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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2005  |  Volume : 16  |  Issue : 4  |  Page : 540-546
Recent Thoughts about the Ethics of Renal Transplantation

1 Health care communication, Ludwig Boltzmann Institute for the Economics of Medicine in Anesthesia and Intensive Care, Austria
2 Health care communication, Vienna, Austria

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Ethical controversies in transplantation medicine are frequent and are not only discussed in the medical societies, but also by the pubic at large. Recently, the shortage of donor organs has led to a discussion of the commonly accepted ethical principles applied in transplantation medicine. In this paper, we highlight some of the thoughts expressed in the literature and discuss them in the context of transplantation.

Keywords: Transplantation, Organ donation, Ethics, Brain death, Non-heart-beating organ donors, Financial incentives.

How to cite this article:
Fitzgerald A, Mayrhofer-Reinhartshuber D, Suske M, Fitzgerald RD. Recent Thoughts about the Ethics of Renal Transplantation. Saudi J Kidney Dis Transpl 2005;16:540-6

How to cite this URL:
Fitzgerald A, Mayrhofer-Reinhartshuber D, Suske M, Fitzgerald RD. Recent Thoughts about the Ethics of Renal Transplantation. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2023 Feb 4];16:540-6. Available from: https://www.sjkdt.org/text.asp?2005/16/4/540/32845

   Introduction Top

Ethical aspects in medicine find increasing interest in the medical literature, attract wide­spread public interest and are regularly covered in the lay press. Since its early days, organ trans­plantation has inflicted controversies within medical societies and the public. However, consensus was reached concerning donation and allocation of organs that resulted in a successful and quick expansion of transplant­ation practices. The success especially of renal transplantation was so great, that it developed into rather an easy and save procedure, saving patients from hemodialysis or death, when dialysis facilities are not sufficiently available. Worldwide more and more patients are listed for renal transplantation, unmatched by supply for the increasing demand. According to the data published on the Eurotransplant homepage for the year 2001 804 Austrian patients and 11184 patients in Germany were waiting for organs. [1] According to the United Network for Organ Sharing (UNOS) [2] 80812 patients (stand of 2002-12-17) are on the waiting list for organs in the USA.

The long waiting periods resulting from the organ shortage constitute a considerable risk for the patients to die before they receive a lifesaving organ. According to UNOS 5000 patients died in the year 2000 in the USA while on the waiting list for organ transplantation. Thus, in the quest to increase the number of transplantable organs, the ethical consensus is challenged. This article attempts to give an overview on the different opinions expressed and to discuss some of the arguments.

   Should we Discuss Ethical Principles? Top

Ethical principles are set as general rules to allow judgement in special aspects and questions. They should be based on the truth of the most basic rules of ethics, which are not altered over time or by circumstances. Thus, concern is sometimes expressed that when these rules were agreed upon, it does not seem understandable that they should be discussed or altered, when circumstances change. In the special case described above, the change in circumstances would be the increasing demand for donor organs. When we have concerns about the use of organs, is it right to question the rules set and to say that they are not right anymore, just because we want to have more organs? Would that not equal a situation where we have made consensus on traffic lights and question them the first moment we have to wait at the red lights?

Of course, a change in demand cannot be the basis for a revision of an ethical consensus. But it is legitimate to review any principles in the light of new aspects, which could alter the consensus. If the basis of a consensus has changed, or new arguments are introduced, decisions have to be reconsidered.

Thus, we want to discuss arguments if they qualify sufficiently for a change of the consensus which is the basis of ethical decisions in transplant medicine.

Changes have been proposed on different levels of the organ donation process: (i) is a donor really dead? (ii) The consent of the family to organ retrieval of a deceased, (iii) the related living organ donation, and (iv) unrelated living organ donation.

   Is the Donor Really Dead? Top

At the moment there are two sources for organs - from the living donors or the deceased ones. Taking organs from cadavers is accepted by many people as a justifiable practice within certain ethical boundaries. Controversies result from an inability to define exactly where those boundaries are. [3] Definitions and procedures throughout the world show considerable differences as well as the acceptance of brain death and the permission to retrieve organs from such donors.

