Opinion 2.15 - Transplantation of Organs from Living Donors
Living organ donors are exposed to surgical procedures that pose risks but offer no physical benefits. The medical profession has pursued living donation because the lives and quality of life of patients with end-stage organ failure depend on the availability of transplantable organs and some individuals are willing to donate the needed organs. This practice is consistent with the goals of the profession—treating illness and alleviating suffering—only insofar as the benefits to both donor and recipient outweigh the risks to both.
(1) Because donors are initially healthy and then are exposed to potential harms, they require special safeguards. Accordingly, every donor should be assigned an advocate team that includes a physician. This team is primarily concerned with the well-being of the donor. Though some individuals on the donor advocate team may participate in the care of the recipient, this team ideally should be as independent as possible from those caring for the recipient. This can help avoid actual or perceived conflicts of interest between donors and recipients.
(a) To determine whether a potential living donor is an appropriate candidate, the advocate team must provide a complete medical evaluation to identify any serious risk to the potential donor’s life or health. This includes a psychosocial evaluation of the potential donor to identify disqualifying factors, address specific needs and explore potential motivations to donate.
(b) Before the potential donor agrees to donate, the advocate team should provide information regarding the donation procedure and its indications, as well as the risks and potential complications to both donor and recipient. Informed consent for donation is distinct from informed consent for the actual surgery to remove the organ.
(i) The potential donor must have decision-making capacity, and the decision to donate must be free from undue pressure. The potential donor must demonstrate adequate understanding of the disclosed information.
(ii) Unemancipated minors and legally incompetent adults ordinarily should not be accepted as living donors because of their inability to fully understand and decide voluntarily. However, in exceptional circumstances, minors with substantial decision making capability who agree to serve as donors, with the informed consent of their legal guardians, may be considered for donation to recipients with whom they are emotionally connected. Since minors' guardians may be emotionally connected to the organ recipient, when an unemancipated minor agrees to donate, it may be appropriate to seek advice from another adult trusted by the minor or an independent body, such as consultation with an ethics committee, pastoral service, or other counseling resource.
(iii) Potential donors must be informed that they may withdraw from donation at any time before undergoing the operation and that, should this occur, the health care team is committed to protect the potential donor from pressures to reveal the reasons for withdrawal. If the potential donor withdraws, the health care team should report simply that the individual was unsuitable for donation. From the outset, all involved parties must agree that the reasons why any potential donor does not donate will remain confidential for the potential donor’s protection. In situations of paired, domino, or chain donation withdrawal must still be permitted. Physicians should make special efforts to present a clear and comprehensive description of the commitment being made by the donor and the implications for other parties to the paired donation during the informed consent process.
(c) Living donation should never be considered if the best medical judgment indicates that transplantation cannot reasonably be expected to yield the intended clinical benefit or achieve agreed on goals for care for the intended recipient.
(2) Living donors should not receive payment for any of their solid organs. However, donors should be treated fairly; reimbursement for travel, lodging, meals, lost wages, and the medical care associated with donation is ethically appropriate.
(3) The distribution of organs from living donors may take several different forms:
(a) It is ethically acceptable for donors to designate a recipient, whether a close relative or a known, unrelated recipient.
(b) Designation of a stranger as the intended recipient is ethical if it produces a net gain of organs in the organ pool without unreasonably disadvantaging others on the waiting list. Variations involve potential donors who respond to public solicitation for organs or who wish to participate in a paired donation or “organ swap” (e.g., blood type incompatible donor-recipient pairs Y and Z are recombined to make compatible pairs: donor-Y with recipient-Z and donor-Z with recipient-Y) domino paired donation, and nonsimultaneous extended altruistic donation (also known as chain donation).
(c) Organs donated by living donors who do not designate a recipient should be allocated according to the algorithm that governs the distribution of deceased donor organs.
(4) Novel variants of living donation call for special attention to protect both donors and recipients:
(a) Physicians must ensure utmost respect the privacy and confidentiality of donors and recipients, which may be more difficult when many patients are involved and when donation-transplantation cycles may be extended over time (as in domino or chain donation)
(b) Physicians should monitor prospective donors and recipients in a proposed nontraditional donation for signs of psychological distress during screening and after the transplant is complete.
(c) Physicians must protect the donor’s right to withdraw in living paired-donations and ensure that the individual is not pressured to donate.
(5) To enhance the safety of living organ donation through better understanding of the harms and benefits associated with living organ donation, physicians should support the development and maintenance of a national database of living donor outcomes, similar to that of deceased donation. (I, V, VII, VIII)