living donation
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2022 ◽  
pp. medethics-2021-107574
Author(s):  
Sanjay Kulkarni ◽  
Andrew Flescher ◽  
Mahwish Ahmad ◽  
George Bayliss ◽  
David Bearl ◽  
...  

The transplant community has faced unprecedented challenges balancing risks of performing living donor transplants during the COVID-19 pandemic with harms of temporarily suspending these procedures. Decisions regarding postponement of living donation stem from its designation as an elective procedure, this despite that the Centers for Medicare and Medicaid Services categorise transplant procedures as tier 3b (high medical urgency—do not postpone). In times of severe resource constraints, health systems may be operating under crisis or contingency standards of care. In this manuscript, the United Network for Organ Sharing Ethics Workgroup explores prioritisation of living donation where health systems operate under contingency standards of care and provide a framework with recommendations to the transplant community on how to approach living donation in these circumstances.To guide the transplant community in future decisions, this analysis suggests that: (1) living donor transplants represent an important option for individuals with end-stage liver and kidney disease and should not be suspended uniformly under contingency standards, (2) exposure risk to SARS-CoV-2 should be balanced with other risks, such as exposure risks at dialysis centres. Because many of these risks are not quantifiable, donors and recipients should be included in discussions on what constitutes acceptable risk, (3) transplant hospitals should strive to maintain a critical transplant workforce and avoid diverting expertise, which could negatively impact patient preparedness for transplant, (4) transplant hospitals should consider implementing protocols to ensure early detection of SARS-CoV-2 infections and discuss these measures with donors and recipients in a process of shared decision-making.


2021 ◽  
pp. 83-107
Author(s):  
Lainie Friedman ◽  
J. Richard Thistlethwaite, Jr

In this chapter, two demographic traits of living donors are observed: the over-representation of women and the under-representation of Blacks. This raises the question of whether these differences should be considered a disparity or a preference. A traditional bioethics approach would state that as long as living donors believe that the benefits of participation outweigh the risks and harms (beneficence) and the donors give a voluntary and informed consent (autonomy or, more accurately, respect for persons), then the demographics reflect a mere difference in preferences. Such an analysis, however, ignores the social, economic, and cultural determinants as well as various forms of structural discrimination (such as racism and sexism) that may imply that the distribution is less voluntary than may appear initially. The distribution also raises justice concerns regarding the fair recruitment and selection of living donors and their recipients. A vulnerabilities analysis can help explain the demographics of living donation.


2021 ◽  
pp. 147-172
Author(s):  
Lainie Friedman ◽  
J. Richard Thistlethwaite, Jr

From the outset of kidney transplantation, some living donors were “Good Samaritan” donors—that is, individuals who donated a kidney without a specific recipient in mind. However, non-genetically related donors fell out of favor quickly because the results were no better than deceased donor grafts. As immunosuppression improved and graft outcomes from non-biologically related donors improved, attitudes changed (with greater and earlier support from the public than from transplant professionals and with greater support for spouses then friends then acquaintances, and then strangers). This chapter examines ethical controversies raised by Good Samaritan donors using a living donor ethics framework. It examines the moral justification for permitting living donation by strangers, the ethics of the donor and recipient selection and allocation processes, and whether Good Samaritan donors should be encouraged to catalyze a domino multi-donor-recipient pair chain rather than donate to a single candidate on the waitlist.


2021 ◽  
pp. 261-284
Author(s):  
Lainie Friedman ◽  
J. Richard Thistlethwaite, Jr

As the supply-demand gap for organs for transplantation grows, transplant programs are more accepting of less healthy donors. This chapter focuses on the extreme case: whether and when individuals who have life-limiting conditions (LLC) should be considered for living organ donation. Two types of cases are examined: living donation by individuals with advanced progressive severe debilitating disease for whom there is no ameliorative therapy; and pre-mortem living donation by individuals who are imminently dying or would die of the donation process itself. With appropriate safeguards, some donations by individuals with LLC could be ethical. Pre-mortem donations challenge the dead donor rule (DDR), an ethical norm that prohibits organ procurement until after the individual is dead. The chapter argues that attempts to circumvent the DDR fail to respect the living donor as a patient in his or her own right.


2021 ◽  
pp. 108-123
Author(s):  
Lainie Friedman ◽  
J. Richard Thistlethwaite, Jr

In 1957, three years after the first successful kidney transplant between identical twin brothers, the Supreme Judicial Court in Massachusetts authorized kidney transplantation between three sets of identical twin minors and approved another two dozen living donor transplants involving minor donors over the next twenty years. Today, minors rarely serve as living solid organ donors, and donation by minors is prohibited in much of the world. In this chapter arguments are made to restrict children from serving as living donors except as a last resort. It is also argued that if one embraces the concept of the living donor as patient, then one would not make an exception for living donation by a minor to his or her identical twin sibling.


2021 ◽  
pp. 306-324
Author(s):  
Lainie Friedman ◽  
J. Richard Thistlethwaite, Jr

This chapter examines the arguments in favor of and opposed to a market for kidney grafts from living sources. Although the National Organ Transplant Act (NOTA) of 1984 made it illegal to buy or sell organs in the US, and the World Health Organization recommended a similar ban in 1991 (which was reaffirmed in 2010), there is some support for a kidney market in academic circles. While measures to make living donation financially neutral for living donors are ethical and widely popular, payments that serve as incentives or bribes are neither. The buying and selling of living organ grafts are not an ethical means to mitigate the shortage of organs for transplantation.