The handling of non-heart beating donors remains a point of conflict, where lack of time eliminates the procedures necessary for the declaration of brain-death in heart beating donors. Are these donors really dead? [5] Is there a prohibitive conflict of interest of professionals and institutions [6],[7] or is there even a danger of euthanasia? [8] Is unethical and illegal practice preventable? [9] While non-heart-beating organ donation was widely used before the intro­duction of the brain death criteria, this source for organs remained almost unused until the demand for transplantable organs led to the re-emergence of this method with the intro­duction of the Pittsburgh Protocol. [10] An observation period of 5 min for verifying the absence of circulation and respiration was proposed to be sufficient to allow organ retrieval. Immediately a discussion arose on how sure a person would be dead or how much time would have to pass, to be sure, that resuscitation would not restore body functions. [11],[12] Also, as potential non-heart beating organ donation often follows a decision to withdraw medical support, a potential conflict of interests must be considered.

This debate and the need for specific standard criteria led to a position paper of the Ethics Committee of the American College of Critical Care Medicine of the Society of Critical Care Medicine in 2001. [13] In short the authors conclude, that

- organ procurement from non-heartbeating donors is ethical

- consent is requested

- death must be certified

- pediatric donation is possible, even in the light of the special situation, that the guardian has to choose for them.

While these recommendations are a landmark in the process of forming an acceptable con­sensus, the discussion is surely not at an end. Presumably, an internationally valid consensus will have to include more the situation in other cultures and nations.

Consent of the Family

A controversial topic in organ transplantations is the question whether relatives of the deceased organ donors should receive a financial incentive for their consent to organ removal. However, in most countries it is illegal to acquire, receive, or transfer any human organ for use in human transplantation. The implementation of such suggestions cannot be carried out without a change of the established laws, which is already discussed in some countries. In Great Britain a change of the current laws concerning financial compensation of living relative organ donation is in pre­paration. [14]

In the discussion in favor or against financial incentives for the consent to organ donation many arguments were published.

Models about the form of such financial incentives are multiple. [15] The direct payment of a lump sum to the decedents or estate as advocated by Peters [16] or Lysaght and Mason [17] is the most straightforward form of payment. The amount discussed varies up to 20,000 $ [17] based on the price for fertilized eggs. Critics oppose this suggestion because the payment of a lump sum could easily give the impression of selling the body of the deceased relative.

Another similar suggestion is a tax benefit for the relatives of the deceased organ donor. [18],[19] Although a direct payment or a tax benefit might provide the greatest likelihood of increasing donation , they are regarded as the ethically least acceptable. [18]

Another suggestion to a financial incentive, regarded by some to be more ethical, is the reimbursement of funeral expenses in the amount of 300$. [18],[19] This system, already implemented in Taiwan [20] is devised to avoid the impression of selling the body but rather express appreciation for the donation. The reimbursement for the funeral expense would not subvert the altruistic donation system but rather improve and support it. In a pilot project in the US state of Pennsylvania the effects of the reimbursement on the consent rate are currently investigated. [19]

A form of financial incentive regarded to be very ethical constitutes a contribution to a charitable organization determined by the family or the deceased. However, it is questioned whether such a form of a financial incentive would increase the rate of consent for donation. [18]

Another suggestion to the form of financial incentives is the implementation of a future market system, [15] where an individual agrees in advance to donate his organs after death with a payment to be made to his beneficiaries or his estate only when the donation has taken place. The advantage of this proposal is that the donors can opt-in to the donation process. The family is neither confronted with the decision for donation nor with the ethical problem for receiving money for consent.

Supporters of financial incentives for organ donation are convinced that by the existing donor shortage the established altruistic donation model is not adequate to meet the current needs. [16],[17] Lysaght and Mason [17] compared the current situation with leaving fire-fighting in a major metropolis to the same volunteer fire department that served the city well during its early years. They discuss, that the lack of organ donors can only be compensated by financial incentives. Supporters also argue that the demands of other medical resources like blood plasma, sperm as well as for corpses for teaching purposes in medical schools can only be satisfied by payment. [17]

Another argument of the supporters of financial incentives is that the families of deceased donors are the only ones involved not directly benefiting from the transplantation process. All other persons concerned like physicians, surgeons, nurses, coordinators etc. are paid, the recipients receive an organ and only the family of the donor is not compensated. [16],[17] According to Peters [16] this is one of the main reasons why many families refuse to consent to organ removal and it would be appropriate that the relatives of the deceased donors should also benefit from the transplant­ations process.

