Ethics Of Transplantation Research Articles

Ethics of Organ Donation and Transplantation: Toward Self-Sufficiency.

Organ donation, intersecting medical necessity and ethical responsibility, calls for policies respecting individual autonomy while aiming for societal selfsufficiency. This article evaluates various government policies, emphasizing the ethical use of nudges in decision-making and the potential impact on autonomy. We argue that, while some policies might be coercive, others may inadvertently disrespect autonomy through subtle influences on decisionmaking. To reach self sufficiency in organ donation and transplantation and to keep adherent to medical ethics, especially informed consent, and gift of life campaigns, governments must determine the legal procedures by which their residents are registered, or can register, as organ donors. Provided that governments recognize that people have a right to determine what happens to their organs after they die, there are 4 feasible options to choose from: optin, opt-out, mandated active choice, and voluntary active choice. This article investigated the ethics of these policies' use of nudges and pokes to affect organ donor registration ways, rules, and rates. We argue that the use of nudges in this context is morally problematic. It is disrespectful of people's autonomy to take advantage of their cognitive biases since doing so involves bypassing, not engaging, their rational capacities. We conclude that, although mandated active choice policies are not problem free, they are coercive; after all, voluntary active choice, opt-in, and opt-out policies are potentially less respectful of people's autonomy since their use of nudges could significantly affect people's decision making.

P.499: Ethics of organ donation and transplantation – The road traversed.

P.499: Ethics of organ donation and transplantation – The road traversed.

Another Defense of Abortion: What Transplant Ethics Tells Us about the Ethics of Abortion after Dobbs.

In 1971, two years before Roe v. Wade affirmed federal protection for abortion, Judith Jarvis Thomson attempted to demonstrate the wrongs of forced gestation through analogy: you awake to find that the world's most esteemed violinist is wholly, physically dependent on you for life support. Here, the authors suggest that Thomson's intuition, that there is a relevant similarity between providing living kidney support and forced gestation, is realized in the contemporary practice of living organ donation. After detailing the robust analogy between living kidney donation and gestation, we turn to current ethical guidelines incorporated in the United Network for Organ Sharing's requirements for legally authorized organ donation and transplantation. We conclude that if, as we-and Thomson-suggest, organ donation and gestation are relevantly similar, then the ethical framework supporting donation may aid in articulating ethical grounds that will be compelling in informing the legal grounds for a defense of abortion.

Developing Guidance for Donor Intervention Randomized Controlled Trials: Initial Discussions From the Canada-United Kingdom 2022 Workshop.

Donor interventions, including medications, protocols, and medical devices administered to donors, can enhance transplantable organ quality and quantity and maximize transplantation success. However, there is paucity of high-quality evidence about their effectiveness, in part because of ethical, practical, and regulatory challenges, and lack of guidance about conduct of donor intervention randomized controlled trials (RCTs). With the vision to develop authoritative guidance for conduct of donor intervention RCTs, we convened a workshop of Canadian-United Kingdom experts in organ donation and transplantation ethics, research, and policy to identify stakeholders, explore unique challenges, and develop research agenda to inform future work in this promising field. Donor intervention trials should consider perspectives of broad group of stakeholders including donors, transplant recipients, and their families; researchers in donation and transplantation; research ethics boards; and healthcare providers and administrators involved in donation and transplantation. Unique challenges include (1) research ethics (living versus deceased status of the donor at the time of intervention, intervention versus outcomes assessment in different individuals, harm-benefit analysis in donors versus recipients, consent, and impact on research bystanders); (2) outcome data standardization and linkage; and (3) regulatory and governance considerations. Donor intervention RCTs hold potential to benefit organ transplantation outcomes but face unique research ethics, outcome data, and regulatory challenges. By developing research agenda to address these challenges, our workshop was an important first step toward developing Canada-United Kingdom guidance for donor intervention RCTs that are poised to improve the quality and availability of transplantable organs.

The Ethics of Human Brain Organoid Transplantation in Animals

In this paper, we outline how one might conduct a comprehensive ethical evaluation of human brain organoid transplantation in animals. Thus far, ethical concerns regarding this type of research have been assumed to be similar to those associated with other transplants of human cells in animals, and have therefore not received significant attention. The focus has been only on the welfare, moral status, or mental capacities of the host animal. However, the transplantation of human brain organoids introduces several new ethical issues. Many of these are related to uncertainty regarding whether or not brain organoids might be conscious. While these concerns might not be immediately relevant, they warrant closer scrutiny. We discuss how various ethical issues are relevant to different stages of human brain organoid transplantation and can guide the ethical evaluation of research. Our examination would broaden the horizons of the debate on the transplantation of brain organoids.

