Truthfulness in transplantation: non-heart-beating organ donation

The current practice of organ transplantation has been criticized on several fronts. The philosophical and scientific foundations for brain death criteria have been crumbling. In addition, donation after cardiac death, or non-heartbeating-organ donation (NHBD) has been attacked on grounds that it mistreats the dying patient and uses that patient only as a means to an end for someone else's benefit.     

Legal briefing: organ donation and allocation

This issue's "Legal Briefing" column covers legal developments pertaining to organ donation and allocation. This topic has been the subject of recent articles in JCE. Organ donation and allocation have also recently been the subjects of significant public policy attention. In the past several months, legislatures and regulatory agencies across the United States and across the world have changed, or considered changing, the methods for procuring and distributing human organs for transplantation. Currently, in the U.S., more than 100,000 persons are waiting for organ transplantation. In China, more than 1.5 million people are waiting. Given the chronic shortage of available organs (especially kidneys and livers) relative to demand, the primary focus of most legal developments has been on increasing the rate of donation. These and related developments are usefully divided into the following 12 topical categories: 1. Revised Uniform Anatomical Gift Act. 2. Presumed Consent and Opt-Out. 3. Mandated Choice. 4. Donation after Cardiac Death. 5. Payment and Compensation. 6. Donation by Prisoners. 7. Donor Registries. 8. Public Education. 9. Other Procurement Initiatives. 10. Lawsuits and Liability. 11. Trafficking and Tourism. 12. Allocation and Distribution.     

Sequential requests and organ donation

The author investigated the effectiveness of the foot-in-the-door technique as a method of increasing participants' intention to become organ donors. The participants who agreed to a 1st request were presented with a larger request either immediately or 3 days later. The 2nd request was presented either by the same requester or by a different requester. Compared with a control group receiving only the 2nd request, a significant foot-in-the-door effect emerged in all conditions except 1 (same requester-immediate request), in which the participants showed neither more nor less intention to become organ donors than did the control group.     

Defining the vital condition for organ donation

The issue of organ donation and of how the donor pool can or should be increased is one with significant practical, ethical and logistic implications. Here we comment on an article advocating a paradigm change in the so-called "dead donor rule". Such change would involve the societal and legal abandonment of the above rule and the introduction of mandated choice. In this commentary, we review some of the problems associated with the proposed changes as well as the problems associated with the current model. We emphasize the continuing problems with the definition of death and the physiological process of dying; we discuss the difficulties associated with a dichotomous view of death; we review the difficulties with non-beating heart donation and emphasize the current limitations of society's understanding of these complex issues. We conclude that public education remains the best approach and that such education should not be merely promotion of a particular ideology but honest debate of what is socially and morally acceptable and appropriate given the changes in vital organ support technology and the need to respect patient autonomy.     

The failure to give: reducing barriers to organ donation

Moral frameworks for evaluating non-donation strategies to increase the supply of cadaveric human organs for transplantation and ways to overcome barriers to organ donation are explored. Organ transplantation is a very complex area, because the human body evokes various beliefs, symbols, sentiments, and emotions as well as various rituals and social practices. From a rationalistic standpoint, some policies to increase the supply of a transplantable organs may appear to be quite defensible but then turn out to be ineffective and perhaps even counterproductive because of inadequate attention to these rich and complex features of human body parts. Excessively rationalistic policies neglect deep beliefs, symbols, sentiments, and emotions and the like, and that deficiency marks many actual and proposed policies. In addition, policies are often too individualistic and too legalistic.     

Defining the vital condition for organ donation

Luke Demaitre's Leprosy in Premodern Medicine: A Malady of the Whole Body is a highly interesting study of the medical history of leprosy and the medical and social perceptions on leprosy that have been around for centuries. Remarkably, it is likely that leprosy will disappear from the face of the Earth in our generation, thanks to the development of a curative treatment and its increasing availability (although the battle has not yet been won completely). Demaitre's book is a very good read not only for its information about leprosy but also for all interested in or affected by the social phenomenon of stigma. In illnesses such as leprosy, HIV/AIDS, epilepsy, and mental disorders such as schizophrenia, the stigma attached to the condition may be worse than the condition itself.     

Non-heart-beating organ donation: a reply to Campbell and Weber.

In the preceding commentary, Campbell and Weber raise two valid and important issues concerning non-heart-beating organ donation (NHBOD). First, because the procedure links withdrawal of life support and the potential for subsequent organ donation, the desire for organs may create a situation in which care of the dying individual has relatively less importance and the dying may receive suboptimal care. Second, even if concerns about care of the dying were dealt with adequately, there will not be enough non-heart-beating donors to significantly decrease the organ shortage that exists, making the procedure not worth the risk. We agree that attention to the important details of caring for the dying are, and must be, the primary concern of all health care workers caring for those individuals. Ensuring the patients' comfort, dignity, and autonomy, and providing for family and social support are the mainstays of this care. All policies for NHBOD should clearly support and mandate these concepts. Regarding the second concern, we agree that NHBOD is currently rare; however, evidence is increasing that this type of donation has great potential. Continued growth of the practice in this country will depend largely on public acceptance, which we believe will be directly influenced by whether the public perceives that care of the dying is not compromised by this procedure.     

