Attitude Toward Organ and Tissue Xenotransplantation Questionnaire (PCID-XENOTx-Ríos): Characteristics and Psychometric Properties of the Validation in Spanish-Speaking Populations

INTRODUCTION

Making xenotransplantation socially acceptable is the first step in working toward the promotion of this potential therapy option for providing transplant organs. However, most of the questionnaires used for this task are not validated.

OBJECTIVE

To analyze the psychometric characteristics of the questionnaire of attitud toward xenotransplantation PCID-XENOTx-Ríos (Questionnaire of Proyecto Colaborativo Internacional Donante about Xenotransplantation developed by Dr. Ríos) to validate the questionnaire in the Spanish speaking population.

METHODS

The study population was the native Spanish population living in southeast Spain. A sample of the population was obtained randomly and stratified by age and sex (N = 600), using the following inclusion criteria: 1. being older than 18 years; 2. being Spanish; and 3. living in Spain. Instrument valuation. Attitude was assessed using the validated PCID-XENOTx-Ríos questionnaire to gauge attitudes toward organ and tissue xenotransplantation. The statistical analysis included an initial description of the data, an exploratory factor analysis, an items analysis, and an internal consistency analysis.

RESULTS

The questionnaire consists of a total of 30 items, distributed in 4 subscales: 1. Factor 1: consequences (11 items); 2. Factor 2: associated risks (7 items); 3. Factor 3: transmission of infections (6 items); and 4. Factor 4: origins of transplantation (6 items). This structure presents a total explained variance of 61.18%. The internal consistency of each factor was as follows: α1 = 0.91; α2 = 0.92; α3 = 0.89; and α4 = 0.72. The analysis of items and internal consistency supported the 4 factors' composition.

CONCLUSIONS

Dimensions analyzed in the PCID-XENOTx-Ríos questionnaire of attitudes toward organ and tissue xenotransplantation show a good fit in relation to their factorial validity and internal consistency values.

Xenotransplantation: The Challenge to Current Psychosocial Attitudes

Because of the limited availability of transplantable human organs, xenotransplantation, the use of animal organs as an alternative source, has received considerable attention in recent years. Xenotransplantation would provide an unlimited supply of organs, and these organs would be available whenever required. Although the pig is considered the best source for organs, significant immunologic barriers currently prohibit the implementation of a clinical trial of organ transplantation. However, as medical research gains more insight into the mechanisms underlying rejection of pig organs in primates, therapeutic xenotransplantation is becoming more feasible. Clinical trials of porcine cell transplants are currently underway. Although xenotransplantation will minimize the waiting period for an organ and obviate the feelings of guilt or indebtedness commonly experienced by recipients of human organs, several psychosocial issues may hinder the reintegration of patients into society. For example, concerns that infectious pathogens could be transferred to recipients of pig organs will necessitate life-long monitoring and perhaps even temporary isolation of patients. The possible risk of the spread of a xenozoonosis from the patient to other members of the community may inspire public controversy and even fear, which may have an adverse impact on the patient's emotional state. Additionally, some patients may be psychologically disturbed by the need to incorporate pig organs into their body. This article addresses these and other psychosocial issues that may be associated with clinical xenotransplantation.

Communicating about xenotransplantation: models and scenarios

Xenotransplantation entails using organs from genetically modified animals as a way to solve the shortage of human organs for transplantation. As with other novel technologies, if xenotransplantation is to be judged fairly, proponents must explain its complex, uncertain, and unfamiliar risks and benefits. Xenotransplantation's risks include the possibility of a recombinant virus infecting human transplant recipients, potentially causing an epidemic of an unfamiliar disease. Using materials vetted by scientific experts, we communicated the variables and relationships determining this risk in three formally equivalent formats: (a) a graphic model, (b) scenarios structured by the graphic model, and (c) both the model and the scenarios. Participants were randomly assigned to receiving one set of materials. They rated them as equally clear and studied them equally long, suggesting similar ease of cognitive processing. Compared to participants receiving the scenarios, those who received the graphic model better identified causes and effects of the risk, and saw less risk of xenotransplantation. Participants who received both the model and the scenarios generally showed intermediate responses. The study demonstrates a general procedure for developing and evaluating formally equivalent graphic and scenario communications regarding highly uncertain risks. In this application to xenotransplantation, presenting a graphic representation improved people's understanding of the risk.

Medizinethische Aspekte im Umgang mit muslimischen Patienten

In today's world, the plurality of values is considered to be a constitutive feature of modern societies. In these societies, transcultural patient-physician relationships are a part of daily medical practice. Culturally determined value systems can be crucial for understanding the perception of notions such as "health" and "illness", leading to fundamental differences in assessing medical interventions and therapeutic objectives. Therefore, transcultural conflicts of interest are presenting medical ethical decision-making with new challenges. Time and again, medical practice demonstrates that cultural differences between physician and patient are correlated with the complexity of medical ethical conflicts, as can be seen in the relationship between Muslim patients and non-Muslim physicians in the German health care system. This paper discusses some of the central issues in these relationships like communication, sense of shame, religious duties, and medical end-of-life decisions, analyzing some concrete cases. Subsequently, a number of medical ethical theses relevant for multicultural societies will be discussed.

