Voluntariness in Living-Related Organ Donation

Family-Oriented Living Organ Donation in Bangladesh: A Bioethical Defence

This study focuses on issues related to living organ donation for transplantation in Bangladesh. The policy and practice of living organ donation for transplantation in Bangladesh is family-oriented: close relatives (legal and genetic) are the only ones allowed to be living donors. Unrelated donors, altruistic donors (directed and non-directed), and paired/pooled or non-directed altruistic living donor chains-as many of these are implemented in other countries-are not legally allowed to serve as living donors in Bangladesh. This paper presents normative arguments explaining why the family-oriented nature of regulations and practices surrounding living organ donation for transplantation is essential for Bangladesh. In this article, I specifically argue that if the Bangladesh government revises the current biomedical policy robustly beyond relatives and allows unrelated donors to donate organs legally, this may foster organ selling due to the poverty and corruption problems in Bangladesh. The family-oriented requirement of the living organ donation policy and practice is defensible and morally justifiable as it preserves common notions of the family unit and family bonding in Bangladesh. Maintaining the current living-donation regulations and promoting deceased donation is the way forward, as this safely preserves the family values, protects against organ selling, and increases access to organ transplantation.

An Analysis by the European Committee on Organ Transplantation of the Council of Europe Outlining the International Landscape of Donors and Recipients Sex in Solid Organ Transplantation

Discrepancies in donation and transplantation by sex and gender have previously been reported. However, whether such differences are invariably the inevitable, unintended outcome of a legitimate process has yet to be determined. The European Committee on Organ Transplantation of the Council of Europe (CD-P-TO) is the committee that actively promotes the development of ethical, quality and safety standards in the field of transplantation in Europe. Whilst the ultimate objective is to shed light on the processes underlying potential gender inequities in transplantation, our initial goal was to represent the distribution by sex among organ donors and recipients in the CD-P-TO Member States and observer countries. Our survey confirms previous evidence that, in most countries, men represent the prevalent source of deceased donors (63.3% in 64 countries: 60.7% and 71.9% for donation after brain and circulatory death, respectively). In contrast, women represent the leading source of organs recovered from living kidney and liver donors (61.1% and 51.2% in 55 and 32 countries, respectively). Across countries, most recovered organs are transplanted into men (65% in 57 countries). These observations may be explained, at least in part, by the higher burden of certain diseases in men, childbearing related immune sensitization in women, and donor-recipient size mismatch. Future research should establish whether gender-related socially-constructed roles and socioeconomic status may play a detrimental role reducing the access of women to transplantation.

Consent and living organ donation

This paper focuses on voluntary consent in the context of living organ donation. Arguing against three dominant views, I claim that voluntariness must not be equated with willingness, that voluntariness does not require the exercise of relational moral agency, and that, in cases of third-party pressure, voluntariness critically depends on the role of the surgeon and the medical team, and not just on the pressure from other people. I therefore argue that an adequate account of voluntary consent cannot understand voluntariness as a purely psychological concept, that it has to be consistent with people pursuing various different conceptions of the good and that it needs to make the interaction between the person giving consent and the person (or people) receiving consent central to its approach.

Worlds apart or two sides of the same coin? Attitudes, meanings, and motives of potential oocyte and sperm donors in Austria

Purpose

Gamete donors and recipients of such donations have been explored by previous studies, which mostly focus on post-donation scenarios. Our study analyses the general willingness to donate oocytes or sperm and focuses on differences between potential female and male donors in attitudes, meanings, and motives in a pre-donation setting.

Methods

An electronic survey (n = 555 students) was used in this anonymous observational study. To enable comparisons between men and women regarding their attitudes, meanings, and motives and their willingness to donate gametes, we designed two separate questionnaires.

Results

The sample was divided into three groups based on the willingness to donate: potential donors (n = 133; women: 48.1%, men: 51.9%); doubtful donors (n = 207; women: 75.8%, men: 24.2%); and non-donors (n = 215; women: 68.3%, men: 31.7%). The group of potential male donors (39.2%) was significantly larger than the group of potential female donors (16.9%). Significant differences regarding altruism, the meaning of one’s self-worth, and passing on the own genes were found between doubtful and potential donors. Potential donors attached less value to altruism but more value to the enhancement of one’s self-worth and passing on one’s genes than doubtful donors. The motive of passing on one’s genes and altruistic motives were more important to men than to women.

Conclusion

This study helps to create a better understanding of potential donors in the existing donation framework and supports the evaluation of the given regimes in the context of designing an improved framework.

Post-donation satisfaction in kidney transplantation: a survey of living donors in Japan

Background

No studies using a valid, standardized method to measure post-donation satisfaction levels among living kidney donors (LKDs) have been published.

Methods

Donor satisfaction levels were measured using the Japanese version of the Client Satisfaction Questionnaire-8 (CSQ-8), a validated, self-report questionnaire. To identify factors related to post-donation satisfaction levels, we compared donors’ sociodemographic and psychological characteristics and health-related quality of life (HRQoL), using the Short Form-36 Health Survey (SF-36), as well as recipients’ clinical characteristics and SF-36 scores between donors with and without low satisfaction. In addition, donors’ perceptions of the donation results and transplant procedure were assessed using measures that we developed.

