Canada has a marked shortfall between the supply and demand for kidneys for transplantation. Median wait times for deceased donor kidney transplantation vary from 5.8 years in British Columbia, 5.2 years in Manitoba and 4.5 years in Ontario to a little over 2 years in Quebec and Nova Scotia. Living donation provides a viable option for some, but not all people. Consequently, a small number of people travel abroad to undergo kidney transplantation by commercial means. (...) The extent to which they are aware of the potential risks to their health and the health of the kidney vendors is unclear. Travel abroad to obtain a kidney commercially i.e. transplant tourism (TT), raises ethical issues which include the exploitation of the poor, uncertainty of donor informed consent to nephrectomy, poor clinical care and lack of follow up for the donor, commodification of the body and inequity of access to medical care for donors. Also, TT widens socioeconomic disparities in access to transplantation, differing from the Canadian system of universal coverage for healthcare. The Canadian transplant community has discussed how to respond to patients who plan to travel abroad for TT or return with a purchased kidney. Unease rests in the tension between the duty to care for legitimate Canadian residents and the unwillingness to enable TT. This paper discusses three anonymized cases and the Canadian responses to TT as recorded in academic literature and a formal statement by relevant professional bodies. (shrink)

Kidney donation by young children and the mentally retarded has been supported by court decisions, arguments based on obligations inherent in family relationships, an array of contextual factors, and the principle of beneficence. These justifications for taking organs from people who cannot protect themselves are problematic and must be weighed against our obligation to protect the vulnerable. A compromise solution is presented that strongly protects young children and the mentally retarded but does not abdicate all responsibility to relieve suffering. (...) Guidelines are proposed that prohibit the retrieval of kidneys from young children and the mentally retarded but permit one exception. They would allow retrieval of a kidney when the consequence to a first order relative with whom the donor has a meaningful and valuable relationship is otherwise imminent death. This would be done in accordance with additional guidelines that minimize harm to the donor. Since most patients with end stage renal disease can be maintained on dialysis the need for a kidney to prevent death should be an uncommon occurrence. This compromise is proposed as a solution to a dilemma that exists because two ethical principles are in conflict and one cannot be honored without violating the other. (shrink)

Is the lower rate of kidney transplantation into African Americans medically and ethically justifiable? Or is it a form of racial discrimi nation comparable to if not worse than denial of employment opportunities, housing, and educational opportunities? This essay focusses on the medical problems associated with matching antigens in donors and recipients, and the implications of those problems for social justice.1 Racially discriminatory practices in bank lending, education, and hiring provide a context for understanding how medical criteria treat (...) black recipients unfairly. Although antigen matching is only one aspect of the general problem of finding medically suitable black recipients, it presents an especially interesting challenge for theories of justice, as well as for medical research. (shrink)

Amit Sharma, Rajesh Ramanathan, Marc Posner, Robert A Fisher Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA, USA: Pediatric kidney transplantation is the preferred treatment for children with end-stage renal disease. The most common indications for transplantation in children are renal developmental anomalies, obstructive uropathy, and focal segmental glomerulosclerosis. Living donor kidney transplants are often performed pre-emptively and offer excellent graft function. Policy changes in deceased-donor kidney allocation have increased the proportion of such transplants in (...) pediatric recipients. Adequate pretransplant workup along with evaluation of urologic abnormalities is imperative in achieving good outcomes. Overall, patient and graft outcomes after kidney transplantation have improved, with five-year deceased donor and living donor graft survivals of 78.8% and 84.3%, respectively. Improvements in induction and maintenance immunosuppression have contributed to the gradual improvement in outcomes. Unique challenges in pediatric recipients include increased graft thrombosis, adverse growth, and abnormal development relating to immunosuppression, increased rejection due to nonadherence, increased susceptibility to opportunistic infections, and post-transplant malignancy. This review focuses on the current practices and outcomes in pediatric kidney transplantation in North America. We discuss the indications for transplantation, the evaluation process, some key surgical and immunologic considerations, and the common risk factors for graft dysfunction. Keywords: pediatric kidney transplantation, end-stage renal disease, dialysis, organ donors, immunosuppression. (shrink)

