Regulated compensated donation in Pakistan and Iran

Supporting Financial Neutrality in Donation of Organs, Cells, and Tissues

The avoidance of financial gain in the human body is an international ethical standard that underpins efforts to promote equity in donation and transplantation and to avoid the exploitation of vulnerable populations. The avoidance of financial loss due to donation of organs, tissues, and cells is also now recognized as an ethical imperative that fosters equity in donation and transplantation and supports the well-being of donors and their families. Nevertheless, there has been little progress in achieving financial neutrality in donations in most countries. We present here the findings of an international ethics working group convened in preparation for the 2023 Global Summit on Convergence in Transplantation, held in Santander, Spain, which was tasked with formulating recommendations for action to promote financial neutrality in donation. In particular, we discuss the potential difficulty of distinguishing interventions that address donation-related costs from those that may act as a financial incentive for donation, which may inhibit efforts to cover costs. We also outline some practical strategies to assist governments in designing, implementing, and evaluating policies and programs to support progress toward financial neutrality in donation.

Barriers and Enablers to Joining the National Organ Donation Registry Among Patient Population at a Tertiary Care Hospital of Peshawar, Pakistan

Background Organ transplantation is a life-saving therapy for patients with end-stage organ failure. However, the demand for organs far exceeds their availability, leading to longer waiting times and increased mortality rates. Pakistan faces a similar situation, with a shortage of organ donors and several barriers to therapeutic organ donation, including cultural, religious, and political ones. Objective The objective of this study was to understand the barriers and enablers to joining the national organ donation registry among patient populations at a tertiary care hospital in Peshawar, Pakistan. The findings can then guide targeted educational campaigns to improve the state of therapeutic organ transplants in the country. Methods A descriptive, cross-sectional study was conducted at the Outpatient Departments of Lady Reading Hospital, Peshawar, targeting all patients and visitors aged 18 to 60 who presented to the outpatient departments of the hospital. A modified and validated questionnaire was used to collect data, which were analyzed using Statistical Package for Social Sciences (SPSS) version 26. Results: The study analyzed the attitudes of 342 individuals, among which 82.18% had not heard about Pakistan's Organ Donation Registry, 58.09% agreed with organ donation, and 23.68% suggested they would like to join the registry someday. Religious beliefs and the lack of knowledge about the laws related to organ donation stood out as statistically significant barriers to joining the national organ donation registry of Pakistan (p<0.05). The study also found that the willingness to donate was significantly higher among those who themselves encouraged organ donation and were willing to do so if the country's system were to support it (p<0.05). Conclusion The majority of participants had not heard of the organ donation registry, and a lack of knowledge about the legal framework and religious beliefs were significant barriers to joining the registry. This is hindering the growth of therapeutic organ transplantation in Pakistan. In addition, the willingness to donate was higher among those who supported organ donation and believed in its benefits. Increasing awareness and promoting a culture of organ donation in Pakistan can help address the shortage of organ donors and improve the state of therapeutic organ transplantation in the country.

How a compensated kidney donation program facilitates the sale of human organs in a regulated market: the implications of Islam on organ donation and sale

BACKGROUND

Advocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales.

METHODS

This study reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation.

RESULTS AND DISCUSSION

According to Islamic law, organ donation is an act of sadaqatul jariyah, and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim eethaar, undermining donors of 'selfless' or 'altruistic' motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran's unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran's unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of 'buyer and seller', ensuring the philosophy of 'donor and recipient' is maintained.

CONCLUSIONS

Offering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors' health and reducing human suffering without legalizing the human organ trade.