British citizens in a regional community of southeastern Spain with a pre-clinical organ xenotransplantation program. A study of attitude toward xenotransplantation

BACKGROUND

It is important to find out about the social acceptance of xenotransplantation, especially in populations where there are pre-clinical xenotransplantation projects, and therefore the possibility of xenotransplantation to humans. In the native population of southeastern Spain this situation is well-known, but in recent years there has been an important social change because of a considerable migrational flow into Spain, especially from the British Isles.

OBJECTIVE

To analyze the attitude toward xenotransplantation among the population living in southeastern Spain born in the British Isles and to determine the variables that affect this attitude.

METHOD

A random sample was taken of British and Irish citizens resident in southeast Spain and stratified according to a respondent's nationality (n = 1700). The data were obtained between November 2005 and April 2006. Attitude was evaluated using a validated questionnaire that was completed anonymously and self-administered. The control group comprised a random sample (n = 250) of the native population. Student's t-test, the chi-squared test, Fischer's exact test and a logistic regression analysis were used in the statistical analysis.

RESULTS

The questionnaire completion rate was 91% (n = 1546), with 69% of respondents in favor of xenotransplantation, 8% against and 23% unsure, an attitude that is similar to that of the control group (P = 0.1616). These attitudes were based on the assumption that transplanted animal organs had the same outcomes and involved the same risks as human ones. This attitude is related to the following factors: (i) being of male sex (P = 0.0477); (ii) level of education (P = 0.012); (iii) being natives from England or Wales (P = 0.016); (iv) participation in voluntary pro-social activities (P = 0.035); (v) the respondent's religion (P < 0.001); (vi) knowing that one's religion has a favorable attitude toward transplantation (P < 0.001); (vii) having discussed the subject of organ donation and transplantation within the family (P < 0.001); (viii) a partner's favorable attitude toward transplantation (P < 0.001); (ix) previous experience of donation or transplantation (P = 0.024); (x) the belief that in the future one might need a transplant (P = 0.007) and (xi) a favorable attitude toward human donation, both deceased and living (P < 0.001). In the multivariate analysis, the following are significant independent variables: sex [odds ratio (OR) = 2.206], a favorable attitude toward deceased donation (OR = 1.977), and attitude toward living donation (OR = 2.097).

CONCLUSIONS

Attitude toward xenotransplantation among British residents who usually live in the southeast of Spain is similar to that of the native Spanish population, and is determined by many psychosocial factors, mainly related to previous attitude toward the different types of human organ donation and the respondent's sex.

Hospital personnel faced with organ xenotransplantation: an attitudinal survey in a hospital with a pre-clinical liver xenotransplantation program

BACKGROUND

In situations of extreme urgency when there is a need for vital organs, xenotransplantation could provide a bridge until the arrival of a human organ. However, it is important to find out the level of acceptance of this potential therapy among the health care workers who would be involved in its implementation. The objective of this study is to analyze attitude among personnel in a hospital with a pre-clinical xenotransplantation program toward xenotransplantation and to determine the variables that influence this attitude.

MATERIALS AND METHODS

A random sample (n=1168) was taken and stratified according to job category and service. Attitude toward xenotransplantation was evaluated using a validated questionnaire. Contact was made with the head of each service who was given an explanation of the project. This person was made responsible for the distribution and collection of the survey in each service in randomly selected work shifts. Such a survey was completed anonymously and was self-administered. A random sample of 250 individuals from our regional community was used as a control group.

RESULTS

The survey completion rate was 98% (n=1148). Most respondents are in favor (67%), 7% are against and 26% undecided. Such an attitude is more favorable in the control group (74% vs. 67%; P=0.0378). The following factors are positively related to such an attitude: (1) male sex (P<0.0005); (2) a younger age (P=0.013); (3) participation in prosocial voluntary activities (P=0.002); (4) knowing that the church has a positive attitude toward donation and transplantation (P<0.0005); (5) a partner's favorable attitude toward transplantation (P<0.0005); (6) a physician's job category (P<0.0005); (7) a resident physician's job contract situation (P=0.017); (8) a respondent's belief that he or she may need a transplant in the future (P<0.0005); and (9) a favorable attitude toward human donation, whether this be cadaveric or living (P<0.0005). In the multivariate analysis, the following persist as independent variables: (1) sex (odds ratio=1.6); (2) participation in prosocial voluntary activities (odds ratio=2.2); (3) a partner's unfavorable attitude toward transplantation (odds ratio=0.3); (4) a favorable attitude toward cadaveric donation (odds ratio=2); and (5) attitude toward living liver donation (odds ratio=3.8).