In Canada, there are currently no guidelines at either the federal or provincial level regarding the provision of kidney transplantation services to foreign nationals (FN). Renal transplant centres have, in the past, agreed to put refugee claimants and other FNs on the renal transplant waiting list, in part, because these patients (refugee claimants) had health insurance through the Interim Federal Health Programme to cover the costs of medication and hospital care. However, severe cuts recently made to this programme (...) have forced clinicians to question whether they should continue with transplants for FNs, for financial and ethical reasons. This paper first examines different national policies (eg, in Canada, USA, France and the UK) to map the diversity of approaches regarding transplantation for FNs, and then works through different considerations commonly used to support or oppose the provision of organs to these patients: (1) the organ shortage; (2) the free-rider problem; (3) the risk of becoming a transplant destination; (4) the impact on organ donation rates; (5) physicians’ duties; (6) economic concerns; (7) vulnerability. Using a Canadian case as a focus, and generalising through a review of various national policies, we analyse the arguments for and against transplantation for FNs with a view to bringing clarity to what is a sensitive political and clinical management issue. Our aim is to help transplant centres, clinicians and ethicists reflect on the merits of possible options, and the rationales behind them. (shrink)

Bulang He,1,2 Jeffrey M Hamdorf2 1Liver and Kidney Transplant Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia; 2School of Surgery, The University of Western Australia, Perth, WA, Australia Aims: The aim of this paper was to review the current status of laparoscopic/robotic kidney transplant and evaluate its feasibility and safety in comparison with conventional standard "open" kidney transplant. Methods: An electronic search of PubMed, Embase, and the Cochrane library database was performed to identify the papers between January (...) 1980 and June 2013 that reported on laparoscopic/robotic kidney transplantation. The terms "laparoscopic kidney/renal transplant" and "robotic kidney/renal transplant " were used. Cross-referencing was also used to find the further publications. Only English language reports were selected and accepted for descriptive analysis. Results: A total of 17 papers and abstracts were retrieved. There were two case-control studies of small volume. High-level evidence comparing the safety and efficacy of laparoscopic/robotic kidney transplant with conventional open kidney transplant was not available at the time of this review. Conclusion: The limited published data have suggested that laparoscopic/robotic kidney transplant may offer the advantages of less pain, better cosmesis, possible shorter hospital stay, and fewer wound complications, without compromising graft function. Accordingly, some immunosuppressive agents, such as sirolimus, might be able to be commenced earlier, after laparoscopic/robotic kidney transplant. The techniques are various at this early stage. A uniformed operative technique may be established in the near future. With refinement of laparoscopic devices, this technique may be widely employed. Further studies will be needed to demonstrate the advantages of laparoscopic/robotic kidney transplant over the conventional open kidney transplant. Keywords: laparoscopic surgery, robotic surgery. (shrink)

In order to consider how best to address relationship concerns with potential research participants arising in this study, we will first describe unique features...

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the (...) favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors. An "opting in" paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An "opting in" program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of "organ takers" who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who "opt in" would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive. An "opting in" paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an "opting in" paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an "opting in" policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity. (shrink)

