Organ donation systems and ethical considerations

Medicine

Organ Donation

Organ donation consists of the removal of organs and tissues from one human body for the purpose of transplanting them into another. Organ and tissue donors can be people of any age. Organ donations tend to be higher from deceased donors than from living ones. The laws surrounding organ donations are different from country to country. Some allow possible donors to give permission for or refuse donation while others give the choice to relatives. The need for organ donations is ever growing but the amounts that are being donated are not. There have been numerous studies done into why it is that people don't donate and several factors have been identified. This paper will explore these reasons along with the ethical issues that surround the idea of organ donation. Future trends will also be looked at that are attempting to increase the amount of transplantable organs that are available.

The crucial steps to increase the low rates of organ donors in many Western countries include ensuring that potential donors are identified and that authority is sought and obtained from family members of the potential donor before organ procurement can occur. Many studies have identified family consent as the critical connection in making sure that the organ supply meets the increasing demand for transplantable organs. Approximately half of the families approached for organ donation deny consent, a pattern which is constant in the UK (41%), USA (54%), and Australia (50%). One feature thought to play a central role in improving the likelihood of obtaining consent is family members' prior knowledge of their loved one's intentions to donate their organs upon death. Family members who are aware of an individual's positive attitude to donation and have previously discussed donation are more likely to fulfill the wishes of their family member by giving consent (Hyde and White, 2009).

There are many ways to express donation intentions including signing a donor card, registering on a donor register, or stating the preference on a driver's license. It is becoming increasingly clear that, regardless of the method by which an individual records their intentions, they also need to communicate their wishes to their family members or next-of-kin. This is a behavior that many individuals do not do. Previous research has identified the attitudes and beliefs impacting upon willingness to donate organs in general. Very few studies have investigated the reasons why individuals fail to communicate their donation decision. Reasons for not recording donation wishes identified in previous studies include a perceived family objection or lack of support for donation, distrust of the medical system, avoidance of bodily mutilation and premature death, having to defend one's decision to family, and lack of knowledge or being unsure about the donation process. Negative beliefs about discussing donation wishes include the perceived reluctance or objection of family members to talk, a lack of knowledge about organ donation, having to defend the donation decision to family, difficulty- starting the conversation, and talking about the death of one's self among others (Hyde and White, 2009).

Public education promotions are a very common strategy that is used to try and increase awareness about the need for more transplantable organs. Organ procurement associations, independently or in cooperation with private and public organizations and businesses, have put into practice innovative strategies to notify the public about organ donation and to encourage individuals to register as donors. An assortment of public education venues have been executed and evaluated, including motor vehicle offices, driver's education classes, community events, worksites, hospitals, and media. Moreover, some education campaigns have targeted specific audiences known to have less favorable attitudes toward organ donation, like minorities (Rodrigue, Cornell and Howard, 2009).

Regardless of the public education strategies used, organ donation outreach in mainstream media markets is less likely to reach minorities and persons with less formal education. Minorities are more likely to report mistrust of the health care system and misunderstanding about organ donation, so it is imperative that organ donation outreach efforts address these barriers in particular. Additionally, members of minority groups may be underexposed to positive messages about organ donation and may not know how to document their organ donation intentions. For instance, it has been found that more than half of the Hispanic-Americans report that they do not know how to sign up as an organ donor and more than one-third of them claim that they would sign a donor card if asked. Also, the print media contains very little coverage of minority-specific organ donation and transplantation issues. As demonstrated by several researchers to date, enhancing awareness of the need for organ donation in minorities requires more targeted public education campaigns that are culturally sensitive, use ambassadors that are known within the community, and use culturally similar community outreach educators. In light of the unbalanced representation of minorities on transplant waiting lists in the United States and the less favorable attitudes among minorities toward organ donation, effective strategies for disseminating culturally appropriate organ donation education must be urgently identified and evaluated (Rodrigue, Cornell and Howard, 2009).

