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Volume: 7 Issue: 1 March 2009

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Ethical Issues in Live Donor Kidney Transplant: Views of Medical and Nursing Staff

Objectives: The ongoing development of live donor kidney transplant has generated many ethical dilemmas. It is important to be aware of the attitudes of transplant professionals involved in this practice.
Materials and Methods: An anonymous and confidential questionnaire was sent to 236 members of the medical and nursing staff of the West London Renal and Transplant Centre, to assess their views on the ethics of the current practice of live donor kidney transplant.

Results: Of the 236 questionnaires, 108 (45.8%) were returned. Respondents considered live donor kidney transplant ethically acceptable between blood relatives (100%), nonblood relatives and friends (92.6%), and strangers (47.2%). Most respondents were willing to donate a kidney to a blood relative (92.6%) or a nonblood relative or friend (81.5%), and 12.0% were willing to donate to a stranger. Considering themselves as potential recipients if they had end-stage renal disease, most would accept a kidney from a blood relative (91.7%) or nonblood relative or friend (85.2%), while 44.5% would accept a kidney from a stranger. The highest number of respondents (43.5%) believed that the recipient should approach the potential donor. About one-third believed there should be no financial reward, not even compensation for expenses, for donors; 8% favored direct financial rewards for donors known to recipients, and 18% favored rewards for donors not known to recipients. Slightly more than half were in favor of accepting donors with mild to moderate medical problems.

Conclusions: Live related and unrelated kidney donation are considered ethically acceptable procedures, and non-directed donation is gaining support among transplant professionals. A substantial minority favored direct financial rewards for donors, especially in the case of non-directed donation.


Key words : Related donor, Unrelated donor, Paid donation

Live donor kidney transplant is the treatment of choice for end-stage renal failure (1, 2). However, retrieving kidneys from otherwise healthy individuals and exposing them to the risks of surgery for the benefit of other persons poses several ethical questions that have initiated a great deal of medical and public debate. These ethical issues regarding live donor kidney transplant have been debated intensely, with differences in ideas and practice between countries, transplant centers, and health care professionals (3-7). However, following a thorough literature review, we found no survey that addressed these issues as a whole. The purpose of this study was to survey the views held on the ethics of live donor kidney transplant by the medical and nursing staff of the West London Renal and Transplant Centre, one of the largest in the United Kingdom, with extensive experience over many years in all aspects of renal transplant.

Materials and Methods

The project was approved by the Hammersmith and Queen Charlotte’s and Chelsea Hospitals Research Ethics Committee. The study was conducted by inviting 236 potential respondents to complete a questionnaire. The questionnaire had 2 parts; the first collected basic demographic information, and the second addressed ethical issues in live donor kidney transplant. The questionnaire was anonymous and confidential. The estimated time for its completion was 10 to 15 minutes. The design of the questionnaire was based on a thorough literature search as well as on the ethical issues faced in everyday clinical practice by the members of staff of the West London Renal and Transplant Centre regarding live donor kidney transplant. The questionnaire was discussed extensively with various members of the Centre and revised 5 times taking their comments into consideration.

The potential respondents were the 236 members of the medical (consultants and trainees) and nursing staff of the West London Renal and Transplant Centre. Potential respondents received an information sheet concerning the study, a consent form to sign, and the questionnaire and were asked to return them via internal mail. To provide anonymity, 2 envelopes were given to the potential respondents in which to return the consent form and questionnaire separately.

Statistical analysis was performed by entering the data into Microsoft Excel 2003. The respondents were divided into subgroups according to their demographic characteristics, and the results were compared using the chi-square test when there were more than 5 observations per subgroup.

Results

Of the 236 potential respondents who received the questionnaire, 108 members (45.8%) returned it completed. The respondents included 22 consultants (20.4%), 23 trainees (21.3%), and 63 nurses (58.3%). Participant demographics are displayed in Table 1. Two-thirds of respondents (66.4%) identified themselves as Christian (Figure 1). Regarding ethnic origin, the largest subgroups were white British (28.7%) or other white background (23.2%) (Table 2).

All respondents believed that live donor kidney transplant between blood relatives is ethically acceptable; 92.6%, between nonblood relatives and friends; and 47.2%, between strangers (Table 3). When respondents were asked if they would donate their own kidney, 92.6% said they would donate to a blood relative, 81.5% would donate to a nonblood relative or friend, but only 12.0% would donate their kidney to a stranger (Table 3). As potential recipients with end-stage renal disease, 91.7% would accept a kidney from a blood relative, 85.2% would accept from a nonblood relative or friend, and 44.5% would accept from a stranger.