This thesis examines the practice of haemodialysis and kidney transplantation, the two medical therapies available for persons with kidney failure, from a phenomenological perspective. A basic assumption made in the thesis is that contemporary biomedicine is deeply embedded in the cultural, historical, economic, and political circumstances provided by the particular local, national, and transnational contexts in which it is practiced. The aim of the thesis is twofold. On the one hand, the aim is to examine the forms (...) of person- and patienthood enacted and negotiated in haemodialysis and kidney transplantation care and in the daily lives of persons with kidney failure. On the other hand, the aim is to investigate the ways in which the enacted and negotiated forms of person- and patienthood are culturally embedded and normatively charged. In order to examine and investigate this twofold aim, an empirical material has been gathered that comprises observations and in-depth interviews with patients and caregivers at four haemodialysis units, one in Riga, Latvia, and three in Stockholm, Sweden. The theoretical approach and methodology of the study is cultural and phenomenological in character, drawing on an ethnological and anthropological understanding of culture as processual and relational, and on a phenomenological understanding of personhood as embodied and intertwined with the surrounding world. The thesis shows that patients’ encounters and attempts to deal with the diagnoses and treatments associated with kidney failure are complex and often misalign them with the normatively charged orientations enacted and recommended by medicine. The complex situation that emerges when they undergo transplantation, for example, stands in stark contrast to the widespread official view of organ transplantation as a self-evidently health-bringing and normalising therapy. Through their repeated and extensive experiences of undergoing haemodialysis and living with the disease, patients eventually become able to create a synthesis between their lived experiences of their own body and their body as a medical object – what in the thesis is called a ‘sick body’ – a synthesis that allows them to reorient themselves in life and experience a sense of direction. This process relies, to a large extent, on the temporal structure that haemodialysis affords life; it is by repeatedly undergoing the treatment that patients become able to create a sick body. Even so, many of them find this temporal structure problematic; they experience it as disruptive of their control and future-orientedness and as causing an existentially difficult-to-handle boredom. The thesis also shows that the political developments and the norms prevalent in the two national contexts studied greatly affect the orientations of the treatment practices and the participants’ lives. In both Riga and Stockholm, ideals of freedom, activity, control, and self-actualisation influence what forms of patienthood and personhood are enacted. The study indicates that persons who fall ill with a serious and chronic disease only gradually become able to understand and actively cope with their differently embodied circumstances of life. This suggests that medical professionals should not too hastily enlist their patients as experts on their own bodies, but rather provide them with the time and support necessary for making repeated attempts at creating and maintaining a life with a sick body. (shrink)

At first glance, this case might give the impression that a resolution would have been straightforward. A 17-year-old young man with moderate to severe learning disabilities and other conditions discussed below required a kidney transplant–the Court of Protection was tasked with determining whether this was in his best interests. However, the case of WV was in fact far more technical and required nuanced discussion and expert medical evidence from a range of specialists to objectively balance the needs of WV (...) and the risks to WV, and to ultimately determine his fate of life or death based on receiving a kidney transplant.Manchester University NHS Foundation Trust applied for a declaration in relation to the capacity of William Verdon and for the court to consider whether an order should be made that it was not in his best interests to have a kidney transplant with sedation and ventilation post-operatively. (shrink)

Acceptance of elderly or marginal health individuals as kidney donors is debated, with practices varying between centres. Transplant recipients, live kidney donors and health-care professionals caring for patients with renal failure were surveyed regarding their views on live donor kidney transplantation (LDKT) of marginal health (diabetes, hypertension, atherosclerosis, obesity, etc.) and elderly donors. Participants were recruited within a tertiary renal and transplant centre and invited to participate in focus groups and structured interviews. They also completed an (...) anonymous questionnaire. Of 464 participants who completed the questionnaire (36% health-care professionals and 64% patients), 49% and 64%, respectively, stated that marginal and elderly donors should be accepted for LDKT. In the structured interviews, emphasis was given to presenting to donor, recipient and their respective families a calculated risk regarding the effect that either a nephrectomy or transplant has on long-term quality of life. Participants stated that an independent third party in addition to the transplant team should discuss involved risks. Issues of ‘how desperate’ the recipient's situation is should also be considered. Health-care professionals stated that regardless of the strength of will of an individual to donate a kidney (despite age, health problems or personal risk), they should always have the right to say ‘no’ if performing a specific LDKT was against their professional and ethical values. About half of those surveyed considered that marginal health and elderly donors were acceptable for LDKT. Emphasis was given to the explanation to donors and recipients of the risks involved in such transplantation. (shrink)