Opponents of financial incentives base their objections primarily on the argument that the established altruistic system has not failed as much as it has not been fully promoted. [15] The number of organ donors could also be increased by additional information and adver­tisements to raise the knowledge and the public opinion towards the organ transplantation process. As it was shown that attitudes in medical personnel are inhomogeneous 21 another possibility to increase the number of organ donors is to increase the qualification of the requestor and to sensitize all medical staff involved in the transplantation. [22],[23] Opponents have also suggested that donation rates could decrease under a system of financial incentives due to a backlash and losses from the current donor pool based on pure altruistic giving. [15]

Protas [24] calculated that if 50% of the families now refusing to give consent to the organ removal would donate the organs in return for financial compensation and 30% of the present donors would refuse to do so under a system of financial incentives the supply of the organ remains about the same.

For Protas [24] one of the main problems in the discussion about financial incentives for deceased organ donation is the economic rea­soning. It is stated that increasing the price will increase the supply of a commodity and that no shortage can persist in a market where truly free pricing prevails. [17] First the validity of this reasoning depends on its basic assumption - that human bodies are commodities and that families of potential organ donors will treat the bodies of the deceased relatives as commodities. If they refuse to consider the bodies of the next-of-kin as tradable commo­dities, then the economics of supply and demand are irrelevant to this question.

Payment for blood donation also posed the problem that donors who have an economic need for compensation were not truthful of their medical history. Therefore the blood of paid donors had a higher rate of post-trans­fusion infection. [18] The same problem could occur in organ donation if donors or the rela­tives of a donor are motivated with financial incentives.

It is argued that another risk of the imple­mentation of financial incentives would be that a moral barrier would be broken and it would be difficult to contain abuses by regu­lations and laws. [25] If the current prohibition against the sale of organs would be repealed, there would be little legal or ethical justifi­cation for preventing persons from bypassing the regulated system and using other means to obtain or sell an organ at a better price. [25]

A free market of organ brokerage would discriminate the poor in the population because they would not be able to afford organ trans­plantation on the one hand and on the other hand they would become the donors for the more wealthy due to their financial demands. [25]

Summarizing all these arguments it is obvious that most arguments of the supporters and the opponents are assumptions and fears and not empirical findings. However, little attention has hitherto been paid to the psychological aspects of the introduction of financial incent­ives for consent to organ donation, e.g. on the family, the society, or the staff involved. Apply­ing the theory of cognitive dissonance of Festinger, [26] Mayrhofer and others have investi­gated the effects of a financial incentive on consent rates and concluded that reduction of consents would be possible. [27],[28]

Living Related Donors

While living related donation is commonly assumed to be ethically correct, this was questioned in a recent publication by Al-Khader and co-workers. [29] Overlooking a period of 24 years of doing live related transplantation they report on many examples of pressure exerted on the donor be it financial, psycho­logical, familial, social or tribal. The pressure put to bear might often be subtle and indirect. The donor in question may be pressured by body language of the other relatives or by putting the situation in such a way that a specific relative will have to come forward to donate. The authors summarize 'that (i) a gift of a kidney should be entirely altruistic. If it is not and if the above argument holds, then one might as well buy the kidney - which is abhorred by all International Transplant Societies. (ii) Moreover, a kidney given under these circumstances goes against the long­held view that no medical intervention should take place to an adult, conscious and mentally normal patient without his unprejudiced consent. This should apply even more so as we are dealing not with a patient but with a perfectly normal person. (iii) Perhaps more importantly, a kidney given under these circum­stances leads to a drastic psychological adverse upheaval in the donor and a sense of long lasting guilt among the family members including the recipient.

Thus, while little attention is paid to the ethical and psychological background of the 'accepted' living related donor situation, this situation should require more attention

Living Unrelated Donors

Traditionally, most donors have strong relationship with the recipient (related donors). However, in situations of donor-recipient incompatibility, systems of paired exchange and list-paired exchange have been proposed. In the paired exchange system, two recipients who do not have compatible donors can be matched where the donor of one recipient donates to the other and vice versa. [30]

Altruistic donors are donors who do not necessarily know the recipient. The donation is a pure act of altruism, with no expectation of a material reward of any sort. There are few examples in the literature on this kind of donation. [31]