In considering who should make the initial request of the potential donor, the highest number of respondents (43.5%) felt that the potential recipient should do so (Table 4). The respondents’ age had an impact on this issue, with 39.3% of respondents aged 18 to 30 years believing that the approach should come from the transplant team, whereas 51.4% of respondents aged 31 to 50 years and 50% aged 51 to 70 years believed that the recipient should first approach a potential donor (difference about the recipient being the first to approach the donor between age groups 18-30 years and 31-50 years was statistically significant a P = .091).

The motives reported by respondents to be very important in kidney donation were relief from the recipient’s improved health (63.0%) and altruism (58.3%), while financial rewards were considered not important by 79.6%. When considering increased self-esteem and pressure from the recipient or relatives as motives for donation, opinion was almost equally divided between “important” and “not important” (Table 5).

Addressing the issue of how long should the potential donor be given to reconsider his decision to donate a kidney, 47.2% of the respondents answered that “up to 3 months” was an acceptable period; 28.7%, “up to 6 months”; and 6.5%, “up to 1 year.” No period of time for reconsideration was felt to be necessary for 15.7% of respondents. No respondent answered that the period for reconsidering the potential donor’s decision should be over 1 year. In addition, the majority of consultants (77.2%) and trainees (56.5%) believed that the period allowed for the donor to review his decision should be up to 3 months, yet the nursing staff were divided, since 33.3% believed in the 3-month period (P = .0003 for nurses versus consultants; P = .041 for nurses versus trainees) but 35.5% answered that such a period for reconsideration should be extended up to 6 months.

There was a nearly even split as to whether or not consensus by the donor’s family is required to donate, with 46.3% considering that such consensus is necessary before proceeding with the transplant, while 50.9% did not consider it necessary. One participant answered that it depends on the closeness of the family members while two participants did not answer at all. Moreover, there was a nearly even split with 51.9% of the respondents answering that potential donors with mild to moderate medical problems, such as borderline hypertension or obesity, who are adequately informed and prepared to take the risk, should be accepted as potential donors, while 47.2% felt that such potential donors should not be allowed to donate. One participant did not answer at all. Consultants (68.2%) and trainees (65.2%) were more willing to accept donors with mild to moderate health problems compared with the nursing staff (41.3%) ( for both consultants versus nurses P = .0246 and trainees versus nurses P = .0411).

About two-thirds of respondents (67.6%) supported donation by donors over 65 years old if they were adequately informed and prepared to take the risk, while 27.8% objected to such donation. Regarding the timing of transplant, 68.5% of respondents answered that live donor kidney transplant is better appreciated by the recipient when it occurs after at least a short period of dialysis; 25.9% answered that the transplant should be performed before any experience on dialysis if this was an option. Two participants responded that it made no difference while the remaining did not answer at all.

In terms of follow-up for the donor, 50.9% of respondents answered that the transplant team should follow the donor for 1 year, while 33.3% supported longer follow-up (26.7% of participants felt that such follow-up should last for life). Most respondents (88.9%) felt that the transplant team should monitor quality of life as well as medical condition of the donor during postoperative follow-up. To maintain the donor’s positive attitude after donation, respondents identified as important factors detailed medical follow-up (selected as very important by 76.9%) mainly by their general practitioner and the opportunity to share his or her experience with other prospective donors, recipients, and their families (selected as very important by 51.9%).

Regarding compensation, 57.4% of respondents supported compensation for expenses incurred (eg, travel expenses, compensation for lost workdays) for donors known to the recipient, and 50.0% supported this kind of compensation when the donor was a stranger. About one-third (34.3%) believed that there should be no financial reward at all for donors known to the recipients, and 32.4% supported this principle when the donor was a stranger. For donors known to the recipient, 8.3% supported direct financial rewards in addition to reimbursement of expenses, while 17.6% believed in direct financial rewards for a donor not known to the recipient. A higher proportion of respondents with children (14.0%) supported direct financial reward for the donor when he was a blood relative or nonblood relative or friend, compared to 3.5% of those who had no children (P = .0511). The percentage of males supporting direct financial rewards for the donor was almost double compared to females, regarding blood and non-blood-related relatives and friends (11.9% vs 6.1%) as well strangers (23.8% vs 13.6%), however both these results did not reach statistical significance (P≤1 and P≤.2 respectively).