In this article, we perform a thought experiment about living donor kidney transplantation. If a living kidney donor becomes in need of renal replacement treatment due to dysfunction of the remaining kidney after donation, can the donor ask the recipient to give back the kidney that had been donated? We call this problem organ restitution and discussed it from the ethical viewpoint. Living organ transplantation is a kind of ‘designated donation’ and subsequently has a (...) contract-like character. First, assuming a case in which original donor wishes the return of the organ which had been transplanted into B, and the original recipient agrees, organ restitution will be permissible based on contract-like agreement. However, careful and detailed consideration is necessary to determine whether this leaves no room to question the authenticity of B’s consent. Second, if B offers to give back the organ to A, then B’s act is a supererogatory act, and is praiseworthy and meritorious. Such an offer is a matter of virtue, not obligation. Third, if A wishes B to return the organ, but B does not wish/allow this to happen, it is likely difficult to justify returning the organ to A by violating B’s right to bodily integrity. But B’s refusal to return the donated organ cannot be deemed praiseworthy, because B forgets the great kindness once received from A. Rather than calling this an obligation, we encourage B to consider such virtuous conduct. (shrink)

Background The allocation of scarce deceased donor kidneys is a complex process. Transplant providers are increasingly relying on constructs such as frailty and cognitive function to guide kidney transplant (KT) candidate selection. Patient views of the ethical issues surrounding the use of such constructs are unclear. We sought to assess KT candidates’ attitudes and beliefs about the use of frailty and cognitive function to guide waitlist selection.Methods KT candidates were randomly recruited from an ongoing single-center cohort study of frailty (...) and cognitive function. Semi-structured interviews were conducted, and thematic analysis was performed. Inductively derived themes were mapped onto bioethics principles.Results Twenty interviews were conducted (65% contact rate, 100% participation rate) (60% male; 70% White). With respect to the use of frailty and cognitive function in waitlisting decisions, four themes emerged in which participants: (1) valued maximizing a scarce resource (utility); (2) prioritized equal access to all patients (equity); (3) appreciated a proportional approach to the use of equity and utility (precautionary utility); and (4) sought to weigh utility- and equity-based concerns regarding social support. While some participants believed frailty and cognitive function were useful constructs to maximize utility, others believed their use would jeopardize equity. Patients were uncomfortable with using single factors such as frailty or cognitive impairment to deny someone access to transplantation; participants instead encouraged using the constructs to identify opportunities for intervention to improve frailty and cognitive function prior to KT.Conclusions KT candidates’ values mirrored the current allocation strategy, seeking to balance equity and utility in a just manner, albeit with conflicting viewpoints on the appropriate use of frailty and cognitive impairment in waitlisting decisions. (shrink)