Ethical Analysis of Appropriate Incentive Measures Promoting Organ Donation in Bangladesh

Bangladesh, a Muslim-majority country, has a national organ donation law that was passed in 1999 and revised in 2018. The law allows living-related and brain-dead donor organ transplantation. There are no legal barriers to these two types of organ donations, but there is no legislation providing necessary costs and incentive measures associated with successful organ transplants. However, many governments across the globe provide different types of incentives for motivating living donors and families of deceased donors. This study assesses the merits and demerits of incentive measures already in use around the world and proposes ethical measures that can promote organ donation in Bangladesh. The primary focus of this paper is to present an ethical analysis of the comparison of incentive measures on organ donation between Bangladesh and the Islamic Republic of Iran as two Muslim countries that operate organ donation for transplantation practices according to Islamic principles. In this paper, I mainly argue that providing a fixed bare minimum financial incentive measure to distantly related living donors and families of deceased donors will encourage Bangladeshis to donate organs in a manner that is ethically justifiable, morally permissible, and socio-economically appropriate. The government of Bangladesh should revise the existing biomedical law to include a provision related to incentive measures and set a strict policy to properly regulate these measures as key stewardship that can ethically promote organ donation for transplantation.

Can Living Donor Liver Transplantation in the United States Reach Its Potential?

Living donor liver transplantation (LDLT) is a vital tool to address the growing organ shortage in the United States caused by increasing numbers of patients diagnosed with end-stage liver disease. LDLT still only makes up a very small proportion of all liver transplantations performed each year, but there are many innovations taking place in the field that may increase its acceptance among both transplant programs and patients. These innovations include ways to improve access to LDLT, such as through nondirected donation, paired exchange, transplant chains, transplant of ABO-incompatible donors, and transplants in patients with high Model for End-Stage Liver Disease scores. Surgical innovations, such as laparoscopic donor hepatectomy, robotic hepatectomy, and portal flow modulation, are also increasingly being implemented. Policy changes, including decreasing the financial burden associated with LDLT, may make it a more feasible option for a wider range of patients. Lastly, center-level behavior, such as ensuring surgical expertise and providing culturally competent education, will help toward LDLT expansion. Although it is challenging to know which of these innovations will take hold, we are already seeing LDLT numbers improve within the past 2 years.

If the Price is Right: The Ethics and Efficiency of Market Solutions to the Organ Shortage

Due to the shortage of organs, it has been proposed that the ban on organ sales is lifted and a market-based procurement system introduced. This paper assesses four prominent proposals for how such a market could be arranged: unregulated current market, regulated current market, payment-for-consent futures market, and the family-reward futures market. These are assessed in terms of how applicable prominent concerns with organ sales are for each model. The concerns evaluated are that organ markets will crowd out altruistic donation, that consent to sell organs is invalid, that sellers will be harmed, and that commodification of organs will affect human relationships in a negative way. The paper concludes that the family-reward futures market fares best in this comparison but also that it provides the weakest incentive to potential buyers. There is an inverse relationship between how applicable prominent critiques are to organ market models and the increase in available organs they can be expected to provide.

The changing paradigm of ethics in uterus transplantation: a systematic review

The first uterus transplantation was performed in 2000. As key milestones are reached (long-lasting graft survival in 2011, and first birth from a transplanted womb in 2014), the ethical debate around uterus transplant evolves. We performed a systematic review of articles on uterus transplantation. Ethical themes were extracted and categorized according to four bioethical principles. Papers were divided into time periods separated by key events in uterus transplant history: Phase I (first technical achievement, 2002-2011), Phase II (clinical achievement, 2012-2014), and Phase III (after the first childbirth, 2015-2018). Eighty-one articles were included. The majority of ethics papers were published in Phase III (65%, P < 0.0001), that is after the first birth. Eighty percent of papers discussed nonmaleficence making it the most discussed principle. The first birth acted as a pivotal point: nonmaleficence was discussed by a lower proportion of articles (P = 0.0073), as was beneficence (P = 0.0309). However, discussion of justice increased to become the most discussed principle of the time period (P = 0.0085). The ethical debate surrounding uterus transplantation has evolved around landmark events that signify scientific progress. As safety and efficacy become evident, the focus of ethical debate shifts from clinical equipoise to socioeconomic challenges and equitable access to uterus transplantation.