Transplantation is often limited by the shortage of available organs along with many factors that contribute to this shortage. In Spain the main reason for loss of potential donors is rejection of their family members to donate. Family refusal leads to the loss of 1 out of every 4 or 5 probable donors. In addition to psychosocial factors in the population, one of the barriers that appear to prevent the procurement of more transplant organs is that a considerable number of hospital professionals may be opposed to organ donation. Typically, organ donation and transplantation activities have surrounded physicians, but it is now known that physicians have the most favorable attitudes toward organ donation of all hospital personnel. As a result it is thought that efforts should focus on other subgroups of hospital personnel. In this respect, nurses are fundamental in the organ donation and transplantation process. In addition, nurses often have more direct contact with patients and for longer periods of time than physicians do. This means that they have the opportunity to have a very important influence on patients. Consequently nurses' attitudes toward organ donation are thought to affect patients and their families as well as the general public in an important way that is reinforced by nurses' position as health care professionals. In this situation, it is a matter of great concern that various studies have shown that organ donation and transplantation generate stress among nurses and that nurse's lack information on the topic, although some researchers have reported that nurses have a very favorable attitudes (Zambudio, Martinez-Alarcon, Parrilla and Ramirez, 2009).

Only a few years after the first successes with kidney transplants from deceased donors, various authors began to study the psychosocial factors that influence donation. Initially the focus was on the general public, but later more emphasis was placed on studies of other health care workers, given that part of the problem with organ procurement is found within the hospitals themselves. Nurses are a fundamental subgroup of health care workers who look after patients and promote health in the population. In this respect, their attitudes toward health matters are fundamental, so if they are against donation, they generate a negative attitude toward donation among persons who might be exposed to such an attitude or they at least generate distrust about the matter. Information offered by health care personnel has a considerable influence on the general public. Moreover, the generation of a negative attitude in the general public from comments made by health care professionals is very difficult to reverse, given that the source of information holds a lot of credibility (Zambudio, Martinez-Alarcon, Parrilla and Ramirez, 2009).

Among the factors that influence attitudes on this topic, knowledge of the concept of brain death is very important. This classic factor has been described in the general population, but it is surprising to find it among nursing personnel. Nurses work in health care centers and have extensive training, so it is assumed that they understand the concept of brain death. Yet 34% of respondents did not understand this concept. This finding is similar with the main reason given for not donating organs: fear of apparent death. If a closer look is taken, the health care profession will be able to see that although they undertake campaigns in the general public, in schools, and so on, they have not ensured that their own personnel are well informed and fully understand what is being done. Therefore, it is important to provide information about brain death to health care professionals. In this respect, some experts have already highlighted that the establishment of a protocol about the diagnosis of brain death increases confidence in the process and reduces uncertainty (Zambudio, Martinez-Alarcon, Parrilla and Ramirez, 2009).

Fear of manipulation of the body is another factor that makes donation difficult. Thus, nurses have a more negative attitude toward donation when they are not prepared to have an autopsy carried out on themselves upon death if it were necessary. Some authors show that, contrary to the belief that health care professionals are less sensitive than the general public toward the manipulation of the body, they in fact have great difficulty in allowing action to be taken on the deceased donor, even actions as well accepted as transplantation. Various authors have reported that, as in the general public, knowing transplant patients has a parallel in the hospital setting, and therefore it would be useful to highlight the successful organ transplants within the hospital and to make sure that all the professionals know the success rates. Among nurses, this does not seem to be a fundamental factor, because although it is necessary to know transplant patients, it is also necessary to understand the transplant process well in order to avoid unfounded fears. Another significant factor is religion. The Catholic Church clearly accepts organ donation and transplantation, and Catholics are slowly becoming aware of this situation. Thus, it can be seen why Catholics tend to have a more favorable attitude toward donation, being nearly 3 times more in favor than are non-Catholics (Zambudio, Martinez-Alarcon, Parrilla and Ramirez, 2009).

Another basic factor is the opinion of a respondent's partner toward the idea of donation. A respondent's favorable attitude is related to a partner's favorable attitude and vice versa, being against is related to a partner's negative opinion. Results of a recent study indicated that if the partner is against donation and the respondent knows the partner's opinion, the respondent is nearly 10 times less likely to be in favor than a respondent who does not have a partner. It has been seen that family discussion about donation is a favorable factor. Health care professionals who have discussed the topic of donation within their own family have been shown to have a more favorable attitude towards it. Therefore, as in the population, it seems to be beneficial to encourage dialogue about transplantation and donation within family circles (Zambudio, Martinez-Alarcon, Parrilla and Ramirez, 2009).

