The availability and quality of an organ obtained from a live donor combined with the continuing shortage of recoverable organs from deceased donors has propelled an extensive effort to promote live donor organ transplantation. The well being of the donor should be a primary consideration of any live donor organ transplantation. Although the possibility of injury to a live donor has been acknowledged since the inception of organ transplantation as a viable medical field, a basic tenet of medicine is to do no harm. Thus, transplantation of an organ from a live donor stands in ethical contrast to all other care that a physician provides. If a seriously ill patient does not completely understand a plan of treatment, the physician may still act in his or her best interest. However, if a living donor does not understand the process and risks of donation, the consequences of not assimilating this important information in their decision-making process are profound.
Competing interests arise in live organ donation that are unique. These include the interests of the donor, the needs of the recipient and society for tissues or organs for transplantation, the interests of the next of kin of both the donor and recipient, as well as the interests of the transplant center.
A. The Donor
Potential donors donate selflessly for the good of either a family member, loved one, or society. The potential donor, however, must understand the following points:
- In contrast to the consent for donation at the time of death, the living donor is potentially faced with either immediate risk or unknown future medical problems related to his or her organ system. These risks may not be entirely known at the time a living donor procedure is undertaken (such as a right lobe liver donation or laparoscopic nephrectomy).
- The financial and emotional consequences of the donation must be understood. At a minimum, the donation process may cause stress in the family. It may also limit the functionality of the donor for weeks or months following the operation. The financial impact of this loss of functionality must be assessed and addressed before the transplant is performed. Complications of the donation procedure may have limited consequences or may evolve into a state of chronic illness and lead to loss of employment and loss of medical insurability. The donor’s family must consider the possibility of such an outcome, even though it may be unlikely.
- Emotional consequences are much harder to quantify, and may have a varying effect upon donor family members that may impact the ultimate decision on donation. For example, the decision to donate could have a positive emotional bearing upon siblings when a parent is in need of a transplant, while at the same time, having a negative effect on the donor’s primary family (spouse, children).
B. The Recipient
At first glance, it may appear that the recipient would have every reason to encourage living donation. Because the wait for a life-saving or lifeenhancing organ transplant is shortened, the transition to a more functional life is accelerated, and the emotional strain of waiting for a deceased donor’s organ is eliminated. The recipient should, nonetheless, understand the following points:
- Transplantation, whether via a deceased donor or living donor source, is not a process that can be successfully accomplished alone. The recipient outcome is uniquely dependent upon another individual’s willingness to provide a gift to a specific individual or society. In addition, the family is critically important to the success of the endeavor as the transplantation process requires the sacrifice of time, effort, emotion, and functionality of at least one if not more family members.
- Although there are risks for a live donor, the selection process and the efforts of the medical, surgical, and associated health care providers are to minimize these risks and ensure that the donor proceeds voluntarily and safely with the decision to donate.
- There may be additional medical risks associated with receiving an organ from a living donor versus an organ from a deceased donor. These negative factors may be countered by fewer complications in the pretransplant period.
- The recipient should not believe that living donation is the only option to successful transplantation. The recipient must be placed on the transplant waiting list and the team will make every effort to pursue a deceased donor source of an organ so that the recipient does not feel the need to apply pressure on the potential live donor and thus avoid the creation of a coercive environment.
- The recipient should be aware that once the potential donor begins the evaluation process, the team will not be able to provide the recipient with any information regarding the potential donor’s progress in the process. This will provide the potential donor with the confidentiality afforded to all patients.
C. The Family
The families (spouse, children, parent, or person with a significant relationship with the donor) of either the donor or recipient can be either supportive or coercive. Family members are an integral part of the decision-making process they will be affected regardless of whether the decision is to donate or not to donate. The decision not to donate could impact another family member’s fate, while the decision to donate could have a direct impact on the donor and his or her immediate family.
The family must understand that living donation may not be the only option. This concept helps engender a noncoercive environment in which the potential donor can make an independent decision. Both the potential donor’s and recipient’s families should make their preferences and desires known to the potential donor with the understanding that it is solely up to the potential donor to make the decision.
D. The Transplant Center
The professional staff of the liver transplant center is committed to helping patients with liver disease. However, as the demand for organs continues to increase and the pool of organs recovered from deceased donors remains insufficient, there is a compelling incentive for the transplant center to identify a living donor source of organs. The forces influencing the transplant center to solicit live donors include:
- the paramount desire to help the patients who entrust their future to transplant professionals;
- prestige/ professional satisfaction; and
- economic concerns.
- The transplant center exists for the benefit of the recipient. However, when a potential donor is determined to be suitable and becomes a possible surgical candidate, the transplant team must develop an additional ethical and professional relationship with the potential donor.
- Liver transplantation is a highly visible program of a medical center that conveys a sophistication and technical expertise that is commonly associated with an outstanding institution. It fosters professional recognition, scientific publications, academic reward, and personal satisfaction.
- Liver transplantation generates significant revenue for a medical center. The need to generate financial revenues and maintain the skills of the clinical providers may propel the leaders of the program to consider living donation as an alternative source for transplantation.