For this reasons in June of 2000 represent­atives of the transplant community evaluated the current practices in organ transplantation [32] and reached a consensus, recommending certain guidelines for the ethical practice of living organ donation. They established stand­ards of consent, medical suitability for the evaluation of the donor patient, encompassing issues including competency, willingness to donate, freedom from coercion, and full disclosure regarding the risks and benefits of both donor and recipient surgeries. How­ever, Biller-Andorno describes in the findings from empirical data how difficult it is to find the balance between possibility and pressure and that it is not very easy to evaluate especially if there is a combination of the medical doctors authority and the advice. [33]

Trade with organs is happening and was reported in many regions of the world. [34] A panel from the American Society of Transplant Surgeons unanimously opposed to the exchange of money for cadaver donor organs because either a direct payment or tax incentive would violate the ideal standard of altruism and unacceptably commercialize the value of human life by commodifying donated organs. [18] This is further aggravated by the lack of improvement of the life of the donor by the financial compensation and a possible decline in health. [35] However, a majority of the members of the panel mentioned above, favored con­tributions for funeral expenses or donations to charitable organizations as a possible recompensation for the donation. [18]

In general the benefits to both - donor and recipient must outweigh the risks associated with the donation and transplantation of the living donor organ. At least this can be fulfilled if donors are not called upon to donate in clinically hopeless situations.

When several alternatives are discussed, mostly all of them have some truth, but seldom one owns all the truth. Many contemporary moral discussions are "interminable" -i.e. they are endless arguments pitting conflicting positions held by different parties each of whom believes his or her position are un­disputedly correct.

On the other hand various ethical reflections influence and enrich each other. Thinking about principles helps acting in a more professional way, considering aspects of care improves the quality of communication and narrative ethics and casuistry.