CONCLUSIONS

Attitude toward xenotransplantation is not as favorable among hospital personnel as it is in the general public and this is determined by many factors. It will be necessary for research groups to periodically carry out awareness-raising activities about our findings in our own centers, to avoid the rejection that could be generated by a lack of awareness.

Understanding of and attitude to xenotransplantation among Italian university students: impact of a 3-yr university course

BACKGROUND

Young people, and students in particular, generally have a positive attitude to xenotransplantation. We reported previously that university students attending their first year approved of the idea of transplanting animal organs into humans. The aim of this study was to evaluate the impact of a 3-yr course at various faculties on the university students' understanding of and attitude to xenotransplantation.

METHODS

University students in their fourth year at five different faculties of Padua University (Italy), who had previously been surveyed in exactly the same way 3 yr earlier, were re-administered an anonymous 19-item questionnaire on their attitude to xenotransplantation.

RESULTS

A total of 453 students completed the fourth year questionnaire (84 males, 369 females; mean age 24.6 yr, range 21-36 yr). Students were attending courses in Medicine (22.1%), Veterinary Science (16.5%), Agriculture (10.4%), Educational Sciences (22.1%) and Psychology (28.9%). In their fourth year, 85% of the students knew that animal organs could, at some stage, be transplanted into humans, 81.5% approved of this idea and 84% would accept an animal organ to save their life if necessary (these percentages were 88%, 78% and 76%, respectively 3 yr earlier). A significantly larger proportion of the students who approved of xenotransplantation were attending science courses rather than art courses, while no differences emerged as regards gender. Those who refused xenotransplantation justified their position mainly on ethical-moral (41.7%) and immunological (35.7%) grounds.

CONCLUSION

As in their first year, so too in their fourth, University students were well informed about the feasibility of transplanting animal organs into human beings and those attending science courses were more likely to accept this idea than art students. Approval of xenotransplantation was much the same among fourth year males and females, whereas in the first year, male students had approved more than female students.

Xenotransplantation: a bioethical evaluation

Allograft shortage is a formidable obstacle in organ transplantation. Xenotransplantation, the interspecies transplantation of cells, tissues, and organs, or ex vivo interspecies exchange between cells, tissues, and organs is a frequently suggested alternative to this allograft shortage. As xenotransplantation steadily improves into a viable allotransplantation alternative, several bioethical considerations coalesce. Such considerations include the Helsinki declaration's guarantee of patients' rights to privacy; political red tape that may select for undermined socioeconomic groups as the first recipients of xenografts; industry incentives in xenotransplantation investments; conflicts of interest when a clinician supervises a patient as a research subject; the psychosocial impact of transplantation on the xenograft recipient, and the rights of animals. This review illuminates these issues through a conglomeration of expert opinion and relevant experimental studies.

Attitudes Toward Xenotransplantation Among Nonhealth Service Workers in a Hospital With a Preclinical Xenotransplantation Program

INTRODUCTION

Our hypothesis was that nonhealth workers (NHW) in our hospital should have a more favorable opinion toward xenotransplantation than the general population, given that this group is in closer contact with a preclinical xenotransplantation program. Therefore, our objective was to determine the attitude of NHW in a hospital with a preclinical liver xenotransplantation program and to determine the factors that influenced this attitude.

MATERIALS AND METHODS

A random sample of 276 subjects in nonhealth services was used. For the distribution of the questionnaire, we contacted the head of each of the services and explained the project. They became responsible for the distribution and collection of the questionnaires in randomly selected work shifts. A random sample of 250 individuals from our community was used as a control group.

RESULTS

As for animal organ donation for humans, if the results could be superimposed on those achieved by human donors, 63% would be in favor, 30% undecided, and the remaining 7% against. The attitude toward xenotransplantation was more favorable in the control group (74% versus 63%, P < .05). On analyzing the variables that influence attitudes toward xenotransplantation, we found that there is no significant relationship to the classical psychosocial variables (P > .05). However, there is a relationship to prior attitudes toward different types of human organ donation and the possibility of needing a transplant oneself.

CONCLUSIONS

The attitudes toward xenotransplantation among NHW are not as favorable as in the general population.

Les xénogreffes finiront-elles par être acceptées ?