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the (...) favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors. An “opting in” paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An “opting in” program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of “organ takers” who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who “opt in” would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive. An “opting in” paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an “opting in” paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an “opting in” policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Receiving the Gift of Life: My Kidney Transplant StoryJudith W. RyanAs one of three siblings who all inherited an unfortunate gene from our mother, I was born with polycystic kidney disease (PKD). None of us knew of this, however, until later middle age, and my mother not until she was 76. I was the last sibling diagnosed at the age of 56. My brothers had been diagnosed (...) some years before and jokingly started to look at me as a universal donor. Since I had a 50-50 chance of having PKD and with a mother who was one of eight children with none of her siblings known to have the disease, I had not felt an urgency to be tested. Besides, I had no signs or symptoms. But now there was a reason. I made an appointment for a renal ultrasound and while having the procedure, I tipped the screen so that I could see the results. Although the technician was not happy with this, I was repaid with the view of my kidneys looking full of bubbles. Yes, our family was three for three in the genetic game of roulette.I knew immediately how I was going to navigate this health issue. As an adult nurse practitioner I had a very good understanding of what was to come. I knew my blood type “O” was the most common and would mean the longest wait for a deceased donor transplant, at least five years if I were lucky and only after enduring several years of progressing renal failure. In addition, I had cared for dialysis patients and watched my mother endure with difficulty both peritoneal and hemodialysis prior to her death a year before my diagnosis. Knowing I would not choose dialysis left me hoping for a miracle of a living donor or, more realistically, managing my disease as best I could until I died.The next step was managing PKD symptoms and issues as my kidneys continued to fail. One of the errors in my thinking during this time turned out to be that because I had two brothers who had the same disease and were ahead of me in their disease progression, I could follow their lead. It turned out that we manifested our disease very differently. My younger brother, who was diagnosed first, had to deal with significant pain from persistent cyst ruptures, monthly, biweekly then weekly. This continued even after his transplant until he had his native kidneys removed. The other two of us did not have to deal with cyst ruptures. Additionally, anemia was no problem for my younger brother but was for us older siblings. Significant fatigue and weariness were a problem for both of my brothers but not for me.And so it went, as we compared our blood test results, that the idea of a living donor entered the conversation. I knew this would be a problem for me because how do you ask people to consider being a donor? I had difficulty asking friends for a ride to the airport. This is where the grace and kindness of others and divine intervention enter [End Page 107] our story—word about our medical dilemma spread through the visibility of my younger brother, a minister in New England.Fortunately for me, my much beloved younger brother had dozens of people who wanted to be his donor. About 12 of these potential donors were actually tested before finding a match. One of his unmatched donors became the donor for my older brother (our first family transplant). Two years later, my other brother received his transplant. Three years later, after being told he was not a good match for my brother, this dear man came forward to be a possible donor for me. Hence, I got my transplant from an unused donor from my younger brother’s group. Overall, we had living donors from three different churches located within an hour of each other in New England. I even lucked out and acquired the minister of one of the churches as my donor. All three of us received kidneys over five years from living donors who did not know my older brother... (shrink)

It is now possible for someone with HIV disease to receive a kidney transplant from a living donor, although there is evidence only about the short-term outcomes of such a procedure. A person with HIV disease may not wish to disclose their diagnosis to a potential kidney donor. This paper argues that disclosure of the diagnosis of HIV to the donor is not necessary for informed consent. Concerns about the relationship of trust between the clinical team and the (...) donor hold weight in deciding whether disclosure is essential, though openness about the limited nature of informed consent may facilitate a trusting relationship in the absence of disclosure. In general, the recipient's medical information should be treated as confidential, thereby avoiding any need to distinguish between HIV and other medical conditions. (shrink)

Autonomy, an individual's right to make personal decisions regarding his/her own health, represents one of the major ethical principles of medicine. While there are many examples citing the benefits this right provides for the individual, the impact that personal healthcare decisions have on others is often neglected. Here, evidence from end-stage renal disease is reviewed to hypothesise the creation of a universal kidney donation programme that although provides unparalleled benefits to its citizens, relies on the participation of a large (...) proportion of the society. Given that this essay also addresses the public's major concerns regarding kidney donation, one of the only remaining implementation barriers is the individuals' right not to participate. Therefore, irrespective of the humane and complex emotionally laden reasons for not enrolling in such programmes, this essay provides some estimates of the significant resource and quality of life costs associated with autonomy. Assuming humans are competent to make informed personal healthcare choices, similar to recent efforts to increase awareness about the negative impact of certain lifestyle choices on global warming, citizens should also be better informed about the medical costs their autonomy has on society. (shrink)

© 2015 NATCO, The Organization for Transplant Professionals.Despite the known benefits of kidney transplant, less than 30% of the 615 000 patients living with end-stage renal disease in the United States have received a transplant. More than 100 000 people are presently on the transplant waiting list. Although the shortage of kidneys for transplant remains a critical factor in explaining lower transplant rates, another important and modifiable factor is patients' lack of comprehensive education about transplant. The purpose of this (...) article is to provide an overview of known best practices from the broader literature that can be used as an evidence base to design improved education for ESRD patients pursuing a kidney transplant. Best practices in chronic disease education generally reveal that education that is individually tailored, understandable for patients with low health literacy, and culturally competent is most beneficial. Effective education helps patients navigate the complex health care process successfully. Recommendations for how to incorporate these best practices into transplant education design are described. Providing more ESRD patients with transplant education that encompasses these best practices may improve their ability to make informed health care decisions and increase the numbers of patients interested in pursuing transplant. (shrink)