   References Top

1.Eurotransplant.http://www.eurotransplant.nl (2002-12-17).  Back to cited text no. 1    
2.United Network for Organ Sharing. http://www.unos.org (2002-12-17).  Back to cited text no. 2    
3.Childress JF. The failure to give: reducing barriers to organ donation. Kennedy Inst Ethics J 2001;11:1-16.  Back to cited text no. 3  [PUBMED]  
4.Fitzgerald A. Hirntod und Organ transplant­ation. Psychologische, biologische, ethische und kulturelle Aspekte. Thesis at the University of Vienna, Vienna 1997.  Back to cited text no. 4    
5.Lynn J. Are the patients who become organ donors under the Pittsburgh protocol for "non-heart-beating donors" really dead? Kennedy Inst Ethics J 1993;3:167-78.  Back to cited text no. 5  [PUBMED]  
6.Frader J. Non-heart-beating organ donation: personal and institutional conflicts of interest. Kennedy Inst Ethics J 1993;3:189-98.  Back to cited text no. 6  [PUBMED]  
7.Burdick JF. Potential conflicts of interest generated by the use of non-heart-beating cadavers. Kennedy Inst Ethics J 1993;199-202.  Back to cited text no. 7    
8.Childress J. Non-heart-beating donors of organs: Are the distinctions between direct and indirect effects and between killing and letting die relevant and helpful? Kennedy Inst Ethics J 1993;3:203-16.  Back to cited text no. 8    
9.Robertson JA. Policy issues in a non-heart beating donor protocol. Kennedy Inst Ethics J 1993;3:241-50.  Back to cited text no. 9  [PUBMED]  
10.DeVita MA, Snyder JV. Development of the University of Pittsburgh Medical Center policy for the care of the terminally ill patients who may become organ donors after death following the removal of life support. Kennedy Inst Ethics J 1993;3:131-43.  Back to cited text no. 10  [PUBMED]  
11.Enselsberg CD. The dying human heart. Electrocardiographic study of forty-three cases, with notes upon resuscitation attempts. Arch Intern Med 1952;90:15-29.  Back to cited text no. 11    
12.Xiao F, Safar P, Radovsky A, et al. Mild hypothermia (hth) plus cerebral blood flow promotion (cbf), but not drugs, give complete functional recovery after 11 minute cardiac arrest in dogs. Crit Care Med 1995;23 (Suppl): A 179.  Back to cited text no. 12    
13.Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine. Recommendations for nonheartbeating organ donation. Crit Care Med 2001;29:1826-31.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Ahmed K, Revill J. Organ donors could be paid. The Observer 2002; Oct 20.  Back to cited text no. 14    
15.15. Nelson EW, Childress JE, Perryman J, et al. Financial Incentives for Organ Donation. A Report of the UNOS Ehtics Committee Payment Subcommittee 1993. whitepapers finance.htm.   Back to cited text no. 15    
16.Peters TG. Life or death. The issue of payment in cadaveric organ donation. JAMA 1991;265:1302-5.  Back to cited text no. 16    
17.Lysaght MJ, Mason J. The case for financial incentives to encourage organ donation. ASAIO J 2000;46:253-6.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Arnold R, Bartlett S, Bernat J, et al. Financial incentives for cadaver organ donation: an ethical reappraisal. Transplantation 2002; 73:1361-7.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Delmonico FL, Arnold R, Scheper-Hughes N, et al. Ethical Incentives - not Payment - for Organ Donation. N Engl J Med 2002; 346:2002-5.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Shih FJ, Lai MK, Lin MH, et al. Impact of cadaveric organ donation on Taiwanese donor families during the first 6 month after donation. Psychosom Med 2001;63:69-78.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]
21.Fitzgerald RD, Fitzgerald A, Shaheen FA, DuBois JM. Support for organ procurement: national, professional, and religious correlates among medical personnel in Austria and the Kingdom of Saudi Arabia. Transplant Proc 2002;34:3042-4.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]
22.Fitzgerald A, Mayrhofer D, Huber R, Fitzgerald RD. The COPe™ concept for the training of communication in highly emotional situations. Ann Transplant 2004;9:36-8.  Back to cited text no. 22  [PUBMED]  
23.Fitzgerald A, Seidl A. The COPe™ program: Communicational, organizational and personal factors influencing the transplant process and the number of donor reports. Ann Transplant 2005;10:31-4.  Back to cited text no. 23    
24.Prottas JM. Buying human organs - Evidence that money does not change everything. Transplantation 1992;53:1371-3.  Back to cited text no. 24  [PUBMED]  
25.Deci EL. Why we do what we do. New York, 1996: Penguin Books.  Back to cited text no. 25    
26.Festinger L, Carlsmith JM. Cognitive consequence of the forced compliance. J Abnorm Social Psychol 1959;58:203-11.  Back to cited text no. 26    
27.Mayrhofer-Reinhartshuber D, Fitzgerald R. Financial incentives for cadaveric organ donation. Ann Transplant 2004;9:25-7.  Back to cited text no. 27    
28.Mayrhofer-Reinhartshuber D, Fitzgerald A, Fitzgerald RD. Money for consent - psychological considerations. Ann Transplant 2005;10:26-9.  Back to cited text no. 28    
29.Al-Khader A, Jondeby M, Ghamdi G, Flaiw A. Hejaili F. Querishi J. Assessment of the willingness of potential live related kidney donors Ann Transplant 2005;10:35-9.  Back to cited text no. 29    
30.Liu EH, D´Alessandro DA, Hardy MA. Ethical issues in living renal donation. Transplant Proc 2003;35:1174-6.  Back to cited text no. 30    
31.Matas AJ, Garvey CA, Jacobs CL, Kahn JP. Nondirected Donation of Kidneys from Living Donors. N Engl J Med 2000;343:433-6.  Back to cited text no. 31  [PUBMED]  [FULLTEXT]
32.Abecassis M, Adams M, Adams P, et al. Consensus statement on the live organ donor. JAMA 2000;284:2919-26.  Back to cited text no. 32  [PUBMED]  [FULLTEXT]
33.Biller-Andorno N, Schauenburg H: Vulnerable Spender. Eine medizinethische Studie zur Praxis der Lebendorganspende. Ethik Med 2003;15:25-35.  Back to cited text no. 33    
34.Friedlaender M. The right to sell or buy a kidney: are we failing our patients? Lancet 2002;359:971-3.  Back to cited text no. 34    
35.Goyal M, Mehta RL, Schneiderman LJ, Sehgal AR. Economic and health consequences of selling a kidney in India. JAMA 2002;288:1589-93.  Back to cited text no. 35  [PUBMED]  [FULLTEXT]

Correspondence Address:
Robert D Fitzgerald
Ludwig Boltzmann Institute for the Economics of Medicine in Anesthesia and Intensive Care, Wolkersbergenstrabe 1, A-1130, Vienna
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Source of Support: None, Conflict of Interest: None

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