Deceased Donor Transplantation: Patient Selection, Ethics, and New Approaches

RENAL transplantation was a hot topic at the 60th European Renal Association (ERA) Congress 2023, which took place both virtually and in-person in Milan, Italy, between 15th–18th June. One such session saw experts in transplant medicine, surgery, and transplant ethics deliver presentations on deceased donor kidney transplantation. Co-chaired by Marta Crespo, Hospital del Mar, Barcelona, Spain, and Christophe Mariat, University Hospital Saint-Étienne, Saint-Priest-en-Jarez, France, this symposium delivered invaluable insights into donor selection, transplant ethics, and approaches to improve graft viability and implementation.

Dual-Organ Transplantation: Indications, Evaluation, and Outcomes for Heart-Kidney and Heart-Liver Transplantation: A Scientific Statement From the American Heart Association.

Although heart transplantation is the preferred therapy for appropriate patients with advanced heart failure, the presence of concomitant renal or hepatic dysfunction can pose a barrier to isolated heart transplantation. Because donor organ supply limits the availability of organ transplantation, appropriate allocation of this scarce resource is essential; thus, clear guidance for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation is urgently required. The purposes of this scientific statement are (1) to describe the impact of pretransplantation renal and hepatic dysfunction on posttransplantation outcomes; (2) to discuss the assessment of pretransplantation renal and hepatic dysfunction; (3) to provide an approach to patient selection for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation and posttransplantation management; and (4) to explore the ethics of multiorgan transplantation.

Contextual Vulnerability Should Guide Fair Subject Selection in Xenotransplantation Clinical Trials

Contextual Vulnerability Should Guide Fair Subject Selection in Xenotransplantation Clinical Trials

Forced Organ Harvesting

Forced Organ Harvesting

Ethics in Transplantation

Ethics in Transplantation

Kidney disease in non-kidney solid organ transplantation.

Kidney disease after non-kidney solid organ transplantation (NKSOT) is a common post-transplant complication associated with deleterious outcomes. Kidney disease, both acute kidney injury and chronic kidney disease (CKD) alike, emanates from multifactorial, summative pre-, peri- and post-transplant events. Several factors leading to kidney disease are shared amongst solid organ transplantation in addition to distinct mechanisms unique to individual transplant types. The aim of this review is to summarize the current literature describing kidney disease in NKSOT. We conducted a narrative review of pertinent studies on the subject, limiting our search to full text studies in the English language. Kidney disease after NKSOT is prevalent, particularly in intestinal and lung transplantation. Management strategies in the peri-operative and post-transplant periods including proteinuria management, calcineurin-inhibitor minimization/ sparing approaches, and nephrology referral can counteract CKD progression and/or aid in subsequent kidney after solid organ transplantation. Kidney disease after NKSOT is an important consideration in organ allocation practices, ethics of transplantation. Kidney disease after SOT is an incipient condition demanding further inquiry. While some truths have been revealed about this chronic disease, as we have aimed to describe in this review, continued multidisciplinary efforts are needed more than ever to combat this threat to patient and allograft survival.

Current Situation With Organ Donation and Transplantation in China: Application of Machine Learning

China ranks currently as one of the top countries for organ transplantation according to types, capacity, related research, quality, and quantity of procedures. However, the management systems struggle to support these practices. This study aims to review the current situation with organ donation and transplantation in China recently. Data about organ donation and transplantation was collected by using web crawler technology from several news sections of representative portal websites in China. A total of 3475 documents about organ donation and transplantation were analyzed after data preprocessing. The documents were analyzed using machine learning to find out the relationship among the hot topics and their social popularity as well as to explore the dominant subtopics of the hot topics. The results of weighted correlation network analysis and documents clustering analysis identified 9 topics about organ donation and transplantation in China with a wide discussion: transplantation ethics, donor compensation, use of the remains, transportation guarantee of living organs, organ allocation, relevant national standards of organ donation and transplantation, legislation on organ donation, penalties for violation, and the Red Cross Society of China. This study found out the main problems and proposed them for future discussion with organ donation and transplantation system in China: the lack of publicity and education and the difficulty of standardizing legislation about ethical issues arousing ethical problems; the need to understand the relationship and the standardization among costs, expenses, and compensation; and the lack of more support from the government and public to ensure regular organ donation and transplantation.