That Jehovah’s Witnesses may refuse lifesaving blood transfusions is a morally accepted feature of contemporary medical practice. The principle of respect for autonomy supports this, and there is seldom reason to interfere with this choice because it rarely harms another individual. Advances in surgical technique have made it possible for transplant surgeons to perform bloodless organ transplant, enabling Jehovah’s Witnesses to benefit from this treatment. When the transplant organ is a directed donation from a family member or friend, no ethical (...) dilemma arises. However, when a Jehovah’s Witness cannot identify a living donor and wishes to be listed for organ transplant, the transplant team may face an ethical dilemma. On the one hand, it wishes to provide care to the patient that is compatible with her or his preferences. On the other hand, the team may wonder if it is fair to other patients who need an organ and will accept blood transfusion to include the Jehovah’s Witness patient on a waiting list for a donated organ. If the Jehovah’s Witness patient is listed and receives an organ, then a patient who also needs an organ, and who is willing to accept all care to optimize the success of the transplant, may be denied an organ.To frame the ethical dilemma outlined above we present an anonymized case of a Jehovah’s Witness woman in urgent need of a kidney, who was referred to one of the authors’ institution’s transplant center. We review the evolution of the Jehovah’s Witness position on blood transfusion and the medical community’s efforts to provide care that accommodates this religious commitment. If Witnesses are to be denied transplant in the name of justice, there must be an ethically sound reason. We identify two rationales in the literature: (1) this allocation is unacceptable because it will cost lives; (2) resources should be allocated to patients who comply with the standard of care. We argue that neither apply to this dilemma. We also emphasize the importance of examining the data on outcomes of transplant with and without transfusion. Our interpretation of the published data on transplant without transfusion is that the outcomes are similar. We conclude that, in the absence of data that resources are risked, it is not ethical to refuse to include a Jehovah’s Witness patient on a waiting list for an organ. Finally, we reflect on the heterogeneity in transplant institutes’ polices for accepting Jehovah’s Witness patients. (shrink)

Ethical issues in biomedical research are traditionally examined as distinct from those of clinical care. However, this traditional framing may obscure questions of equity and fairness in both rese...

Despite a growing awareness within American biomedicine and bioethics that the social category “race” is of limited use in describing patients, some fields of medicine continue to use it interchangeably with, or instead of, the term “ethnicity.” Doing so reflects the assumption that social categories have a basis in physiology.

This article probes the voucher program from an ethical perspective. It focuses mainly on an issue of inequity. A disparity exists in US kidney transplantation. Although African-Americans suffer far higher rates of ESRD than whites, African-Americans are much less likely than whites to get a transplant. The article explores the voucher program in light of this disparity. It motivates the view that, at least in the short term, more whites than African-Americans are likely to take advantage of the (...) voucher program. The program is, thus, likely to increase the gap in transplantation rates between the two groups. If this is correct, what impact does it have on the moral acceptability of the program? (shrink)

In The Gift Relationship, Richard Titmuss argued that the practice of altruistic blood donation fosters social solidarity while markets in blood erode it. This paper considers the implications of this line of argument for the organ market debate. I defend Titmuss’ arguments against a number of criticisms and respond to claims that Titmuss’ work is not relevant to the context of live donor organ transplantation. I conclude that Titmuss’ arguments are more resilient than many advocates of organ markets suggest, (...) and more relevant to the debate than is commonly appreciated. (shrink)

