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Paired
Organ Exchange
Paired organ exchange refers to the situation
where a couple who have indicated their wish
to donate a kidney from one partner to the
other cannot do so because of blood group
incompatibility, enter into an arrangement
with another couple who are in a similar position
such that the resulting exchanged organ transplants
are not ABO incompatible. This is an extension
of the existing related or unrelated live
organ donation practice and as such does not
pose any particular ethical issues related
to the actual donation. The donor and recipient
will of course be subject to the usual assessment
process and informed consent procedure.
The difficulties which arise are primarily
related to the practicality of the exchange.
It is recommended that the procedure is carried
out as nearly simultaneously as possible,
but not necessarily in the same centre. The
exchange should be anonymous unless both couples
agree otherwise as in non-directed cadaveric
organ gifting. Both couples also need to understand
that there are no guarantees that the organ
must be used in the potential recipient as
there may be unforeseen difficulties and in
that case then the gifted organ should be
made available to the national waiting list
under the normal organ allocation rules
Altruistic
(nondirected) Living Donation
Altruistic donation is the gift of a kidney
from an adult to an unspecified recipient
with allocation of the organ according to
agreed rules. This has now been carried out
successfully in North America where approximately
15% of potential altruistic organ donors were
accepted following full assessment. Ethically
this does not pose a difficulty provided individuals
have capacity to give informed consent and
understand the individual risk. Donation should
be unconditional and anonymous although again
reports of the progress of the recipient should
be made available to the donor if required.
The principle of best usage of a scarce resource
would dictate that kidneys should be allocated
according to an agreed scoring system, and
this could include shipping organs from one
centre to another. The mechanics of organ
allocation fall outside the remit of ethical
consideration and regulation of the process
is clearly within the remit of ULTRA.
Nonheart
Beating Donation
The use of non heart beating donation (NHBD)
has significantly extended the potential donor
pool.
Controlled NHBD where the potential donor
indicated in life their wish to donate and
the organ donation procedure (cannulation
etc) has been discussed with and agreed by
relatives prior to the donor's death is ethical.
The general overriding principle of respect
for the wishes of the individual in life (autonomy)
should, however, be overruled by refusal of
consent for donation by the next of kin. As
is current clinical practice, unless there
is a change in the law which specifically
authorises organ donation if the deceased
wished this to occur, then relatives consent
before retrieval should be required. The distress
caused to living persons and the negative
overall effect of the publicity on organ transplantation
should take precedence over the wishes of
the deceased.
The practical difficulties are recognised
but are outwith the remit of ethical consideration.
The use of such a donated organ should also
be subject to informed consent of the recipient
with explanation of the increased risk of
delayed graft function and somewhat poorer
overall outcome.
Uncontrolled NHBD is more controversial.
It is felt ethically acceptable to cannulate
a potential NHBD if it can be established
beyond reasonable doubt that that individual
has indicated their wish to donate in life
and the view of the next of kin is unknown.
This recognises the right of the individual
to donate their organs and respects the wishes
of the individual in life. There is room for
further debate on what constitutes 'beyond
reasonable doubt'. If the individual had registered
with the National Organ Donor Registry or
carried a Donor Card then this could be taken
as indicative of their wishes. Wishes of relatives
of the deceased, once available, should still
be able to override this process. If the wishes
of an individual cannot be established then
consent for cannulation must be obtained from
a relative prior to cannulation. There is
room for debate on whether any other individual
should be empowered to give such consent -
eg HM Coroner.
Donor
Care
The approach to managing an individual changes
once death is confirmed. After death it is
unethical not to give care to a donor which
preserves organ function for donation if that
was that individual's wish and relatives have
consented to organ donation. Before death
the duty of care of the doctor is to the patient
and any actions must be in the best interests
of the patient. After death then the duty
of care is to the potential recipient of any
organ thus it is mandatory to give care which
preserves organ function, bearing in mind
the need to show respect to the cadaver.
Payment
for Live Organ and Tissue Donation
To be considered in conjunction with the
position statement on Transplant Tourism
The BTS considers that payment for organ
or tissue donation where the donor accrues financial or material
gain is unethical. Such payment is illegal under current legislation.
An organ or tissue for transplantation should be freely given
without coercion, financial or material gain.
Since it is important to increase organ
donation from all sources, the BTS strongly believes that
there should not be any disincentive to donate. It follows
then that financial expenses that arise during the process
of organ or tissue donation that would not otherwise be incurred
should be reimbursed.
Such reimbursement should be the responsibility
of the health services and any system set up to provide such
reimbursement should effectively exclude the possibility of
exploitation of donors or profit to intermediaries.
The suggestion that an "ethical market"
be developed where financial incentives that are independent
of the recipient are employed to increase organ donation contravenes
the principles of equity and justice by encouraging disadvantaged
individuals in society to donate. Furthermore such a market
could allow commerce in organ and tissue transplantation to
arise and is regarded as unacceptable.
Approved by BTS Council September
2003
Transplant
Tourism
To be considered in conjunction
with the statement on Payment for Organ and
Tissue Donation
The British Transplantation Society does not
support the practice of potential organ or
tissue transplant recipients travelling abroad
to circumvent the ethical, moral and legal
framework governing organ transplantation
in the UK.
Clinicians are expected to inform
their patients that they believe this practice to be ethically
unacceptable and to positively discourage their patients from
travelling abroad. It is recognized, however, that although
the clinician is not supportive of their patient's actions,
he/she nevertheless has a duty of care, which continues after
transplantation should this occur. This duty obligates the
clinician to:
i) fully inform and frankly discuss with the patient and their
family the potential risks and benefits of going abroad for
a transplant;
ii) encourage a live donor transplant in this country (such
that the relationship of the donor with the recipient meets
the requirements of the Human Organ Transplant Act);
iii) provide their normal standard of care to that patient
before and after return if the patient carries through the
action.
The reasons for this position are:
- Such an action compromises the standards
of ethical behaviour agreed by the society in which the
recipient lives, in this instance the UK. The recipient
is morally bound to adhere to such standards by virtue of
their chosen residence.
- It is clear that the use of donors from
abroad breaches the principles of equity and justice in
organ allocation, both for the individual travelling abroad
from their usual residence and for recipients in other countries
deprived of the opportunity of an organ transplant.
- Clinical outcomes are frequently demonstrably
inferior in some countries undertaking transplantation from
paid live donors and/or transplantation from donors under
other forms of coercion.
Agreed by BTS Council September 2003
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