Results

The mean (standard deviation [SD]) CSQ-8 score for the 195 participants was 26.9 (3.4). Twenty-nine (14.9%) respondents with total scores < 1 SD below the mean CSQ-8 score were placed into the low satisfaction group. Multiple logistic regression analysis demonstrated that lower perceptions of receiving adequate information prior to transplantation (odds ratio [OR] = 0.17; 95% confidence interval [CI] = 0.079–0.379; p < 0.001), lower optimism according to the Life Orientation Test (OR = 1.24; 95% CI = 1.045–1.470; p = 0.014), and increased serum creatinine levels in the paired recipient (OR = 0.05; 95% CI = 0.250–1.011; p = 0.054) independently increased the odds of having less satisfaction with donation.

Conclusions

Our findings suggest that careful pre-donation education and more detailed informed consent may be needed, especially in LKDs with low constitutional optimism.

Psychosocial Issues Related to Donor's Decision-Making in Living Donor Liver Transplantation

Background

The aim of this study was to investigate the detailed motives, concerns, and psychological defensiveness of living liver donor candidates in a Korean population.

Material/Methods

We analyzed data of 102 donor candidates obtained from routine psychosocial evaluation for living donor liver transplantation (LDLT) using descriptive methods. Donor candidates completed 2 questionnaires regarding their motivations and concerns, as well as a validity scale, the K scale from the Minnesota Multiphasic Personality Inventory-2.

Results

Donor candidates were more likely to cite family-related issues (77.5% to 94.1%) including well-being of the whole family and family affection as the reasons for their liver donation rather than personal motives (38.2% to 57.8%). Donors were also more likely to concern about the recipient’s survival and recovery (52.9% to 58.8%) rather than their own difficulties such as surgical complications and occupational disadvantages (19.6% to 38.2%). Twenty-six donors (25.5%) took a psychologically defensive attitude (T-score of K scale ≥65) during the pre-donation evaluation. Psychologically defensive donors expressed a significantly lower level of concern about liver donation compared to non-defensive donors (P<0.01).

Conclusions

We need to pay more attention to the family-related issues and psychological defensiveness of living liver donor candidates when evaluating psychosocial status before LDLT.

Withdrawal of the Decision to Donate Kidney by Living Related Donors: A Single-center Study in Japan

BACKGROUND

In Japan, 90% of kidney transplantations involve living related donors. A third-party interview is conducted during latter stages of preparation for transplantation to ensure the donor's voluntary decision-making. In this study, we investigated the factors responsible for withdrawal of decision for kidney donation by related living donors after third-party interview.

METHODS

Related living donor candidates were divided into 2 groups based on their final decision: those who finally donated the kidney (FDG; n = 435); and those who withdrew their decision after third-party interview (WG; n = 11). The psychosocial and medical variables were compared and the reasons for withdrawal were investigated.

RESULTS

Multiple logistic regression analysis revealed that none of the variables were significantly related to WG. Six categories of reasons for withdrawal were identified: "avoiding pregnancy risk"; "selecting alternative treatment"; "avoiding physical burden for donor"; "recipients' intemperance"; "need to take more time for decision-making"; and "psychological pressure."

CONCLUSION

A certain number of donor candidates withdrew their decision for different reasons, even in the latter stages of the transplant preparation. Careful verification of the donor candidates' individual situation and provision of adequate information and time are important to protect the donor's right to refuse.

Psychological profiles of excluded living liver donor candidates: An observational study

Living donor liver transplantation has advantages over deceased organ liver transplantation. However, the living liver donor candidates must be carefully assessed before surgery. Candidates may be excluded for various reasons. The purpose of this study was to evaluate the psychological profiles of excluded living liver donor candidates according to the reason for exclusion.A descriptive and cross-sectional study was conducted. Donor candidates were invited to participate if they were at least 20 years of age, related biologically or by marriage to the recipient (within 5 degrees), and had undergone living donor evaluation. Among the 338 participants recruited from August 2013 to December 2015, 116 were excluded for the following reasons: a medical condition (n = 35), failure to be chosen (n = 63), or withdrawal from the selection process (n = 18). The psychological profiles of these 3 exclusion groups were evaluated.There were no significant group differences in age, sex, education level, religion, marital status, and consanguinity (P > .05). The withdrawal group had fewer recipients with an hepatitis B virus infection than did the other groups (χ = 9.28, P = .01). Additionally, compared with the unchosen group, the withdrawal group had lower intimacy with the recipient (F = 5.32, P = .006) and higher ambivalence (F = 5.53, P = .005). In terms of family relationship parameters, the withdrawal group had lower family cohesion than the medical condition and unchosen groups (F = 4.44, P = .01), lower family expressiveness than the medical condition group (F = 3.76, P = .03), and higher family conflict than the medical condition and unchosen groups (F = 7.05, P = .001). The withdrawal group also had lower emotional social support than the medical condition group (F = 3.55, P = .03). There were no significant group difference in motivation, expectations, donation-related concerns, informational social support, value social support, instrumental social support, and health-related quality of life.The living donor candidates who withdrew from the selection process had obvious ambivalence, poorer family relationships, and insufficient emotional social support. The transplantation team should respect the autonomy of the candidate's decision and mitigate the impact of the donation decision on living liver donor candidates.

A liver for a kidney: Ethics of trans-organ paired exchange

Living donation provides important access to organ transplantation, which is the optimal therapy for patients with end-stage liver or kidney failure. Paired exchanges have facilitated thousands of kidney transplants and enable transplantation when the donor and recipient are incompatible. However, frequently willing and otherwise healthy donors have contraindications to the donation of the organ that their recipient needs. Trans-organ paired exchanges would enable a donor associated with a kidney recipient to donate a lobe of liver and a donor associated with a liver recipient to donate a kidney. This article explores some of the ethical concerns that trans-organ exchange might encounter including unbalanced donor risks, the validity of informed consent, and effects on deceased organ donation.

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.