The organ donation and transplantation society in the United States continues to undergo striking and sustainable change in order to obtain better performance and quality. Organ transplantation remains the only life-saving therapy available for many patients who suffer from organ failure. Despite the work of the Organ Donation and Transplant Collaborative's, and the marked increases in deceased donors early in the effort, deceased donors only rose by a total of 67 from 2006 to 2007 and the number of living donors declined during this same time period. The trend has been an increase in the use of organs from donors after cardiac death (DCD) and expanded criteria donors (ECD). There is a continuation of the Health and Human Services/Health Resources and Services Administration (HHS/HRSA) sponsored collaborative efforts currently focusing on transplant centers, and their relationships with Organ Procurement Organizations (OPOs), in order to facilitate growth and efficiency via the Transplant Growth and Management Collaborative (TGMC). With the deployment of DonorNet C. there has been a major change in the way that organs are offered and an increase in patient safety measures. Unfortunately, the goals of 75% conversion rates, 3.75 organs transplanted per donor, 10% of all donors from DCD sources and 20% growth of transplant center volume have yet to be reached across all donation service areas (DSAs) and transplant centers; however, there are DSAs that have not only met, but exceeded, these goals. There are transplant centers that have griped the changes that are necessary to increase their volume of cases, but not at the price of quality. Additionally, changes in organ preservation techniques took place this year, partly in response to expanding organ acceptance criteria and increasing numbers of ECDs and DCDs (Tuttle-Newhall, Krishnan, Levy, McBride, Orlowski and Sung, 2009).

The national transplant setting has changed in reaction to the increased regulatory oversight and new requirements for donation and transplant provider associations. Centers for Medicare & Medicaid Services (CMS) regulations for OPOs were put out in 2006 and for transplant programs in 2007. These, in addition to voluntary Joint Commission (TJC) standards and requests by payers for data, have left some programs beset by the costs of building and maintaining a necessary infrastructure of personnel for the perceived divergent and redundant requirements for documentation and data submission by separate governing and regulatory bodies (Tuttle-Newhall, Krishnan, Levy, McBride, Orlowski and Sung, 2009).

Despite donor designation legislation inmost states, which permits organ procurement organizations (OPO) to recover organs when the deceased's donation intentions have been documented, family members continue to play a prominent role in the donation decision-making process. Several studies in recent years have highlighted many factors that influence donation decisions by next-of-kin. OPO practices and the Organ Donation Breakthrough Collaborative have, in part, used findings from these studies to develop new strategies or to modify existing ones to optimize organ donation consents and organs recovered per donor. In addition to these key objectives, OPOs strive to facilitate a good decision which is one that is characterized by providing families with sufficient organ donation information to make an informed choice, the family feeling comfortable with their decision and OPO and medical staff supporting the family's donation decision, whether donation consent is obtained or not. There is recognition within the OPO community that family members may confront a similar situation in the future and a negative experience now might lead to donation resistance in the future. However, despite the best efforts of OPOs, family members often must consider a donation request in a relatively short time period, and factors such as the deceased's donation intentions, existing organ donation attitudes, family disagreement, requestor characteristics and other contextual variables are related to the donation decision (Rodrigue, Cornell and Howard, 2008).

Although the demand for organ transplants continues to grow, the number of transplantable organs from the cadaveric donor pool remains relatively static. Living organ donation, that is removal and transplantation of organs, or segments thereof, which a donor can live without, has been proposed as an effective alternative source of transplantable organs. In fact, transplants performed from living donors have advantages including increased viability of donor organs, improved survival and reduced waiting times. Nonetheless, ethical dilemmas arise relating to postoperative donor morbidity and mortality. In Europe, a significant increase in living donations has occurred in recent years. Living donation represents 17% of kidney donation activity and 5% of liver transplantation. In Ireland in 2005 -- 2006, just three of 129 kidney transplants were living donor transplants. In 2006, however, the Irish government deemed development of a Living Transplant Program a service priority. Such development is set against the backdrop of a recent European Commission Communication which proposes expansion of living donation to increase organ availability. Establishment of this national program poses ethical, legal, social and psychological questions. An Irish Council for Bioethics poll in 2005 revealed that although 81% of respondents slightly or strongly agreed that living related donation should be promoted in Ireland, about half also agreed that its promotion could put undue pressure on one sibling to donate to another (Browne and Desmond, 2008).