Experience of ethical dilemmas among professionals working in pediatric transplantation: An international survey.

Professionals working in pediatric transplantation commonly encounter complex ethical dilemmas. Most ethical research in transplantation is related to adult practice. We aimed to gain insight into ethical issues faced by transplant professionals when dealing with pediatric transplant recipients. A two-stage study was designed; the first part was a questionnaire completed by 190 (80%) members of the International Pediatric Transplant Association (IPTA) from over 30 different countries. This was followed by a multidisciplinary focus group that explored the preliminary data of the survey. A total of 38% (56 of 149) respondents of the questionnaire had experienced an ethical issue between 2016 and 2018. Surgeons were more likely to have encountered an ethical issue as compared with physicians (60% vs. 35.7%, p= .035). Clinicians from Europe were more likely to have experienced an ethical issue in living organ donation compared with those from North America (78.9% vs. 52.5%, p= .005), with common ethical concerns being psychosocial evaluation and follow-up care of donors. The focus group highlighted the importance of a multidisciplinary approach to ethical issues. The results of this study can direct future research into pediatric transplantation ethics with the aim of producing educational resources, policies, and ethical guidelines.

The philosopher as partner: an introduction to the scholarship of Robert M. Veatch.

A diverse group of scholars reflect on the scholarship of Robert M. Veatch, the breadth of which is unmatched in modern day bioethics. Essays were written by both philosophers and clinician-philosophers, by contemporaries and mentees. They span the breadth of Bob’s work and include analyses of his ideas about death, dying and organ transplantation, human experimentation and research ethics, disability, equality and justice, the doctor-patient relationship, the history of bioethics, as well as his pedagogical approach to teaching bioethics to clinicians across the health care spectrum. Recognition of Bob’s influence in the modern field of bioethics and the challenges that persist are clearly identified.

Execution by organ procurement: Breaching the dead donor rule in China

The dead donor rule is fundamental to transplant ethics. The rule states that organ procurement must not commence until the donor is both dead and formally pronounced so, and by the same token, that procurement of organs must not cause the death of the donor. In a separate area of medical practice, there has been intense controversy around the participation of physicians in the execution of capital prisoners. These two apparently disparate topics converge in a unique case: the intimate involvement of transplant surgeons in China in the execution of prisoners via the procurement of organs. We use computational text analysis to conduct a forensic review of 2838 papers drawn from a dataset of 124 770 Chinese‐language transplant publications. Our algorithm searched for evidence of problematic declarations of brain death during organ procurement. We find evidence in 71 of these reports, spread nationwide, that brain death could not have properly been declared. In these cases, the removal of the heart during organ procurement must have been the proximate cause of the donor's death. Because these organ donors could only have been prisoners, our findings strongly suggest that physicians in the People's Republic of China have participated in executions by organ removal.

Robert Veatch’s transplantation ethics: obtaining and allocating organs from deceased persons

This essay appreciatively and critically engages the late Robert Veatch's extensive and important contributions to transplantation ethics, in the context of his overall ethical theory and his methods for resolving conflicts among ethical principles. It focuses mainly on ways to obtain and allocate organs from deceased persons, with particular attention to express donation, mandated choice, and presumed consent/routine salvaging in organ procurement and to conflicts between medical utility and egalitarian justice in organ allocation. It concludes by examining the unclear relations between Veatch's ideal moral theory and his nonideal moral theory, especially in organ allocation.