Insight into the Knowledge, Attitude, Practices, and Barriers Concerning Organ Donation Amongst Undergraduate Students of Pakistan

Background: In Pakistan, thousands are reported dead due to organ failure annually, owing to the huge discrepancy between the number of people waiting for organ donation and the number of organs available. It is imperative that the young generation, the future donor force, comprehends the concept and importance of organ donation. Hence, this study was conducted to assess the knowledge, attitude, and practices regarding organ donation amongst the youth of Pakistan, and to delineate the factors that motivate or demotivate the new generation for organ donation so our future campaigns may be more successful. 

Methods: A cross-sectional study was conducted on undergraduate medical and non-medical students from various universities of Karachi, Pakistan. Using convenience sampling, 450 students were sent online, structured, 11-item questionnaires. The analysis was conducted using Statistical Package for Social Sciences (SPSS version 23.0, IBM Corp., Armonk, NY, US), and associations calculated through chi-square tests. A knowledge score was calculated to reflect a participant's familiarity with organ donation. 

Results: 88.7% of students were familiar with organ donation; however, only 34.6% were willing to donate, and 0.6% had donated an organ. Belonging to a medical university and female gender were associated with higher knowledge scores. 'To save lives’ (51.7%) was cited by most students as a factor that would motivate them to donate an organ, while ‘Religion’ (27.6%) was chosen as the most popular factor that demotivates them.

Conclusion: Majority of the students had insufficient overall knowledge about organ donation, highlighting the need for inculcating this topic in the curriculum. The differences in knowledge between medical and non-medical students were inconsistent with their practices, indicating that future campaigns should focus on eliminating barriers to organ donation to facilitate an accepting attitude and increased practices with respect to this topic.

Ethical dilemmas related to living donor liver transplantation in Asia

Living donor liver transplantation (LDLT) has evolved rapidly in Asia with good outcomes for both donor and recipient. Nonetheless, LDLT remains a highly demanding technique and complex surgery. The potential risks to the donors provide the basis for many of the ethical dilemmas associated with LDLT. The transplant team must have a good knowledge of the principles of bioethics in order to handle these matters. To look after the need, donor's safety and the chance for good recipient outcomes, the principles of respect for the donor's autonomy, beneficence, and non-maleficence should be practiced. In accordance with the concept of equipoise, the risk to the donor must balance the benefit to the recipient. The transplant center should have adequate experience and proven expertise in LDLT. There are concerns regarding the validity of informed consent given by the donor. While donations to non-relative patients may, at first sight, indicate radical altruism, it is important to apply careful scrutiny. Though organ trading is strictly prohibited by the law, there seems to be an inherent risk with directed donations to strangers. Transplant tourism has flourished in some countries in spite of the existence of strict laws. There are reservations regarding transplantation done by foreign visiting teams. Donor websites facilitating patients and donors and Facebook pages bear no responsibility for the outcomes of their matches and cannot ensure sufficient and accurate information about donation, transplantation, and post-operation life. Telemedicine and virtual consultations appeared to work better when the clinician and the patient know and trust each other.

Living donor risk model for predicting kidney allograft and patient survival in an emerging economy

AIM

Living donor kidney is the main source of donor organs in low to middle income countries. We aimed to develop a living donor risk model that predicts graft and patient survival in an emerging economy.

METHODS

We used data from the Sindh Institute of Urology and Transplantation (SIUT) database (n = 2283 recipients and n = 2283 living kidney donors, transplanted between 1993 and 2009) and conducted Cox proportional hazard analyses to develop a composite score that predicts graft and patient survivals.

RESULTS

Donor factors age, creatinine clearance, nephron dose (estimated by donor/recipient body weight ratio) and human leukocyte antigen (HLA) match were included in the living donor risk model. The adjusted hazard ratios (HRs) for graft failures among those who received a kidney with living donor scores (reference to donor score of zero) of 1, 2, 3 and 4 were 1.14 (95%CI: 0.94-1.39), 1.24 (95%CI:1.03-1.49), 1.25 (95%CI:1.03-1.51) and 1.36 (95%CI:1.08-1.72) (P-value for trend =0.05). Similar findings were observed for patient survival.