2021 ◽  
Author(s):  
◽  
Paula Marie Martin

<p>Increasing numbers of New Zealanders are experiencing end-stage renal failure, requiring kidney transplantation or dialysis. A transplant from a living kidney donor is the preferred treatment, offering better quality of life than dialysis, and greater life expectancy and cost-effectiveness than dialysis and deceased donor transplantation. Living donor transplant rates in New Zealand have plateaued and may even be declining at a time when many comparable countries are experiencing sustained increases. Viewing this issue as a complex policy problem, this research aimed to identify how rates of living donor kidney transplantation could be increased in New Zealand. Based on Walt and Gilson’s health policy triangle, which suggests that understanding policy issues requires attention not only to content (policy options) but also processes, contextual issues and actors, this research asked firstly, what the barriers are for patients in the journey to living donor transplantation, and secondly, why greater attention has not been paid to how to increase current rates, given evidence of better outcomes for patients and cost-effectiveness.  The research took a patient-centred, systems perspective and used a pragmatic, interdisciplinary, mixed-methods research design. Methods included a survey of kidney transplant waiting-list patients; interviews with patients, renal health professionals and key informants; document analysis; and a survey of health managers. A Five-Stage Model of the living donor kidney transplant process was developed to map specific barriers in the journey to transplantation and Kingdon’s multiple streams agenda-setting model was used to examine the issue of why so little attention had been paid to living donor kidney transplantation in New Zealand.  The research found that, in common with patients elsewhere, New Zealand patients are not systematically informed about living donor transplantation, would like to receive a transplant but have concerns about health and financial impacts on donors, and face challenges in approaching people in their networks about living donation. Incompatibility and medical unsuitability are major barriers for potential donors who do come forward. Issues with existing service models, configuration of key roles in transplant services, and delays in donor work-up processes are all evident. Perceived ethical constraints may limit how willing health professionals are to promote living donation, requiring both potential recipients and donors to be very proactive to successfully navigate the living donation process.  There has been political will to address organ shortages in the past but there has been little focus specifically on live donation. An absence of feasible and acceptable options for decision-makers to consider, crowding-out by demand for dialysis services, lack of leadership, absence of an effective advocate, and issues in funding and accountability arrangements may all have contributed to why live kidney transplantation has not had more prominence on the policy agenda in New Zealand in recent years.  Overall, the research concludes that policy and practice in the wider system are not adequately oriented to supporting living donor kidney transplantation as the preferred treatment for end-stage renal failure. A comprehensive national strategy for increasing New Zealand’s rate is recommended.</p>


2021 ◽  
Author(s):  
◽  
Paula Marie Martin

<p>Increasing numbers of New Zealanders are experiencing end-stage renal failure, requiring kidney transplantation or dialysis. A transplant from a living kidney donor is the preferred treatment, offering better quality of life than dialysis, and greater life expectancy and cost-effectiveness than dialysis and deceased donor transplantation. Living donor transplant rates in New Zealand have plateaued and may even be declining at a time when many comparable countries are experiencing sustained increases. Viewing this issue as a complex policy problem, this research aimed to identify how rates of living donor kidney transplantation could be increased in New Zealand. Based on Walt and Gilson’s health policy triangle, which suggests that understanding policy issues requires attention not only to content (policy options) but also processes, contextual issues and actors, this research asked firstly, what the barriers are for patients in the journey to living donor transplantation, and secondly, why greater attention has not been paid to how to increase current rates, given evidence of better outcomes for patients and cost-effectiveness.  The research took a patient-centred, systems perspective and used a pragmatic, interdisciplinary, mixed-methods research design. Methods included a survey of kidney transplant waiting-list patients; interviews with patients, renal health professionals and key informants; document analysis; and a survey of health managers. A Five-Stage Model of the living donor kidney transplant process was developed to map specific barriers in the journey to transplantation and Kingdon’s multiple streams agenda-setting model was used to examine the issue of why so little attention had been paid to living donor kidney transplantation in New Zealand.  The research found that, in common with patients elsewhere, New Zealand patients are not systematically informed about living donor transplantation, would like to receive a transplant but have concerns about health and financial impacts on donors, and face challenges in approaching people in their networks about living donation. Incompatibility and medical unsuitability are major barriers for potential donors who do come forward. Issues with existing service models, configuration of key roles in transplant services, and delays in donor work-up processes are all evident. Perceived ethical constraints may limit how willing health professionals are to promote living donation, requiring both potential recipients and donors to be very proactive to successfully navigate the living donation process.  There has been political will to address organ shortages in the past but there has been little focus specifically on live donation. An absence of feasible and acceptable options for decision-makers to consider, crowding-out by demand for dialysis services, lack of leadership, absence of an effective advocate, and issues in funding and accountability arrangements may all have contributed to why live kidney transplantation has not had more prominence on the policy agenda in New Zealand in recent years.  Overall, the research concludes that policy and practice in the wider system are not adequately oriented to supporting living donor kidney transplantation as the preferred treatment for end-stage renal failure. A comprehensive national strategy for increasing New Zealand’s rate is recommended.</p>


2021 ◽  
Author(s):  
Christie P Thomas ◽  
Sonali Gupta ◽  
Margaret E Freese ◽  
Kanwaljit K Chouhan ◽  
Maisie I Dantuma ◽  
...  

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