It is now eighteen years on since the Human Tissue Act 1961, but this legislation is still unchanged in England, Scotland and Wales. Ian Kennedy, in this paper, lays before us the law as it is, the problems of its interpretation and his opinion of what government should be doing to help clarify the situation and remove some of the problems which exist daily for the doctors who face the dilemma of seeking consent for transplants at the moment of extreme (...) grief for the surviving spouses or relatives of the patient who has been in his care only moments before. Ian Kennedy suggests that by doing nothing the Department of Health and the government are being both callous and less than honest. (shrink)

One of the most common arguments against legalising markets in human kidneys is that this would result in the widespread misuse that is present in the black market becoming more prevalent. In particular, it is argued that if such markets were to be legalised, this would lead to an increase in the number of people being coerced into selling their kidneys. Moreover, such coercion would occur even if markets in kidneys were regulated, for those subject to such coercion would not (...) be able to avail themselves of the legal protections that regulation would afford them. Despite the initial plausibility of this argument, there are three reasons to reject it. Firstly, the advantages of legalising markets in human kidneys would probably outweigh its possible disadvantages. Secondly, if it is believed that no such coercion can ever be tolerated, markets in only those human kidneys that fail to do away with coercion should be condemned. Finally, if coercion is genuinely opposed, then legalising kidney markets should be supported rather than opposed, for more people would be coerced were such markets to be prohibited. (shrink)

We conducted a survey of attitudes towards the sale of kidneys for transplantation within and without the medical community. Half of those polled received a case of a young man in India whose only chance for survival was to purchase a kidney, the other half a case of a Canadian man who was suffering side-effects from dialysis and had been on the transplant waiting list for three years. We found the percentage of responses allowing the patients to purchase (...) a kidney was similar for the two cases (40 per cent in the Canadian case and 49 per cent in the Indian case). The medical groups had much lower rates of approval of this practice than the public. In all groups those allowing the practice showed similar concerns about regulation. This survey indicates public opinion to be contrary to public policy. (shrink)

Terminal kidney patients are faced with lower quality of life, restricted diets and higher morbidity and mortality rates while waiting for deceased donor kidney transplantation. Fortunately, living kidney donation has proven to be a better treatment alternative (e.g. in terms of waiting time and graft survival rates). We observed an inequality in the number of living kidney transplantations performed between the non-European and the European patients in our center. Such inequality has been also observed elsewhere (...) in this field and it has been suggested that this inequality relates to, among other things, attitude differences towards donation based on religious beliefs. In this qualitative research we investigated whether religion might indeed (partly) be the explanation of the inequalities in living donor kidney transplants (LDKT) among non-European patients. Fifty patients participated in focus group discussions and in-depth interviews. The interviews were conducted following the focus group method and analyzed in line with Grounded Theory. The qualitative data analyses were performed in Atlas.ti. We found that religion is not perceived as an obstacle to living donation and that religion actually promotes helping and saving the life of a person. Issues such as integrity of the body were not seen as barriers to LDKT. We observed also that there are still uncertainties and a lack of awareness about the position of religion regarding living organ donation within communities, confusion due to varying interpretations of Holy Scriptures and misconceptions regarding the process of donation. Faith leaders play an important educational role and their opinion is influential. This study has identified modifiable factors which may contribute to the ethnic disparity in our living donation program. We argue that we need to strive for more clarity and awareness regarding the stance of religion on the issue of living donation in the local community. Faith leaders could be key figures in increasing awareness and alleviating uncertainty regarding living donation and transplantation. (shrink)

: Iran has had a program of compensated kidney donation from living unrelated (LUR) donors since 1997. The aim of the program was to address the increasing demand for kidney transplantation in a morally sound manner. The program was successful in terms of increasing the number of kidneys available for transplantation. This paper presents a critical review of the program and its ethical status. Denying organ donors legitimate compensation because of the understandable fear of an organ (...) trade is not morally justifiable, and the Iranian model of compensated LUR kidney donation offers substantial benefits that overcome these concerns. Despite its benefits, the program lacks secure measures to prevent the risk of a direct monetary relationship between donors and recipients, and it must be revised in order to be morally justifiable. (shrink)

