Linda Wright

Disclosure of misattributed paternity: issues involved in the discovery of unsought information.

Kidney transplantation from living donors is generally a safe, effective form of renal replacement therapy. When evaluating potential living donors and their intended recipients, a careful assessment process is followed in order to ensure that ethical standards are upheld. During this assessment, important medical information with serious consequences, which was not being sought as part of the donor/recipient evaluation, may be discovered. The information may or may not be relevant to the decision to donate. However, such a discovery raises the difficult questions of whether or not there is an obligation to disclose the information, to whom does the information belong, and what process should be used to resolve the issue? We present a case that forced us to confront these questions and raised issues of truth telling, autonomy, paternalism, confidentiality, and the nature of the relationship between patients and health care professionals.

KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

Abstract The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a “proof-in-concept” risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidates profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided. In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1–S109.

Evaluation of a mentorship program for Heart Transplant patients

The Heart Transplant Mentor Programme (HTMP) was initiated to augment patient care by providing patients and families with information and support from a peer perspective. We assessed program effectiveness with a pilot study of semi-structured interviews of 63% (10/16) of the mentored patients and an open-ended inquiry that rated the program on a 5-point scale (1, poor, to 5, excellent) and that selected descriptors of the program. Qualitative and quantitative analyses indicated that participants found the information and support provided by their mentors positive (3.8 and 4.0, respectively), discussion focused on medical rather than psychosocial topics, pre-transplant dissatisfaction with the program was caused by late or little mentor contact, and post-transplant dissatisfaction was attributed to difference in clinical course between mentor and patient. Although findings indicate that HTMP augments patient care, recommendations to increase patient satisfaction include earlier introduction of a mentor and individualizing mentors according to demographics and clinical course.

Organ donation and priority points in Israel: an ethical analysis.

Israel’s rates of organ donation have been one of the lowest among developed countries. An attempt to change this has led to the introduction of a pioneering new law, the Organ Transplant Act 2008, which came into effect in January 2010 and sets out principles underlying a new policy in relation to the allocation of organs for transplantation. According to this policy, a person can gain priority points by signing a donor card, making a nondirected organ donation during their lifetime, or as a result of a first-degree relative signing a donor card, or consenting to procurement of organs after death. In this opinion piece, we argue that although this approach merits attention for its innovative aspects and its potential benefits, it raises some ethical difficulties. In particular, we discuss some problems of justice and fairness inherent in the system, focusing on inequalities because of the (a) number of relatives one might have, (b) the type of living donation one makes, (c) the potential for strategic behavior, and (d) problems regarding the consent of family members.

Living Anonymous Liver Donation: Case Report and Ethical Justification

Most living organ donations are from genetically or emotionally related donors. Although some transplant centers are willing to accept donations from living anonymous kidney donors (LAKDs), very few centers will accept donations from living anonymous liver donors (LALDs). The difference in acceptance rates is primarily due to the greater risk in liver donation, which is estimated to be 10‐fold that of the risk in kidney donation. We present a case of donation from a LALD, the first reported in Canada. There are currently no established standards for LALDs. Our criteria for the ethical acceptability of LALDs require such donors to be physically healthy, mentally competent, altruistic, highly motivated, well‐informed and able to give voluntary consent to donation. Another major ethical criterion is that the likely psychological benefit to the LALD balances the physical risks. Our case demonstrates that transplants from LALDs are medically successful and ethically justified under certain conditions.

Should the liver transplant criteria for hepatocellular carcinoma be different for deceased donation and living donation

SUMMARY AND RECOMMENDATIONS Should the liver transplant criteria for HCC be differ-ent for DDLT and LDLT? We have found that there areno high-quality data justifying or refuting the use ofdifferent criteria.According to locoregional circumstances and theavailability of livers from deceased donors, it maysometimes be reasonable to use different acceptancecriteria for DDLT and LDLT. For instance, in theUnited States, a patient with a single unresectableHCC tumor 5.0 cm in diameter or a tumor ortumors within the UCSF criteria would not meet thecriteria for MELD exception points in most UNOSregions and, therefore, would not have access toDDLT; in this setting, LDLT may offer the only chanceof a cure and provide excellent outcomes. 6,21 In manyregions, deceased donation rates are poor or zero. Inthese areas, along with the philosophy of the livingdonor liver as a private gift, the option of LDLT shouldbe considered in the context of paternalism andrespect for the autonomy of the living donor, but thisis a difficult balance to achieve.