Transplantation represents a major advance in modern medicine with a major impact on the interactions between individuals and society. The numbers of patients undergoing organ transplantation increased steadily over the years and around 250,000 individuals are living nowadays in Europe with a transplanted organ. On the other hand, the numbers of cadaveric (brain-dead) donors used for organ transplantation remains stable, at around 5,000 each year, and the numbers of transplantation from living donors only slowly increase in Europe. Therefore, a gap is growing between the numbers of patients in need of a transplant and the numbers of organs available for transplantation. About 45,000 patients are currently on renal transplant waiting lists in Europe and, depending on the countries considered, 15 to 30 % of candidates for liver or heart transplantation die before a life-saving transplant becomes available to them. There is therefore an urgent need to implement innovative research and to take full advantage of recent biotechnological advances to explore new avenues in xenotransplantation, and to simultaneously address the ethical, societal and public health issues related to organ replacement. Much progresses have been accomplished in the understanding of xenograft rejection processes that include hyperacute, acute vascular and cellular rejection mechanisms. Strategies to promote xenograft survival that are currently under evaluation include genetic engineering of donor pigs, adapted immunosuppressive treatments and tolerance induction. Also, the psychological acceptance has been evaluated.

Psychosocial aspects of xenotransplantation: Survey in adolescent recipients of porcine islet cells

INTRODUCTION

Transplantation is a process with several psychosocial challenges. Regarding the case of xenotransplantation, the perceived similarity between humans and pigs may be stressful. Adjustment disorders have been reported among transplantation recipients. We sought to assess the psychosocial aspects of xenotransplantation among porcine islet-cell recipients and their efforts to adapt themselves to this condition.

MATERIAL AND METHODS

Ten insulin-dependent diabetes mellitus patients aged 14.58 +/- 7.93 who received porcine islet-cells were included. The bioartificial steel/fibrous tissue chamber method was used. All patients and their relatives were interviewed about their expectations, overall functioning, and experiences. The quality of life, enjoyment, and satisfaction scale and the hospital anxiety and depression scales were used. A 1-year follow-up was done.

RESULTS

Their motivation was centered on autonomy; there were no troubles regarding the graft origin. Xenotransplantation was perceived with pragmatism, seeing pigs as an unlimited resource. The patients with best outcomes also had the greatest improvements in several quality of life areas (QOL) while the medium responders had fewer QOL improvements. The nonresponders experienced mainly frustration. Parents' concerns were not related to their children's health but to their recently gained autonomy.

CONCLUSIONS

In addition to enthusiasm, the perception of animals as an unlimited source of organs may affect patient compliance; in this group, xenotransplantation was seen as using as a long-lasting drug, with chamber walls considered as a physical, immunologic, and, in certain manner, a psychological barrier.

Public attitude toward xenotransplantation: Opinion survey

BACKGROUND

Although xenotransplantation is still in an experimental phase, it is presented herein as a possible solution to the organ shortage. However, there are few data concerning how the general public would accept treatment with animal organs, especially after recent incidents of infections of animal origin, such as "avian influenza" or "SARS disease." The aim of this study was to determine the attitude of the general public toward xenotransplantation of organs.

MATERIALS AND METHODS

Using an opinion survey, a study was performed on a random sample of 250 subjects in an urban setting. The questionnaire was administered by personnel from the regional transplant coordination center. Completion of the form was self-directed and anonymous for each respondent. The attitude toward donation of human and animal organs was evaluated by analyzing different psychosocial variables that may influence this attitude. A descriptive statistical study was performed using Student's t test and the chi-square test.

RESULTS

Ninety-eight percent of respondents completed the survey (n=245). As for human donation, 60% are in favor of cadaveric donation with 21% are in favor of living donation, a rate that increases to 74% if it is for a living partner. As for animal donation, if the results were similar to those obtained with human organs, 74% (n=181) would accept an animal organ if they needed it, as opposed to 18% (n=45) who were undecided and 8% (n=19) against (P <.005). Analysis of variables that influence attitudes toward xenotransplantation showed that this attitude was more positive among those having had a previous experience with transplantation (P=.028) and those having a positive attitude toward cadaveric donation (P=.007). Factors traditionally related to cadaveric donation, such as manipulation of the body or pro-social activities, showed no influence.

CONCLUSIONS

In the population studied, a positive attitude toward xenotransplantation was greater than toward cadaveric donation, assuming the results of these two types of transplants were comparable. Such an attitude is related to human donation, although it is not influenced by many traditional factors.

Public opinion surveys about xenotransplantation

BACKGROUND

Xenotransplantation may eventually provide a solution to the worldwide shortage of human organs for transplantation. Xenotransplantation is surrounded by profound ethical issues, both for the potential recipients and for the society as a whole. Concurrent with increased scientific interest, there has been an increasing number of quantitative public opinion surveys conducted about xenotransplantation in the last decade. The aim of the present study was to elucidate these surveys, and to assess some factors that may affect the outcome of them.

MATERIALS AND METHODS

Surveys were identified by web and literature searches using key words in Medline and ISI Web of Knowledge. Reference lists of identified surveys were checked. Data was obtained from Inter-University Consortium for Political and Social Research (ICPSR) and directly from authors whose data were presented in another way than percentages. In total, the present material covered surveys from 35 sources, including 23 countries.

