. Specifically, I want to focus on three issues raised by Kahn that merit further discussion: whether relationships matter; how kidneys should be allocated; and the ethical acceptability of the expanded donor pool.