On the ethics of NRP and the American College of Physicians NRP statement

To the Editor: We commend Parent et al.1Parent B Caplan A Moazami N Montgomery RA. Response to American College of Physician’s statement on the ethics of transplant after normothermic regional perfusion.Am J Transplant. 2022; (10.1111/ajt.16947): 1-4Google Scholar for engaging ethical issues regarding “normothermic regional perfusion” (NRP) heart procurement. They critique a 2021 statement by ACP,2American College of Physicians. Ethics, determination of death, and organ transplantation in normothermic regional perfusion (NRP) with controlled donation after circulatory determination of death (cDCD): American College of Physicians Statement of Concern. https://www.acponline.org/acp_policy/policie/ethics_determination_of_death_and_organ_transplantation_in_nrp_2021.pdf. Published 2021. Accessed February 7, 2022.Google Scholar whose ethics committee we lead and staff. ACP calls for a pause of NRP because the manner and declaration of death involved raise ethical and legal concerns. Parent’s article does not lessen those concerns. NRP restarts donor circulation using the donor’s own blood following declaration of irreversible circulatory death. But this restart invalidates the declaration, reversing what was declared irreversible. And because brain death has not occurred, NRP includes active steps (ligation or balloon occlusion) to prevent circulation to the brain. Asserting repeatedly that the donor is dead by circulatory criteria1Parent B Caplan A Moazami N Montgomery RA. Response to American College of Physician’s statement on the ethics of transplant after normothermic regional perfusion.Am J Transplant. 2022; (10.1111/ajt.16947): 1-4Google Scholar,3Wall AE, Fiedler A, Karp S, Shah A, Testa G. Applying the ethical framework for donation after circulatory death to thoracic normothermic regional perfusion procedures. Am J Transplant. 2022. 10.1111/ajt.16959Google Scholar does not refute this. Rather than follow the legal definition of death, the authors redefine it. They claim circulatory death has occurred because “circulation has stopped on its own and there will be no attempt to restart it.” Yet donor circulation is restarted in NRP. This is resuscitation of the donor, not reperfusion of an organ; if not resuscitation, ligating blood vessels would not be part of the protocol. Notably, the NYU NRP protocol details what occurs, calling the procedure heart DCD to which the standard DCD approach applies; explaining the addition of NRP; noting all blood vessels to the donor’s brain will be ligated “to ensure that blood flow to the brain is not reestablished once circulation… to all organs of the body” is reestablished; and stating “standard DBD procurement will commence.”4US National Library of Medicine. https://clinicaltrials.gov/ct2/show/NCT04284319. Accessed February 7, 2022.Google Scholar That switch from DCD to DBD acknowledges (induced) brain death. Yet the donor was declared dead by circulatory criteria. ACP supports DCD. But NRP is different. “Organ retrieval after cardiopulmonary arrest and the induction of brain death”2American College of Physicians. Ethics, determination of death, and organ transplantation in normothermic regional perfusion (NRP) with controlled donation after circulatory determination of death (cDCD): American College of Physicians Statement of Concern. https://www.acponline.org/acp_policy/policie/ethics_determination_of_death_and_organ_transplantation_in_nrp_2021.pdf. Published 2021. Accessed February 7, 2022.Google Scholar is a more transparent description. Moreover, Parent’s assertions the protocol need not be explained because donors/families have a “right not to know the specific information that would be too clinical or burdensome” and that information need only be given in response to questions,1Parent B Caplan A Moazami N Montgomery RA. Response to American College of Physician’s statement on the ethics of transplant after normothermic regional perfusion.Am J Transplant. 2022; (10.1111/ajt.16947): 1-4Google Scholar undermines informed consent. Arguments that cost-savings justify NRP1Parent B Caplan A Moazami N Montgomery RA. Response to American College of Physician’s statement on the ethics of transplant after normothermic regional perfusion.Am J Transplant. 2022; (10.1111/ajt.16947): 1-4Google Scholar are also ethically problematic. Regarding procedural issues, Parent notes that ACP’s brief statement, published on our website (not in a journal), did not include authorship or COI disclosures. While that is the practice of ACP, AMA, and others, a good point is made; we will review our procedures. ACP disclosure of interests and conflicts policy was followed throughout our process with no relevant disclosures made including about NRP or organ transplantation. Having raised this topic—we note the Parent article says, “BP received a gift from United Therapeutics to provide salary support.” However, NYU’s website more broadly says the “Transplant Ethics and Policy research program is funded by a gift from United Therapeutics” and claims independence,5NYU Transplant Ethics & Policy. https://med.nyu.edu/departments-institutes/population-health/divisions-sections-centers/medical-ethics/research/transplant-ethics-policy. Accessed February 7, 2022.Google Scholar yet transplant physicians are advisory board members and/or ethics statement co-authors. Questions about the ethics program’s objectivity seem to be raised. Together, we must support organ transplantation, expanding access—but without violating ethics, physician responsibilities to patients and society, and US law, and while increasing public understanding of donation and maintaining trust in the health care system. The authors of this manuscript have conflicts of interest to disclose as described by the American Journal of Transplantation. The authors are chair (IOO), co-chair (NND) and staff (LSS) to the Ethics, Professionalism and Human Rights Committee of the American College of Physicians.