CONCLUSIONS

Similar to findings in high income countries, our study suggests that donor characteristics such as age, nephron dose, creatinine clearance and HLA match are important factors that determine the long-term patient and graft survival in low income countries. However, other crucial but undefined factors may play a role in determining the overall risk of graft failure and mortality in living kidney donor transplant recipients.

Diferenças e desigualdades no acesso a terapia renal substitutiva nos países do BRICS

Resumo A doença renal terminal (DRT) é um importante problema de saúde pública, sobretudo nos países em desenvolvimento, em vista dos altos recursos econômicos necessários para manutenção dos pacientes nas diversas formas de terapias renais substitutivas (TRS) existentes. O objetivo deste artigo é analisar as diferenças e as desigualdades que envolvem o acesso a TRS nos países que compõem o BRICS (Brasil, Rússia, Índia, China e África do Sul). Estudo aplicado, descritivo, transversal, qualitativo e quantitativo, com análise documental e pesquisa bibliográfica, tendo como fonte de dados censos nacionais e publicações científicas envolvendo o acesso a TRS em tais países. Verificou-se evidências de iniquidade no acesso a TRS em todos os países do BRICS, ausência de censos de diálise e transplante nacionais (Índia), ausência de legislações efetivas que inibam a comercialização de órgãos (Índia e África do Sul) e uso de transplantes de doador falecido de prisioneiros (China). A construção de mecanismos que promovam compartilhamento de benefícios e de solidariedade no campo da cooperação internacional na área da saúde renal passa pelo reconhecimento das questões bioéticas que envolvem o acesso a TRS nos países do BRICS.

Reconsidering Kantian arguments against organ selling

Referring to Kant's arguments addressing the moral relationship between our bodies and ourselves is quite common in contemporary debate about organ selling, although he does not provide us with any specific arguments related to this debate. It is widely argued that the most promising way to show the moral impermissibility of organ selling is to mount an argument on Kantian grounds. This paper asks whether it is possible to argue coherently against organ selling in a Kantian framework. It will be shown that by mounting the argument on Kantian grounds no compelling argument can be given against sale of organs, either because the arguments apply to donation of organs, too, or the arguments are not convincing for other independent reasons. In the first section, it will be argued that donation and selling are not distinguishable in a Kantian framework, since the concern about commodification of the body and its parts shall be raised by both actions. In the second section, some contemporary accounts inspired by Kant will be presented and discussed separately. It will be argued that the reasons for promoting organ donation while arguing against selling clash with each other in an unconvincing way.

The ethical implications and religious significance of organ transplantation payment systems

One of the more polarizing policies proposed to alleviate the organ shortage is financial payment of donors in return for organs. A priori and empirical investigation concludes that such systems are ethically inadequate. A new methodological approach towards policy formation and implementation is proposed which places ethical concerns at its core. From a hypothetical secular origin, the optimal ethical policy structure concerning organ donation is derived. However, when applied universally, it does not yield ideal results for every culture and society due to region-specific variation. Since religion holds significant influence in the organ donation debate, three religions-Catholicism, Islam, and Shinto-were examined in order to illustrate this variation. Although secular ethical concerns should rest at the core of policy construction, certain region-specific contexts require cultural and religious competence and necessitate the adjustment of the optimal template policy accordingly to yield the best moral and practical results.

Doctor can I buy a new kidney? I've heard it isn't forbidden: what is the role of the nephrologist when dealing with a patient who wants to buy a kidney?

Organ trafficking is officially banned in several countries and by the main Nephrology Societies. However, this practice is widespread and is allowed or tolerated in many countries, hence, in the absence of a universal law, the caregiver may be asked for advice, placing him/her in a difficult balance between legal aspects, moral principles and ethical judgments.In spite of the Istanbul declaration, which is a widely shared position statement against organ trafficking, the controversy on mercenary organ donation is still open and some experts argue against taking a negative stance. In the absence of clear evidence showing the clinical disadvantages of mercenary transplantation compared to chronic dialysis, self-determination of the patient (and, with several caveats, of the donor) may conflict with other ethical principles, first of all non-maleficence. The present paper was drawn up with the participation of the students, as part of the ethics course at our medical school. It discusses the situation in which the physician acts as a counselor for the patient in the way of a sort of "reverse" informed consent, in which the patient asks advice regarding a complex personal decision, and includes a peculiar application of the four principles (beneficence, non-maleficence, justice and autonomy) to the donor and recipient parties.

