Keep nondirected donation anonymous, experts say
Efforts to increase supply raises questions
Ethics committees may have an additional concern when confronted with the shortage of organ donors if two recently released studies prove to be accurate.
"We must avoid a slippery slope on which the benefits to the transplant recipients and to the institutions that care for them come to outweigh the risks to the donors," warns Norman G. Levinsky, MD, in an editorial in the Aug. 10 issue of the New England Journal of Medicine (NEJM). Levinsky is a kidney transplant surgeon at the Boston University Medical Center.
Elderly donors considered
The studies center on efforts to increase the levels of organ donors in order to meet the demand for organ transplants. Suggested methods include using donor organs from older people and offering donors or their families some payment for expenses.
Perhaps the most controversial suggestion, however, is allowing kidney donors to be a living donor for someone in need. Usually, kidneys are donated to a friend or relative rather than to strangers. The process, called nondirected donation, is gaining momentum as more donors show interest.
"Potential donors have been calling transplant centers for years," says Arthur J. Matas, MD, a transplant surgeon at the University of Minnesota in Minneapolis and author of a report in the same issue of NEJM.1 The University of Minnesota put a nondirected donation policy into place at its transplant center to meet growing demand, notes Matas. As of March 31, 98 people had called the facility about becoming an organ donor.
Because people can live healthy lives with just one kidney, family members, friends, and spouses often donate a kidney to a loved one or friend when a donor kidney cannot be found. The University of Minnesota has performed a few nondirected transplants in the year of the study, funded by the National Institutes of Health, but several policies were put into place to minimize the ethical dilemmas and "set a bar for other institutions," notes Jeffrey P. Kahn, PhD, a researcher in the study and director of the Center for Bioethics and the University of Minnesota.
For example, donors and recipients remain anonymous following the transplant to ensure that donors are truly altruistic in their donation, Kahn adds.
Put safeguards in place
Levinsky suggests that safeguards need to be in place for organ donors and their families to avoid exploitation. Additionally, Levinsky fears that transplant centers could compete financially for donors.
Matas notes that fears such as Levinsky’s are taken into consideration. One physician performs the surgery on the donor while another transplants the organ into the recipient, he notes. If the donor’s physician decides that there is a medical reason the donor should not proceed, the decision cannot be overruled by another physician. Each transplant takes another person off the waiting list and frees an organ for someone in need, he adds.
All donors undergo physical and psychological evaluations to verify that they are aware of the risks. Donors are prohibited from designating the age, gender, religion, or race of the recipient. In addition, donors, recipients, and families are kept in separate areas of the hospital throughout the process.
It’s still unclear whether donors will continue to come forward for nondirected donation, but several other transplant centers are looking at the University of Minnesota’s program, notes Matas. He predicts that nondirected transplants will never make up more than a small percentage of organ transplants.
Older donors just as good
In a related article in the same issue of NEJM, researchers in Bergamo, Italy propose another method for closing the supply-demand organ gap.2 Researchers Bruno Gridelli, MD, and Giuseppe Remuzzi, MD, of the Mario Negri Institute suggest taking livers from patients in later life — people in their 50s and 60s — as a way to address the shortage.
"Kidneys from elderly donors, which are currently not accepted for single-kidney transplantation, function well when transplanted together," write Gridelli and Remuzzi.
Furthermore, it’s now possible to split a donated liver in two and transplant it into two people, notes Remuzzi. The technique has been used in Bergamo, and was first used on children, he notes, but can be successful in adults.
References
1. Matas A, Garvey C, Jacobs C, et al. Nondirected donation of kidneys from living donors. N Eng J Med 2000; 343:433-436.
2. Gridelli B, Remuzzi G, Current concepts: Strategies for making more organs available for transplantation. N Eng J Med 2000; 343:404-410.
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