Intention to consent to living organ donation: an exploratory study

Living organ donation, that is the removal and transplantation of whole organs or segments of organs that a volunteering donor can live without, has been proposed as an effective and sustainable source of transplantable organs to mitigate the deficit in supply from the traditional cadaveric donor pool. In 2006, the Irish government deemed the development of a national Living Transplant Programme a service priority. The current study aimed to investigate the efficacy of the theory of planned behaviour (TPB) in the context of living organ donation intentions in an Irish sample. One hundred and thirty five undergraduate students (75 females, 60 males; mean age 20.6 years, SD 3.76) completed a self-report questionnaire assessing TPB variables while imagining themselves in a potential living liver donation scenario. In general, attitudes towards living donation were favourable. TPB components explained 44.8% of the variance in intentions. Attitude towards living donation emerged as the strongest predictor of intention. Self-reported levels of knowledge regarding living donation were generally poor. In light of recent EU Communications proposing the expansion of the use of living donors greater understanding of the determinants, psychological implications and ethical considerations in living donation decisions is necessary.     

Perish and publish: non-heart-beating organ donation and unduly iterative ethical review

In the expanding repertoire of practices designed to increase the supply of organs for transplantation, non-heart-beating cadaver organ donation has generated an ongoing debate in the literature. The continuing stream of articles is disquieting in part because it documents a troubling "trial-and-error ethics" approach to the formulation of organ procurement policy, and because it raises serious questions about the reasons that the development of this policy is being mediated by published communication. In the light of concerns about the implicit support and credibility that professional publications give to organ procurement policies, restraint in publishing articles about non-heart-beating organ donation as well as in devising such policies is strongly advocated.     

Attitudes toward posthumous organ donation and commitment to donate

The medical need for human organs suitable for use as transplants far exceed the supply, and is growing. More favorable attitudes about organ donation would increase people's willingness to sign posthumous donation pledges. But effective educational programs require information about the public's present views. Verbal attitude scales were constructed and administered to 110 adults, resulting in reliable measurement of two independent dimensions, prodonation and antidonation (r = .003). Cluster analysis of the instrument revealed that the positive dimension involves belief in the humanitarian benefits of organ donation and feelings of pride experienced by the donor. The negative dimension reflects fears of body mutilation and of receiving inadequate medical treatment when one's life is at risk. Pro and anti scores in combination predicted willingness to sign a donor card. A 2 X 2 analysis of variance (High-Low Positive X High-Low Negative) revealed significant main effects for both positive and negative attitude. Also, a significant interaction effect was obtained. Those subjects who had both strong positive attitudes and weak negative attitudes were especially willing to sign donor cards. Suggestions for designing educational campaigns to promote organ donation are offered.     

History of organ donation by patients with cardiac death

When successful solid organ transplantation was initiated almost 40 years ago, its current success rate was not anticipated. But continuous efforts were undertaken to overcome the two major obstacles to success: injury caused by interrupting nutrient supply to the organ and rejection of the implanted organ by normal host defense mechanisms. Solutions have resulted from technologic medical advances, but also from using organs from different sources. Each potential solution has raised ethical concerns and has variably resulted in societal acclaim, censure, and apathy. Transplant surgery is now well accepted, and the list of transplant candidates has grown far quicker than the availability of organs. More than 30,000 patients were awaiting organs for transplantation at the end of March 1993. While most organs came from donors declared dead by brain criteria, the increasing shortage of donated organs has prompted a reexamination of prior restrictions of donor groups. Recently, organ procurement from donors with cardiac death has been reintroduced in the United States. This practice has been mostly abandoned by the U.S. and some, though not all, other countries. Transplantation has been more successful using organs procured from heart-beating, "brain dead" cadavers than organs from non-heart-beating cadavers. However, recent advances have led to success rates with organs from non-heart-beating donors that may portend large increases in organ donation and procurement from this source.     

Race,sex, and juvenile inmate roles

Mate selection researchers have long assumed that surveyed listings of ''ideal traits'' indicate strong preferences by women for virtuous males. This assumption is contradicted, however, by increasing evidence of sexual abuse in dating relationships and suggests the possibility that the hero-centric Western culture of romance greatly complicates the mating process. A review of literary heroism revealed extraordinary individualism. Notably, George Gordon Byron's protagonists ('Byronic Heroes') are men of stupendous assertiveness and uncertain morality; derivatives abound in contemporary American popular culture. A comparison was made of three typologies; the third, domestic batterers being ''stand-ins'' for abusive dates. Byronic traits were found to much more closely resemble those of batterers than of hypothetical ideal mates. Thus, the development of intense admiration of fictional Byronic Heroes during socialization could lead to an admiration of same traits in encountered males with or even tragic results.