From blood donation to kidney sales: the gift relationship and transplant commercialism

In The Gift Relationship, Richard Titmuss argued that the practice of altruistic blood donation fosters social solidarity while markets in blood erode it. This paper considers the implications of this line of argument for the organ market debate. I defend Titmuss' arguments against a number of criticisms and respond to claims that Titmuss' work is not relevant to the context of live donor organ transplantation. I conclude that Titmuss' arguments are more resilient than many advocates of organ markets suggest, and more relevant to the debate than is commonly appreciated.

Current progress in public health models addressing the critical organ shortage

Since its inauguration in 1954, the field of modern transplantation has made great strides in surgical technique, the prevention of acute and chronic rejection, the minimization of immunosuppression-related side-effects and transplant tolerance. As such, organ transplantation is used worldwide as a curative, life-saving treatment for people with end-stage organ failure. However, the successes of organ transplantation have resulted in the number of patients on transplant waiting lists far exceeding the number of organs available, with growing numbers of patients dying while awaiting transplants. In order to address this critical organ shortage, a number of legislative changes have been implemented worldwide to increase the number of individuals registering as organ donors. These have included presumed consent donation, incentivized organ donation, commercial organ transplantation and mandated choice models. This article will address these public health policies in turn. The implementation of these strategies and the evidence for their efficacy will be evaluated. Based on this, we have identified that well-supported transplant coordinators approaching next-of-kin, incentives and public health campaigns are key factors that increase organ donation. Finally we propose a modified mandated choice model that may be an alternative option to maximize the number of available organs for transplantation.

Knowledge and ethical perception regarding organ donation among medical students

BACKGROUND

To determine the knowledge and ethical perception regarding organ donation amongst medical students in Karachi- Pakistan.

METHODS

Data of this cross sectional study was collected by self administered questionnaire from MBBS students of Ziauddin University from 2010 to 2011. Sample size of 158 (83 First years and 75 Fourth years) were selected by convenient sampling and those students who were present and gave consent were included in the study. The data was analyzed by SPSS version 20.

RESULTS

A total of 158 participants from Ziauddin Medical University filled out the questionnaire out of which 83(52.5%) were first years and 75(47.5%) were fourth year medical students. Mean age of sample was 20 ± 1.7. Majority of students were aware about organ donation with print and electronic media as the main source of information. 81.6% agreed that it was ethically correct to donate an organ. In the students' opinion, most commonly donated organs and tissues were kidney, cornea, blood and platelet. Ideal candidates for donating organ were parents (81%). Regarding list of options for preference to receive an organ, most of the students agreed on young age group patients and persons with family. Willingness to donate was significantly associated with knowledge of allowance of organ donation in religion (P = 0.000).

CONCLUSION

Both 1st year and 4th year students are aware of Organ Donation, but there is a significant lack of knowledge regarding the topic.

A renal transplantation model for developing countries

The estimated incidence of end-stage renal disease (ESRD) in Pakistan is 100 per million population. Paucity and high costs of renal replacement therapy allows only 10% to get dialysis and 4-5% transplants. Our center, a government organization, started a dialysis and transplant program in 1980s where all services were provided free of charge to all patients. It was based on the concept of community government partnership funded by both partners. The guiding principles were equity, transparency, accountability and development of all facilities under one roof. This partnership has sustained itself for 30 years with an annual budget of $25 million in 2009. Daily 600 patients are dialyzed and weekly 10-12 receive transplants. One- and 5-year graft survival of 3000 transplants is 92% and 85%, respectively. The institute became a focus of transplantation in Pakistan and played a vital role in the campaign against transplant tourism and in promulgation of transplant law of 2007, and also helped to increase altruistic transplants in the country. This model emphasizes that in developing countries specialized centers in government sector are necessary for transplantation to progress and community support can make it available to the common man.