RESULTS AND DISCUSSION

Results showed that almost half of the respondents accept xenotransplantation, whereas the remaining half did either not accept or did not have/state an opinion. Over time, the proportions of acceptance seemed unchanged. The proportion of those who did not accept decreased and the remaining proportion increased. This pattern was evident in Europe and the US, but not in Japan. Gender and education were found to be associated with opinions to xenotransplantation. The influence of religion was not as straightforward. This may partly depend on how religiosity was measured in the polls. Wording of items influenced levels of acceptance. If a xenotransplant was the ''only choice'' proportions of acceptance increased, and if a ''risk for zoonotic diseases'' was stated proportions of acceptance decreased. When wording of survey items was somewhat comparable, there were often, but not always, minor differences in proportions of acceptance between surveys from different sources. Trends in opinions are best measured by the use of the same items. It is however difficult to phrase items that will not be affected by external events.

The Road to Clinical Xenotransplantation: A Worthwhile Journey

Xenotransplantation carries numerous ethical dilemmas. In the Position Paper of the Ethics Committee of the International Xenotransplantation Association, Sykes et al. diagram important ethics issues including respect for clinical subjects characterized by proper informed consent, and beneficence to the patient and the community at large, highlighting the possible risk of porcine endogenous retroviruses and xenotourism. We propose optimizing informed consent to take into account the psychological, scientific, and ethical nuances of xenotransplantation. Moreover, regulation of xenotourism should mirror established U.S. guidelines for visitors with communicable diseases, thereby not limiting the rights of xenotransplant recipients.

Understanding of and attitudes to xenotransplantation: a survey among Italian university students

Xenotransplantation is currently at the experimental stages on animal models and many problems still have to be overcome in the biomedical, immunological and ethical fields. Moreover, people's attitudes to xenotransplantation vary: surveys among intensive-care staff have revealed negative opinions, while the general public and students seem to be more positive. Little is known about the influence of schooling and the choice of university faculty on attitudes to xenotransplantation. The aims of this study were: (i) to evaluate university students' attitudes to xenotransplantation; (ii) to investigate any socio-demographic, religious and educational determinants behind students' opinions on xenotransplantation. University undergraduates on five different courses were surveyed at Padua University. A 24-item questionnaire was distributed to students at the end of lectures and completed anonymously immediately after its distribution. No information was given to students beforehand.

STATISTICAL ANALYSIS

chi-squared, Pearson's test; P-values <0.05 were considered significant. A total of 585 of 602 (97.2%) students completed the questionnaire (132 males, 453 females, mean age 20.4, range 19 to 43 yr). They were on courses in Medicine (33.85%), Agriculture (5.98%), Veterinary Medicine (11.45%), Psychology (18.46%) and Educational Sciences (30.26%). As for their previous schooling, they came from classical or scientific high school (58.3%), technical college (14.7%), language college (6.3%), teacher training college (11.9%) or others (8.8%). Concerning their religious beliefs, 83% were Catholics, and 56.2% defined themselves as practising Catholics. Eighty-eight percentage of the students knew of the possibility of animal organs being transplanted into humans and 77.9% of them approved of this idea. When grouped according to gender and education, a higher proportion of students approving of xenotransplantation were male (P = 0.017) and had attended classical or scientific high school (P = 0.011). Disapproval for moral, ethical or religious reasons was higher among practising than among non-practising Catholics; the latter rejected xenotransplantation more for immunological and infectious reasons (P = 0.014). As for the type of university course, a higher proportion of students approving of xenotransplantation attended science courses (Veterinary Medicine, Agriculture and Medicine vs. Educational Sciences and Psychology) (P = 0.013). University students generally approved of xenotransplantation. Male gender and a high-school education were associated with a greater acceptance of xenotransplantation. Practising vs. non-practising Catholics reported significantly different reasons for any disapproval of xenotransplantation. The choice of a science rather than an arts faculty at university was more strongly associated with a positive opinion on xenotransplantation.

Attitudes of Swedes to marginal donors and xenotransplantation

The aim of our survey was to capture the attitudes of Swedes to marginal donors and xenotransplantation. Modern biotechnology makes it possible to replace non-functioning organs, cells, and genes. Nonetheless, people may have reservations and fears about such treatments. With the survey, Attitudes of the General Public to Transplants, we have sought to expose the ambivalence that arises when medical possibilities are juxtaposed with ideas of risk. The design of the questionnaire originates from the interdisciplinary cooperation between ethnologists, medical scientists, and geneticists. By combining qualitative and quantitative methods, it is possible to illustrate the complexity that characterises people's view of modern biomedicine. People's reflections are based on a personal and situation bound morality, which does not necessarily coincide with what they generally consider as ethically justifiable.

