Ethical issues in liver transplantation
- Lisa Anderson-Shaw, DrPH, MA, MSN
Lisa Anderson-Shaw, DrPH, MA, MSN
- Assistant Clinical Professor
- University of Illinois at Chicago
- Scott J Cotler, MD
Scott J Cotler, MD
- Professor of Medicine
- Director, Division of Hepatology
- Loyola University Medical Center
- Section Editor
- Robert S Brown, Jr, MD, MPH
Robert S Brown, Jr, MD, MPH
- Section Editor — Liver Transplantation
- Vice Chair, Transitions of Care, Department of Medicine
- Interim Chief, Division of Gastroenterology and Hepatology
- Weill Cornell Medical College
- Professor of Clinical Medicine, Columbia University College of Physicians & Surgeons
Liver transplantation has evolved rapidly from an experimental procedure to standard therapy for patients with end-stage liver disease. One- and five-year patient survival for deceased donor liver transplants has reached 86 and 72 percent, respectively, and for living donor liver transplants, 90 and 78 percent, respectively, due to advances in surgical techniques, immunosuppression, and organ preservation . While the number of liver transplants performed in the United States has reached approximately 6000 per year, the demand for donor organs far exceeds the supply. As a result, there are more than 1800 deaths per year on the liver transplant waiting list . The relative shortage of donor organs provides the basis for many of the ethical issues associated with liver transplantation.
The current system of organ donation in the United States is based on the Uniform Anatomical Gift Act of 1968 and is referred to as "opting in" or "expressed volunteerism" . This statute authorizes competent adults to specify their preferences regarding organ donation. Procurement agencies generally exceed the provisions of the statute and ask for consent from the next of kin even when there is a signed donor card or online organ donation registration, to be sure that the family is in support of donation. More frequently, there is no signed donor card or other evidence of an advanced directive about organ donation. In this circumstance, the family is asked to make a judgment about the wishes of the deceased. Donation is carried out in the absence of a donor card if the next of kin is in agreement. However, asking a grieving family member to make a difficult decision in a time of crises poses a significant barrier to donation. Further efforts are underway to enhance the process of obtaining advanced directives about organ donation.
A number of states adopted a revised Uniform Anatomical Gift Act (1987) stipulating that next of kin need not consent to organ donations if the deceased made his or her wishes known in writing to a clinician prior to death. The position of the Council on Ethical and Judicial Affairs of the American Medical Association (AMA) is consistent with this legislation. The Council stated: "it is ethically preferable for the individual, rather than the family, to decide to donate organs" . A further iteration of the Uniform Anatomical Gift Act proposed in 2006 contained a provision prioritizing organ donation over other end-of-life care in an effort to increase organ availability. The Act raised ethical concerns that organ donation should not trump other end-of-life management decisions such as refusal of cardiopulmonary resuscitation and intubation . A revised version was proposed subsequently that provides for resolution of any conflict between end-of-life care and organ donation.
Efforts to increase donor organ availability — The organ donation process is relatively inefficient for a number of reasons. Organs are lost when clinicians fail to recognize criteria for brain death. Educational programs for health care providers could be helpful in clarifying the laws regarding the declaration of brain death. Requests for donation often have been handled by inexperienced personnel, a factor associated with a reduced consent rate. Regulations from the Centers for Medicare and Medicaid Services (CMS) require hospitals to report pending deaths and deaths to their local organ procurement organization. Now, only persons approved by the organ procurement organization are authorized to request organ donation from the next of kin. Finally, families decline to consent to donation for reasons including lack of awareness about donation and difficulty in making a rapid decision at a time of emotional turmoil.
Other systems for organ donation have been proposed:
Mandated choice — "Mandated choice" is an alternative system that would require competent adults to record their preference for organ donation. According to this approach, all persons would be asked to complete a standard document, perhaps at the time of applying for a driver's license or filing a tax return. Decisions would not be subject to reversal by family members. Advantages of mandated choice include removing the burden on family members to make decisions about organ donation, while respecting individual autonomy, and ameliorating fears that organs might be harvested from non-consenting individuals.
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- ORGAN DONATION
- Efforts to increase donor organ availability
- Other systems for organ donation have been proposed:
- - Mandated choice
- - Presumed consent
- Controlled donation after cardiac/circulatory death
- - Uncontrolled donation after cardiac/circulatory death
- - Economic incentive
- - Living donor liver transplantation
- Altruistic/stranger donors and the use of social media
- - Prisoners
- TRANSPLANTATION FOR SPECIFIC POPULATIONS
- Alcohol-related liver disease
- Convicted criminals
- Suicidal overdoses/attempts
- Transplantation in HIV-infected patients