Clamping cerebral circulation—breach of the dead donor rule?

To the Editor, As a former medical director of lung transplantation and ICU physician for 30 years, I know, firsthand, the importance of maximizing organ donation for dying patients. This must always be done with utmost respect for the life of the donor. I believe some of the arguments and assertions made by Parent et al.1Parent B Caplan A Moazami N Montgomery RA. Response to American College of Physician’s statement on the ethics of transplant after normothermic regional perfusion.Am J Transplant. 2022; (10.1111/ajt.16947): 1-4Google Scholar on normothermic regional perfusion (NRP) are worthy of scrutiny and deeper conversation. The authors challenge the “statement of concern” regarding NRP published in 2021 by the American College of Physicians (ACP).2American College of Physicians Ethics, determination of death, and organ transplantation in normothermic regional perfusion (NRP) with controlled donation after circulatory determination of death (cDCD): American College of Physicians Statement of Concern. https://www.acponline.org/acp_policy/policies/ethics_determination_of_death_and_organ_transplantation_in_nrp_2021.pdf. Published 2021. Accessed February 12, 2022.Google Scholar The authors explain that the practice of controlled Donation after Circulatory Determination of Death using NRP (cDCD NRP) is well established in many countries. Yet the ethical boundaries of this practice must be considered in the context of each country’s legal definition of death and the dead donor rule. Confusion, in my opinion, revolves around the ambiguity of the use of the terms circulation and resuscitation. Generally, when we use extracorporeal membrane oxygenation (ECMO) to supply the human body with systemic circulation, it is for the purpose of resuscitation and sustaining life. In the circumstances of use of ECMO for NRP, are these two practices suddenly completely distinct? The crux of the authors’ argument is that the person has been declared dead, and, therefore, the re-establishment of systemic circulation is only to preserve the organs and save them from warm ischemic injury. Yet part of the procedure is to add the unique intervention of occlusion of cerebral circulation to prevent the possibility of neuronal activity in the brain, which would obviously create (as the authors write) “questions around the circulatory determination of death.” Precisely. The dead donor rule (DDR) states that a patient cannot be killed by, or for, organ procurement. To justify this added procedure of clamping circulation to the brain itself, the authors feel compelled to explain: “The brain remains a ‘black box’ and the degree or extent of neuronal death cannot be ascertained.” The clamping of circulation is obviously to ensure brain death, yet the authors repeatedly state the DDR is not violated because the patient has been declared dead. Because brain death is, by definition, the cessation of all brain activity, is not this “circulatory” logic? A tautology? Is the re-establishment of circulation a violation of the donor’s DNR order? Indeed, one could argue that with systemic circulation re-established and a question of ongoing neuronal activity (as posed by the authors), the donor could at that point even be sent back to the ICU to determine brain activity over the next 24 to 48 h, as is common practice when we are attempting to establish brain death. Do the authors believe that a procedure to clamp cerebral circulation to cut-off flow to a human brain is worthy of a great deal more consideration before we “update the legal definition of death?” The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

Regarding normothermic regional perfusion: Arguing by insistence is not a strong argument

Regarding normothermic regional perfusion: Arguing by insistence is not a strong argument

Heads, Bodies, Brains, and Selves: Personal Identity and the Ethics of Whole-Body Transplantation.

Plans to attempt what has been called a head transplant, a body transplant, and a head-to-body transplant in human beings raise numerous ethical, social, and legal questions, including the circumstances, if any, under which it would be ethically permissible to attempt whole-body transplantation (WBT) in human beings, the possible effect of WBT on family relationships, and how families should shape WBT decisions. Our assessment of many of these questions depends partially on how we respond to sometimes centuries-old philosophical thought experiments about personal identity. As with so much in bioethics, it is impossible to escape, or at least inadvisable to try to bypass, the relevant foundational philosophical concerns.