Xenotransplantation public perceptions: rather cells than organs

The aim of this study was to describe some of the factors that might play a role in influencing attitude to xenotransplantation: first, the consideration of receiving cells and tissue from xenotransplants in relation to whole xeno-organs; secondly, the fact that there is greater uncertainty regarding the result and risk of infection associated with xenotransplantation than with allotransplantation. We also describe the attitude to research on xenotransplantation, and the relationship between the attitude to receiving a xenotransplant and an allotransplant. Finally, we describe the attitude to xenotransplantation in relation to treatment for renal failure and waiting-time for allotransplantation. A questionnaire was sent to randomly selected members of the public aged 18 to 75 (n=1,000) and to all patients in the same age range who were waiting for kidney transplants in Sweden in the spring of 1998 (n=460). The response rate was 60% among the public and 87% among the patients. Both study groups were positive to a greater extent in their attitude to receiving cells and tissue than to receiving a whole organ such as a kidney. The response 'rather positive' to receiving organs was generally favored by the public, whereas the most generally favored response to receiving cells and tissue was 'very positive'. When there was suggested to be a greater uncertainty regarding the outcome with xenotransplantation compared with allotransplantation, the number of negative and uncertain respondents increased, both among the public and the patients. Eighty percent of the public and about 90% of the patients were in favor of continued research on xenotransplantation. Of those members of the public who responded, the attitude to receiving an organ from a human was positive in 86% of cases, with an emphasis on 'very positive'. There was a moderate relation between the attitude to receiving an organ from a human and to receiving a xenotransplant. Among the patients, there was no systematic or strong relation between the attitude to xenotransplantation and the kind of dialysis treatment they were on. Neither was there any systematic or strong relation to the waiting-time. The overall impression is that the attitude to xenotransplantation seems to be most influenced by whether the xenotransplant would involve whole organs or cells and uncertainty regarding the outcome.

Animal spare parts? A Canadian public consultation on xenotransplantation

Xenotransplantation, or the use of animal cells, tissues and organs for humans, has been promoted as an important solution to the worldwide shortage of organs. While scientific studies continue to be done to address problems of rejection and the possibility of animal-to-human virus transfer, socio-ethical and legal questions have also been raised around informed consent, life-long monitoring, animal welfare and animal rights, and appropriate regulatory practices. Many calls have also been made to consult publics before policy decisions are made. This paper describes the Canadian public consultation process on xenotransplantation carried out by the Canadian Public Health Association in an arm's length process from Health Canada, the ministry overseeing government health policy and regulation. Focusing on six citizen for a conducted around the country patterned after the citizen jury deliberative approach, the paper describes the citizen panelists' recommendations to hold off on proceeding with clinical trials and the rationales behind this recommendation. The consultation process is discussed in the context of constructive technology assessment, a framework which argues for broader input into earlier stages of technology innovation, particularly at the technology design stage.

Living related liver transplantation: medical and social aspects of a controversial therapy

There are more than 15,000 patients waiting for a liver transplant in the USA, with an average waiting time of 468 days and a mortality rate as high as 15-20%. Until artificial organs or xenotransplantation becomes a reality, living donor liver transplantation remains the best option for patients with end stage liver disease.

Xenotransplantation: hope or delusion?

Having moved from the realms of science fiction to a rapidly growing research area, xenotransplantation promises numerous benefits to patients in the future. However, deep suspicions of this technology are rife. We suggest an alternative viewpoint to that given in E M Engels' article in Biologist 46(2).

People's feelings and ideas about receiving transplants of different origins--questions of life and death, identity, and nature's border

The aim of this study was to explore the public's feelings and ideas with regard to receiving transplants of different origins. Sixty-nine individuals with varying sociodemographic background, selected from samples who had responded to a questionnaire on receiving and donating organs, were interviewed in-depth. A wide variety of reactions was displayed. The feelings and ideas about receiving organs were summarized in ten categories: 1) the emergency situation; 2) the functioning of the transplant; 3) the influence of transplants on personality, behaviour, and appearance; 4) the influence of transplants on body image; 5) disgust; 6) cannibalism; 7) trespassing nature's border; 8) tradition; 9) ethical considerations; and 10) the debt of gratitude. Most individuals were willing to accept at least one organ. Animal organs were the least preferred. The hierarchy of organ preferences--with organs from a relative at the top and animal organs at the bottom was explained in terms of rational, magical, and analogy thinking. Finally, the consequences for the encounter between health care personnel and transplantation candidates were briefly discussed.

