Special Issues Concerning Living Donors

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Ubel and Mahowald have identified four key factors in the ethical assessment of organs or tissues from living donors: 1) risks and benefits to the donor; 2) risks and benefits to the recipient; 3) possibility and validity of consent for donation; and 4) donor privacy and confidentiality.32

Risks and Benefits to the Donor

Two techniques of assessing risk to potential donors involve the consideration of (a) "whether the body can naturally replace the donated material" and (b) the "invasiveness, discomfort, and risks of the procedures used in obtaining tissues or organs." Similarly, psychological benefits have been found in significant increases in donor self-esteem and confidence.32

Risks and Benefits to the Recipients

The assessment of risks and benefits to the recipients focuses primarily on "the organ, the prospects of success, and the possibility of alternative therapy, including cadaver donation" Liver donations are seen by Ubel and Mahowald as offering the greatest benefit to recipients because they shorten the time patients wait for organs, whereas they see live-donor kidney transplants being done primarily for a recipient's better quality of life since dialysis is available, the benefits of pancreas transplants are still unclear, and bone marrow transplants sometimes being used in situations where there is little chance of a recipient's recovery.32

Possibility and Validity of Consent

Here the focus is on both the presence of coercion and the possible absence of informed judgment: "Can a donor, under pressure to save another person, sufficiently understand the risks and benefits described above and arrive at a decision regarding donation without being coerced?" Since most living donors are relatives of recipients, the potential for direct or indirect coercion is great, and aside from needing to find the capacity in the potential donor to make informed decisions, the temptation for donors to make a snap decision to donate without further reflection creates ethical concerns. This may be particularly true with adolescents who may be motivated by "the desire to be recognized as an adult."32

Donor Privacy and Confidentiality

Because transplant teams must evaluate potential donors in a recipient's family, issues of privacy and confidentiality are raised that may lead to pressure on specific individuals either to donate or not to donate, thus compromising their autonomy. Similarly, issues can arise with unrelated potential donors (e.g., in a bone marrow registry) when potential recipients seek to identify the names of potential donors who may have declined to donate to a nonrelative.32

Other categories of potential living donors in which Ubel and Mahowald find informed consent to be problematic or even impossible include fetuses, anen-cephalic newborns, prisoners, and women (the last because of their roles often as

"primary caregivers of those in need of transplants" and their lower incomes when compared to men, thus putting pressure particularly on housewives to make a sacrifice for the employed male spouse).32

There have been numerous proposals for increasing the pool of living organ donors, including those unrelated to the recipient.33 In a most ethically responsible and scientific manner, researchers and clinicians at the University of Chicago have begun a process of what they call "research-ethics consultation for surgical innovations" that includes the publication of a paper in a major clinical journal seeking professional and public criticism. Two of these consultations have involved the use of living donors, one in connection with liver transplantation34 and the other proposing a paired-kidney-exchange between two donor-recipient pairs to resolve the problem of ABO-compatibility.35

Potential living donors should have their autonomy and privacy maximized and an adequate opportunity to reflect on the risks and benefits of their decision regarding donation, according to Ubel and Mahowald. Ideally, their evaluation should be conducted by someone who can be an advocate for the donor and who is not a member of the transplant team, and ethical questions should be considered by an appropriate ethics resource within the institution or community.32

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