We study the allocation of cadaveric donor kidneys for transplantation based merely on waiting time. This simple allocation rule turns out to possess very attractive ethical and medical properties. Current allocation rules, on the other hand, violate some basic requirements of distributive justice. Perhaps for fear of exacerbating these problems, these rules also fail to consider criteria such as sex, age and race although certain combinations of these criteria are known to affect graft survival rates. We demonstrate that allocation (...) by waiting time automatically protects disadvantaged patient types and puts them in a near to optimal position. The inclusion of sex, age and race will therefore not lead to morally unacceptable allocations. This allows individual patients to improve the expected survival time of their graft relative to the status quo without being penalized by the allocation rule. Moreover, decisions ab out when to start compromising on expected graft survival rates in favour of shorter waiting times are made locally by patients and their medical advisers rather than by a centralized protocol. (shrink)

In this paper, we seek to re-conceptualize the ethical framework through which ethicists and medical professionals view the practice of live kidney donations. The ethics of organ donation has been understood primarily within the framework of individual rights and impartiality, but we show that the ethic of care captures the moral situation of live kidney donations in a more coherent and comprehensive way, and offers guidance for practitioners that is more attentive to the actual moral transactions among donors (...) and recipients. A final section offers guidelines for the practice of live kidney transplants that emerge from an ethic of care. (shrink)

There is a global shortage of organs for transplantation and despite many governments making significant changes to their organ donation systems, there are not enough kidneys available to meet the demand. This has led scientists and clinicians to explore alternative means of meeting this organ shortfall. One of the alternatives to human organ transplantation is xenotransplantation, which is the transplantation of organs, tissues, or cells between different species. The resurgence of interest in xenotransplantation and recent scientific breakthroughs (...) suggest that genetically-engineered pigs may soon present a realistic alternative as sources of kidneys for clinical transplantation. It is therefore important for nurses and allied health professionals to understand what is involved in xenotransplantation and its future implications for their clinical practices. First, we explore the insufficiency of different organ donation systems to meet the kidney shortage. Second, we provide a background and a summary of the progress made so far in xenotransplantation research. Third, we discuss some of the scientific, technological, ethical, and economic issues associated with xenotransplantation. Finally, we summarise the literature on the attitudes of healthcare professionals toward xenotransplantation. (shrink)

In the Eurotransplant region transplantable kidneys from cadaveric donors are allocated according to the Wujciak-Opelz algorithm. This paper shows that the algorithm as it stands fulfils certain normative standards of a more formal nature while violating others. In view of these insights, it is explored how the algorithm could perhaps be improved. Even if issues of substantial rather than formal adequacy need to be addressed separately, analyses as presented in this paper can prepare the ground for a discussion of substantive (...) normative issues. In any event, axiomatic accounts can tell us something about what we are in fact doing when using a procedure like the Wujciak-Opelz algorithm. (shrink)

This paper challenges the view that bans on kidney sales are unjustifiably paternalistic, that is, that they unduly deny people the freedom to make decisions about their own bodies in order to protect them from harm. I argue that not even principled anti-paternalists need to reject such bans. This is because their rationale is not hard paternalism, which anti-paternalists repudiate, but soft paternalism, which they in principle accept. More precisely, I suggest that their rationale is what Franklin Miller and (...) Alan Wertheimer call ‘group soft paternalism’. Group soft paternalistic policies restrict the freedom of autonomous individuals, not for their own good (hard paternalism), but as an unavoidable consequence of seeking to protect other, non-autonomous individuals from harms that they have not voluntarily chosen (soft paternalism). Group soft paternalism supports prohibiting kidney sales on three conditions: (1) that such sales are potentially harmful to vendors, (2) that many vendors would suffer impaired autonomy, and (3) that distinguishing between autonomous and non-autonomous vendors and interfering only with the latter is unfeasible. I provide reasons for thinking that these conditions will often hold. (shrink)