Animal models in xenotransplantation

The severe shortage of donor organs has provided a strong impetus to push the investigation into the use of animal organs for humans. Xenotransplantation will not only benefit patients, but also represents a unique and potentially profitable business opportunity. However, there are many barriers to successful clinical xenotransplantation, including immunological barriers, physiological incompatibility, zoonosis and ethical concerns. This overview will focus on currently available animal models used in attempts to break through the immunological barriers to xenotransplantation. There are many advantages to using small animal, namely rodent, models in xenotransplantation research. For example, the use of the mouse model allows the use of knockout mice and careful dissection of rejection mechanisms at the molecular level. The following models can be used to study hyperacute rejection (HAR): guinea-pig-to-rat, mouse-to-rabbit, guinea-pig-to-mouse, rat-to-presensitised mouse and rat-to-alpha-Gal knockout mouse. The hamster-to-rat, mouse-to-rat and rat-to-mouse models are commonly used to study acute vascular rejection. Large animal models are complex and expensive, but they are more relevant to clinical xenotransplantation. Based on experiments using transgenic pig-to-primate models, HAR can be overcome. However, acute vascular rejection remains a major barrier at the present time. A pig cartilage-to-monkey model has been developed to study chronic rejection. Other novel models such as pig venous segment-to-monkey model and rat-to-primate model may represent viable options to study immunological barriers following xenotransplantation. Like many other medical breakthroughs, animal research will continue to make enormous contributions towards the eventual success of xenotransplantation.

Students' acceptance of clinical xenotransplantation

The aim of this study was to elucidate undergraduate university students' views on clinical xenotransplantation. A total of 1875 students from eight faculties at Uppsala University and the Swedish University of Agricultural Sciences answered a questionnaire. Three out of four respondents would be prepared to receive a transplant from an animal on medical grounds if necessary. Forty percent had signed an organ donation card. There was no difference in attitude between those who had signed an allotransplantion card and those who had not. According to gender, age, length of university program, and faculty, results showed that a higher proportion of those who approved were male, young, and studying on programs longer than three years; also, they were more likely to study programs in the Faculties of Agriculture and Pharmacy. At the Medical Faculty, nursing students seemed to be less approving, compared to future biomedical analysts, biomedical scientists, and physicians. The acceptance of xenotransplantation also tended to be positively associated with morally accepting and understanding the use of animals in biomedical research, the approval of euthanasia, the approval of early abortion, and the use of human fetuses in research, as well as clinical testing of humans.

[Some ethical considerations, especially identity, during xenotransplantation]

Provided that a pandemic due to retroviruses or prions eventually transmitted by animals is under control, in accordance with the fundamental ethical rule to serve the best interest of the patient, any organ xenotransplantation raises an important ethical dilemma: how to deliver proper and adapted information to the patient on the preservation of his identity. Xenotransplantation of any part of the brain seems to us unethical.

[Patients' attitudes to xenotransplantation: "I'll do anything, I don't want to die!"]

Transplantation of neural tissue is an effective therapeutical approach in Parkinson's disease, but the method is constrained by the lack of suitable donor material. Embryonic neural tissue from pigs, xenografts, is considered as an alternative source of donor tissue. The attitudes towards neural tissue grafting in general and xenografts in particular were investigated by interviewing a group of patients with Parkinson's disease. The analysis revealed an ambivalence regarding xenografts. A pragmatic view, with priority placed on survival over ethical and other reservations, became apparent.

Issues surrounding xenotransplantation

Currently there is a shortage of cadaver organs that can be transplanted from one human being to another. In response to this shortage, scientists and medical researchers have developed techniques for transplanting animal organs into humans, a procedure known as xenotransplantation. This may address the shortage of organs for patients in need; however, it raises other concerns related to cross-species disease transmission, consent issues, ethical issues of sacrificing animals for their organs, psychological issues of receiving organs from an animal, religious concerns, and economic factors. These medical, ethical, and philosophical issues need to be thoroughly addressed before xenotransplantation becomes a reality.

Attitude of patients toward transplantation of xenogeneic organs

BACKGROUND

The prospect of xenotransplantation has stimulated considerable hopes as well as major concerns. The question of whether or not patients accept xenografts is influenced not only by scientific facts but also by psychological factors. It was the aim of this study to analyze the attitudes of patients toward transplantation of xenogeneic organs and evaluate factors influencing these attitudes.

METHODS

To this end, attitudes toward xenogeneic compared with allogeneic organ grafts were evaluated by means of detailed questionnaires in 1049 patients in Germany, who either had received transplants (n=722) or were on the waiting list for various organ grafts (n=327). Answers were correlated to demographic data as well as to the physical and mental conditions of the patients.

RESULTS

The survey indicates that 77% of patients would accept xenografts while 7% would refuse them if results of xenotransplantation were comparable with those of allotransplantation. If xenotransplantation were associated with increased risks due to more intensive medication 58% would still basically accept xenografts. Acceptance of xenografts was significantly higher in patients who had received transplants and among males. Age, religion, waiting time, and type of organ were not found to influence acceptance rates. Xenografts were thought to be associated with considerable or severe emotional stress by 23% of patients, versus 3% for allografts. The pig was the preferred donor animal, and gene therapeutic manipulation for improvement of results would be accepted by 84%. Inadequate graft function/increased risk of rejection and risk of disease transmission were the major concerns for 60% and 52% of patients, respectively; emotional concerns were the major concerns for 24% and animal-rights concerns for 15%.

