Living donors require adequate protection
Make sure risks are understood
Providers working in living donor transplant programs face not only clinical challenges, but ethical ones as well. Donors are placing themselves at significant risk of death or injury to help another person. How do you make sure that the donors understand all the risks involved, are truly willing to be a donor, and are making the decision to donate out of guilt, fear, family pressure, or coercion?
"We have learned along the way that, really, some donors are forced or coerced into this," says Elizabeth Pomfret, MD, director of the living donor program at the Lahey Clinic in Burlington, MA. "Maybe they are the member of the family who doesn’t have a job, or they are the one the family decided should be the one who does it, and there are these outside pressures put on these people."
Develop a foolproof procedure
Even without pressure from family or the potential recipient, sometimes the donor’s desire to help the patient can blind that person from understanding real reasons they cannot or should not donate. That’s why it’s essential that living donor programs have a foolproof procedure for evaluating potential donors that is completely separate from the process of evaluating the patient’s qualifications for undergoing the procedure, advises Pomfret.
Not all people who want to be a donor will qualify. "One of the more important criteria that has to be met is the issue of anatomy," Pomfret explains.
"The liver is much less finicky from a genetic standpoint than the kidney; you need to match genetics there much more closely than you would for liver transplantation. But with liver transplantation, it comes down to an issue of size," she points out. "We know we need to leave the donor with at least 30% of what they started with in order to be safe. We know we need to give the recipient about 1% of liver volume to body weight. For instance, you have a 70-kg person; we need approximately 700 g of liver tissue. So, the size, blood vessel anatomy, the anatomic considerations become more of an issue in live donor organ transplantation."
At Lahey, a surgeon, psychiatrist, and social worker give the prospective donor a thorough clinical and psychological work-up to determine if there are any medical or emotional reasons why the procedure shouldn’t be performed.
"The medical evaluation of the donor is conducted by a physician who has never met the recipient, so that has no bearing on their conclusions," she says. "The psychiatrists are completely different than the ones evaluating the recipient. The steps are set up along the way so that if there is coercion or family pressure, those things will be culled out during the course of the evaluation."
If the counselors determine that the person is not truly prepared to be a donor, they usually "construct" a vague medical reason why the person cannot participate, Pomfret says. "You have to have a way in which the donor can bow out without becoming the bad guy in the family. The family is usually told there is some anatomic abnormality which is not harmful to the donor’s health, but makes it impossible to divide the liver in two."
Prospective lung lobe donors at the University of Minnesota also are evaluated by a separate team of physicians, psychiatrists, and social workers, says Soon Park, MD, assistant professor of cardiovascular and thoracic surgery. If a potential donor is ruled out for any reason, medical or psychological, they are only told that they have not been cleared as a candidate, he says. "They know up front that the answer is just yes, you can be a donor; or no, we cannot accept you."
Sometimes, even if a potential donor meets both clinical and psychological criteria, the surgeons themselves may have qualms for other reasons.
Altruism still questionable
Both Park and Pomfret say they would have problems with, and probably would not accept, a donor who did not have either a close familial or emotional relationship with the recipient.
"I think many people are still in debate as to whether or not Good Samaritan donations should be done, people donating who have absolutely no relationship [to the recipient] whatsoever, who are just looking to do this for altruistic reasons, there is a lot of debate over whether that is reasonable to pursue in this situation," she says. "And, to this point, we do not do Samaritan donations, but there are groups in the United States that do."
Nondirected donations, or list-paired donations, might be acceptable for kidney donors, where there is enough past data showing that donors go on to have normal lives and their future is not severely affected by the donation, she adds. "We certainly do not have that level of experience in either lung or liver donation."
Park admits he initially had reservations about performing a living lobar transplant with a donor who was not related to the patient, but was a friend. "I really could not believe that someone would go through such a procedure like this. I thought that there must be something going on somewhere, something was wrong," he says.
But, the woman made it through the screening process and talked with Park himself and convinced him that the procedure should be done. "I am convinced that some people out there just have really good hearts," he says.
Even if the potential donor is related, there are some cases that Pomfret feels surgeons might still impose their own ethical judgments. "From my perspective, I am always concerned when we are talking about a donor who has young children," she says. "Certainly, say a scenario in which the husband needs a liver transplant, the wife wants to be the donor, and they have children under the age of 10. You have to really think about, Is that a reasonable thing for her to do?’ By and large, that sort of scenario is not something we would do at this point."
• Authors for the Live Organ Donor Consensus Group. Consensus statement on the live organ donor. JAMA 2000; 284:2,919-2,926. n
• The American Society of Transplant Surgeons has initiated a registry of living liver donor procedures and developed a position paper on adult living liver transplants. For information, visit the ASTS site on the web: www.asts.org.