New requirements for organ donor screening

Providers in "difficult position" ethically

Some hospitals are now being required to inform living donors of the risks they face, fully evaluate their medical and psychological suitability, and track their health for years after donation.

The United Network for Organ Sharing, which manages the transplant system under a federal contract, voted to establish uniform minimum standards and will require hospitals to collect medical data, including laboratory test results, on most living donors to study lasting effects, with results reported at six months, one year, and two years.

The high demand for organs and relatively scarce supply put transplant hospitals and their personnel in "a particularly difficult position," says Leslie M. Whetstine, PhD, an assistant professor of philosophy at Walsh University in North Canton, OH.

"How aggressively must they vet a donor when there is a human life on the line and a person has come forward to save them?" she asks.

Whetstine says that in addition to psychological screenings, the use of donor advocates can be useful in safeguarding the donor's autonomy. "The presumption in this case is, of course, that a donor may feel pressured to sell his or her organs or may have second thoughts about going through with the procedure," she says.

In these scenarios, a donor advocate can simply tell the recipient that the donor isn't a match or was rejected on medical grounds, rather than disclose the donor's actual reasons, she explains. "While this is an important role, advocacy proves fruitless when a donor and recipient and/or a third party broker a deal to voluntarily engage in organ vending," says Whetstine.

Donors need to be comfortable with the realization that their act is permanent and might have future health consequences, says Stuart M. Flechner, MD, FACS, professor of surgery at Cleveland (OH) Clinic Lerner College of Medicine and director of the clinical research section of the Cleveland Clinic's Center for Renal Transplantation/Glickman Urological and Kidney Institute. Flechner is former chair of the Joint Societies Work Group charged with establishing standards for the informed consent, medical evaluation, and follow-up of living kidney donors.

"However, they should have easy access to outcome data that they can understand," Flechner says. "In the end, it should be the donor's decision about who they want to help and what degree of risk they want to take."

Cases are atypical

Unfortunately, there have been a few well-publicized cases involving harm to donors, which also showed poor practices in the transplant program regarding informed consent and other aspects of donor education and advocacy, notes Mary Ellen Olbrisch, PhD, designated living donor advocate for the liver transplant program at the Virginia Commonwealth University Medical Center, and professor of psychiatry and surgery/director of education and training in clinical health psychology at Virginia Commonwealth University in Richmond.

"Nevertheless, I do not believe that these cases are, in any sense, typical of donor care in the transplant community," she says. "If anything, I believe that transplant programs and transplant physicians, on the whole, are extremely conservative about allowing individuals to become donors."

Most transplant programs and transplant physicians already adhere to a very high standard, and are quite concerned that donors be fully informed and free of coercion, says Olbrisch.

"The existing interpretation and implementation of the [Centers for Medicare & Medicaid] rule pertaining to living donor advocates is based on the most extreme ideas about how an advocate might be tainted by a potential conflict of interest," says Olbrisch.

In reality, Olbrisch says it is "pretty much impossible" to have a truly independent living donor advocate, and it is essential that everyone connected with the transplant program be a person of integrity who respects the donor as an individual just as much as the recipient.

"Perhaps the trickiest issue would be how to protect living donors by taking away incentives for doing a larger number of transplants, or at least scrutinizing outlier programs that appear to have lower standards of donor acceptability and protection," she says.

Tightening up or standardizing what are already common practices with regard to donor screening and selection will not make much difference, according to Olbrisch.

"If there are a few programs that have not been doing as good a job as they should have been doing, perhaps they will improve and this will eliminate a few medically inappropriate, higher-risk donors," she says.

Informed consent does not usually discourage donors, says Olbrisch, adding that once a person requests to be evaluated as a donor, "little will discourage him except to be found medically unsuitable."

Encouraging transplants can be achieved by creating public awareness about people in need and about successful donor and recipient pairs, according to Olbrisch.

"It is not the job of transplant programs and transplant physicians involved in living donor programs to encourage transplants at the level of how donors are screened and cared for," she says.

The only legitimate goal is to assure the best interests of the prospective donor, adds Olbrisch. "Every time a donor is exploited or comes to harm because someone cut corners to help a recipient or to do more surgeries, it harms the entire field of organ transplantation," she says. n

Sources

  • Stuart M. Flechner, MD, FACS, Professor of Surgery, Cleveland Clinic Lerner College of Medicine/Director, Clinical Research Section of Center for Renal Transplantation/Glickman Urological and Kidney Institute, Cleveland, OH. Phone: (216) 445-5772. E-mail: flechns@ccf.org.
  • Mary Ellen Olbrisch, PhD, ABPP, Professor of Psychiatry and Surgery/Director of Education and Training in Clinical Health Psychology, Virginia Commonwealth University, Richmond. Phone: (804) 827-0053. E-mail: molbrisch@mcvh-vcu.edu.
  • Leslie M. Whetstine, PhD, Assistant Professor, Philosophy, Walsh University, North Canton, OH. Phone: (330) 244-4697. E-mail: lwhetstine@walsh.edu.