CONCLUSIONS

These findings show that the potential acceptance rate of xenografts would be quite high, with a more positive attitude in transplanted patients than in waiting-list patients; there was no major difference in acceptance rate for various types of organs. Major concerns about xenotransplantation currently are functional inferiority and transmission of diseases.

Giving and taking--to whom and from whom? People's attitudes toward transplantation of organs and tissue from different sources

The aims of the study were: 1) to describe the willingness of the public to receive material of different origins in one's own body; 2) to compare the willingness to donate and receive body material; 3) to compare the willingness to donate while alive and after death; 4) to compare the willingness to donate to a next-of-kin and unknown recipients. A random sample of 1500 inhabitants, 18 to 70 yr old, in the county of Uppsala, Sweden, were sent a questionnaire asking about their opinion on transplantation and transfusion issues. The response rate was 71%. Ninety-five percent accepted to receive blood transfusion, 89% bone-marrow transplantation, and 85% transplantation of a solid organ. Organs from living donors were preferred (77%), then organs from decreased donors (69%), then artificial organs (63%), and last animal organs (40%). More than half of those accepting transplants made exceptions for some types of organs. The youngest and those with higher education were more positive toward receiving all types of organs than the older ones and those with lower education. Women were less prepared than men to accept animal organs. Those who accepted organs from animals usually also accepted all other types of organs, and were willing to donate organs and tissue more often than those who did not accept to receive animal organs. The readiness to support a sick family member by giving bone-marrow and even a kidney was considerable, 89 and 81%, respectively. The attitudes were less positive with regard to giving blood and bone-marrow to unknown recipients, 54 and 41%, respectively. Sixty-one percent of the respondents were positive toward donating their own organs after death. Of those who were positive, 10% made exceptions for special organs that they did not want to donate, mostly heart, eyes, and brain. Individuals with higher education and young people were more often positive than those with lower education and old people regarding donation of blood and organs, and bone-marrow donation to a relative. Women were somewhat more accepting to donate while alive than males. Thirty-one percent, more often women than men, had signed a donor card and/or registered with the Swedish Organ Donation Registry. The results with regard to receiving organs and tissue are discussed in terms of two different sets of explanations, which can be seen as different sides of the same coin, and mutually strengthening the reactions. The great readiness to donate to a family member as well as the discrepancy between giving in life and after death is commented upon.

[Social and ethical issues of xenotransplantation]

The worldwide shortage in the supply of donor organs and tissues is becoming more pronounced. Xenotransplantation may probably give the hope to overcome the problem ultimately. However, it gives rise to a number of social and ethical issues, among them, the pig appears to be a likely source for human transplantation because it entails least social and ethical issues than no-human primates or other animals and the pig is similar to human in many aspects. The ethical and economic aspects must also be taken into consideration. Patient and his family's privacy may be stripped because the patient has received a new or unusual treatment. Xenograftings will squint towards a kind of commodities which are different from human graftings and it is a challenge to human transplantation. Xenotransplantation brings a risk of creating new human disease and pandemic, so, it is necessary to formulate a policy and provide input to draft guidelines on the regulation of xenotransplantation.

Survey results of transplant patients' attitudes on xenografting

For centuries, many cultures have described mythical creatures with bodies that combined human and animal features, often the result of violating taboos. This study attempted to investigate the beliefs of transplant patients about xenografting. A survey was given to 100 patients ranging in age from 17 to 74 years old, with 65 men and 35 women, including 72 whites, 18 Hispanics, 5 African Americans, and 4 Asian Americans. The subjects included liver, heart, kidney, lung, and multi-organ transplant patients. The patients were not aware of plans for xenografting at the center under study. Eighty patients agreed with xenografting in an emergency situation. Ten subjects replied, "under no circumstances." Ninety percent believed animal research has advanced medical science. In descending order, the patients preferred human (96%), monkey (44%), mechanical (43%), pig (42%), or dog (34%) organs. Twenty-four patients thought a xenograft would change their appearance, personality, or eating or sexual habits. Twenty patients believed animals have souls. The patients also documented any ethical concerns about xenografting.

Recipient and non-recipient attitudes regarding xenotransplantation

Xenotransplantation research has occurred intermittently without success this century and is also not an area without controversy, which includes the potential health risks that could occur and the use of animals. The tremendous discrepancy between those in need of transplantation and the number of living and cadaveric donors has once again renewed interest in this field. The National Kidney Foundation undertook an opinion survey to facilitate understanding of both transplant recipients' and non-recipients' knowledge of, and attitudes toward, xenotransplantation. The majority of respondents approved of the concept and greater than 70% of both groups would consider a xenotransplant. The main concern of both groups was the ability of the animal organ to function properly.

Animal magic? A study about xenografting

The pursuit of an acceptable solution to solve the "transplant gap" continues. Those awaiting an organ transplant have always far exceeded the donor population. Xenografting, the transplantation of organs from one animal species to another is already technically viable; for example, a pig's kidney to a human being (1).