In terms of oversight, 76.8% advocated that the government should strictly monitor direct financial rewards, while 23.2% felt it was a private affair between the donor and recipient. These figures are derived from both those who supported direct financial reward for the donor and those who did not. Almost one-third of these participants (29.6%) felt that the National Health Service (NHS) should fund a direct financial reward if such a practice is established. The remaining number of participants did not answer at all or were against such a reward being provided by the NHS. Eighteen respondents suggested various amounts as a direct financial reward for a potential donor ranging from £500 to £50,000 (5 respondents answered over £10,000).

Discussion

Our survey demonstrates that most professionals involved in live kidney donation are comfortable with the principle of donation between individuals who have a relationship with each other, whether or not they are blood relatives. In the past, most transplant centers did not accept strangers as donors because of concerns about their motivation and commitment to donation, their understanding of the potential risks, and their psychological stability (8). However, surveys in the United States reported strong medical and public support for the use of strangers as donors; 82% of physicians not involved in transplant and 94% of the nonmedical public supported live kidney donation from strangers (9). Until 2006, it was not legal in the United Kingdom. In a survey in Hungary, all 78 donors who had already donated were in favor of blood relative and spousal donation, while 63.3% would have donated to a friend and 46.6% to a stranger (10). However, other authors still express doubt that strangers would consider becoming donors without a substantial reward (11).

Our results as to who should make the initial approach to the donor were interesting. The highest number of respondents identified the recipient, although younger respondents (aged 18-30 years) were more likely to believe that the transplant team should make the initial approach. Issues of coercion must be considered in either case, although the nature of coercion is different in each situation.

The health care professionals who participated in our study believed that altruism was a very important motivating factor in choosing to be a donor. The other very important issue identified was relief on the part of the donor from the recipient’s improved health.

Direct financial rewards were not considered as an important motive by the majority of respondents. However, we must acknowledge that the rating of the motives for donation could be different if the survey had been performed in different populations, such as patients on dialysis or potential donors (12,13). Although situations in which offers made by close relatives to donate were then rapidly followed by donation have been considered as ethically acceptable (14), our survey indicated that about half of the respondents supported a short period of time (up to 3 months) for the potential donor to reconsider his decision; some noted that such a period is usually spent anyway in the thorough donor evaluation.

When the decision to donate is spontaneous, donors do not usually experience negative consequences regarding family relationships, with conflicts between donors and families being rare (15). However, it might be ideal for the transplant team to achieve the widest possible family consensus for the live donor kidney transplant, so as not to affect sensitive interfamilial relationships (16). Of course, this raises issues of confidentiality. The respondents in our study were divided whether consensus of the donor’s family is desirable before live donor kidney transplant. If one accepts that family consensus is desirable, the next step would be to investigate how broad this consensus should be, something that will certainly be affected by the cultural background of the donor and the recipient.

In a survey performed in the United States, public opinion supported donation by donors at added risk, providing that they were properly informed and prepared to take that risk (9). Our study demonstrated that just over half of the respondents supported accepting donors with mild to moderate health problems, with the nursing staff being less willing to accept such donors compared with consultants. One important issue is the definition of mild to moderate health problems. The calculation of the consequent extra risk is anything but straightforward, as is the way to present that risk since the “spin” attached to it by the transplant team can influence the decisions of the donors and recipients.

Some have advocated that there are neither medical nor ethical grounds for excluding elderly donors and recipients from transplant (17). Graft survival of kidneys obtained from donors over 60 years of age is comparable to that from younger donors, with similar occurrence of delayed graft function (18). However, other authors have recommended that kidneys from older donors should be matched with older recipients (19), and donors older than 70 years should not be used for renal transplant (20). In our survey, about two-thirds of respondents supported accepting potential donors over 65 years old. As with donors with mild to moderate health problems, we face the same issues of calculation and presentation of the risk related to age over 65 years. Also, how far should we go? Should we accept a fit, well-informed 80-year-old as a potential donor?

Some may believe that time on dialysis allows patients to better appreciate the transplant. However, time on dialysis is a negative predictor of graft outcome (21) and recipient survival (22), and pre-emptive transplant is associated with better graft survival when compared with transplant after the initiation of dialysis (23-25). Despite these data, about two-thirds of the respondents in our survey believed that a live donor kidney transplant is better appreciated by the recipient after a short period on dialysis.

It has been suggested that in addition to medical follow-up, lifelong psychological counseling should be available for donors to help deal with the possible negative impact of organ donation on their quality of life, especially for younger donors who seem to develop anxiety and depression more frequently (26). The loss of attention for donors once the donation was over had a very negative psychological impact (15, 27-29). About half of our respondents support postoperative follow-up of the donor by the transplant team lasting for up to 1 year, while many answered that long-term follow-up by the donor’s general practitioner should be ensured. Most respondents agreed that the donor’s follow-up should comprise both medical condition as well as quality of life.

It has been estimated that a live donor kidney transplant program with direct financial rewards for the donor would save society in the United States over $90,000 per transplant, by subtracting the cost of dialysis, while providing improved quality of life for patients with end-stage renal failure (30). Thus, in purely financial terms, society would gain by paying up to $90,000 per kidney vendor. The same authors support the idea that payment of the donor should be sufficient to balance the risks of mortality and morbidity and the costs related to lost income from time out of work and for inconvenience. Thus, payment should include life insurance and health insurance to cover treatment for surgical complications. Information about several types of commercial donation is already available, although centers involved in commercial donation are probably reluctant to report results since in most countries such a practice is either legally or ethically condemned. Some centers involved in commercial donation have reported high complications (31, 32), yet others in India (33) and Iran (34) have proved to be more successful. In a survey from Hungary (10), 63.3% of those interviewed who already had been donors in the past were not in favor of selling and buying organs; however, it was interesting to note that the same participants stated that if they had end-stage renal failure, they would buy a kidney if one were available.

Recipients and potential recipients may be unwilling to accept a donation if this would inflict any financial burden on the donors (35). It has been suggested that, if such a donor later develops a need for a kidney transplant, the donor should be placed at the top of the deceased donor kidney waiting list (35). In our study, about half of the respondents supported the idea of compensating expenses for the donor regardless of whether the donor was known or unknown to the recipient. Many respondents held the relatively widely accepted view that they objected to the donor “making money” out of donation, but that they also did not want the donor to lose money on account of this altruistic act. Interestingly, about one-third of the respondents were against direct financial rewards but also against any compensation for the donor regardless of whether or not the donor was known to the recipient. This may reflect the view that live kidney donation should be a purely altruistic act and that any kind of compensation could “dilute” it to the point of being ethically unacceptable. In addition, it is possible that the respondents who were against payment of compensation expenses could see a slippery slope of compensation being converted into direct financial gain for the donor.

Nevertheless, a substantial minority of respondents were in favor of direct financial rewards to blood relatives or nonblood relatives and friends, with twice as many respondents supporting direct financial rewards when the donor and recipient are strangers. This indicates that the idea of paid donation is supported not only by desperate patients on dialysis or “organ traders” but also by some highly qualified professionals who have proven over the years their genuine commitment to the treatment of patients with end-stage renal failure (30, 33, 34, 36). Of all respondents (including those who were for and against direct financial rewards), about three-quarters believed that, if direct financial rewards were established, this should be done under strict government monitoring. Of 18 respondents who suggested specific amounts for rewards, 5 respondents thought direct financial reward for kidney donation should be over £10,000. The relatively small size of this amount makes one wonder if it is intended as a financially significant incentive or merely as a token. Interestingly, respondents under 30 years were more often in favor of direct financial rewards if the donor and recipient were strangers. In our survey, twice as many men respondents supported direct financial rewards compared with female respondents. Respondents with children were more likely to support financial rewards than those who did not have children.

The views expressed in the present study depend on the social, cultural, and professional experience of each participant. Interesting data have been accumulated regarding the views on ethical issues in live donor kidney transplant of a specific cohort of health care professionals with great interest and experience in kidney transplant. The present study may prompt larger studies in different cohorts of respondents, including patients, to broaden the evidence on attitudes in this area.


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Volume : 7
Issue : 1
Pages : 1 - 7


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From the West London Renal and Transplant Centre, Imperial College Kidney and Transplant Institute, Hammersmith Hospital, DuCane Road, London W12 0HS, UK
Address reprint requests to: Mr. Vassilios Papalois, Consultant Transplant & General Surgeon, Hammersmith Hospital, DuCane Road, London W12 0HS, UK
Phone: +44-208-3835165 Fax: +44-208-3835169 E-mail: vassilios.papalois@imperial.nhs.uk