Incentives for organ donation: Israel's novel approach

In view of the global shortage of transplantable organs, does an individual’s willingness to accept an organ transplant create a responsibility to agree to organ donation? In The Lancet today, Jacob Lavee and colleagues describe an Israeli initiative which aims to increase rates of organ donation, which are presently low, and address the challenge of free riders (ie, people who are willing to take but not to give) by bestowing privileges on individuals who are willing to donate in preference to those who are not. Specifi cally, individuals who sign donor cards are prioritised, as are their fi rst-degree relatives, to receive an organ in preference to individuals of equal medical need who have not signed a donor card. Safeguards are included to ensure that acutely ill patients will be fi rst to receive organs irrespective of allocation points accumulated. The Israeli initiative also gives privileges to living nondirected organ donors in preference to living directed donors—a step not previously seen elsewhere. This system is referred to as reciprocal altruism, although incentive system might be more apt, because altruism does not imply a notion of quid pro quo. The use of incentives to increase donation rates has been hotly debated, including a claim that incentives are a moral imperative to prevent more deaths on the waiting list. Irrespective of ethical challenges to the use of incentives, Israel is to be commended for taking concrete steps to increase organ donation. The Israeli incentive system raises several questions: fi rst and foremost, will this make a diff erence? Signing a donor card does not guarantee organ donation because doing so forms no contractual obligation; hence, taking organs still ultimately depends on a family’s consent. Lavee and colleagues argue that because the families of holders of donor cards “have consistently given their consent for organ donation”, more holders of donor cards will mean more actual donors. Surely, current card holders are most probably people who are already committed to organ donation, a commitment that might not be shared by others. The extent to which the new law will make donor cards enforceable upon the family of the deceased is as yet unclear. Will the incentive to donate be enough to encourage families to agree to donation if they have more pressing moral and cultural reasons not to donate? without HIV infection are at similar risk for malaria and bacterial diseases?

How Young Is Too Young to Be a Living Donor

Assessing people in adolescence and early adulthood who wish to become living organ donors (LDs) provides unique challenges. In several Canadian provinces, 16‐year‐old can legally consent to living organ donation. While the World Health Organization states that adolescence corresponds roughly to the ages of 10–19 years, parts of the brain associated with judgment continue to develop into the mid‐20s. Therefore, it is legally possible for some young people to donate organs before their capacity to judge the benefits and risks of surgery has fully matured. Potential young living donors (YLDs) may be financially and/or psychologically dependent on their recipients (e.g. parents), which can make it difficult to determine if the YLDs donation is voluntary. This paper suggests ways to manage three ethical challenges in the use of young people as LDs: (1) determining the YLDs ability to appreciate the consequences of living organ donation, (2) determining whether the YLDs donation is voluntary and (3) evaluating the unique risks and benefits to the YLD. We conclude that there are compelling ethical reasons to offer the opportunity of living donation to selected young people. A thorough and fair evaluation process can address social, emotional and developmental issues associated with YLDs.

Attitudes to sharing personal health information in living kidney donation.

BACKGROUND AND OBJECTIVESnIn living kidney donation, transplant professionals consider the rights of a living kidney donor and recipient to keep their personal health information confidential and the need to disclose this information to the other for informed consent. In incompatible kidney exchange, personal health information from multiple living donors and recipients may affect decision making and outcomes.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnWe conducted a survey to understand and compare the preferences of potential donors (n = 43), potential recipients (n = 73), and health professionals (n = 41) toward sharing personal health information (in total 157 individuals).nnnRESULTSnWhen considering traditional live-donor transplantation, donors and recipients generally agreed that a recipients health information should be shared with the donor (86 and 80%, respectively) and that a donors information should be shared with the recipient (97 and 89%, respectively). When considering incompatible kidney exchange, donors and recipients generally agreed that a recipients information should be shared with all donors and recipients involved in the transplant (85 and 85%, respectively) and that a donors information should also be shared with all involved (95 and 90%, respectively). These results were contrary to attitudes expressed by transplant professionals, who frequently disagreed about whether such information should be shared.nnnCONCLUSIONSnFuture policies and practice could facilitate greater sharing of personal health information in living kidney donation. This requires a consideration of which information is relevant, how to put it in context, and a plan to obtain consent from all concerned.

Summary of Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

Abstract Kidney Disease: Improving Global Outcomes (KDIGO) engaged an evidence review team and convened a work group to produce a guideline to evaluate and manage candidates for living kidney donation. The evidence for most guideline recommendations is sparse and many “ungraded” expert consensus recommendations were made to guide the donor candidate evaluation and care before, during, and after donation. The guideline advocates for replacing decisions based on assessments of single risk factors in isolation with a comprehensive approach to risk assessment using the best available evidence. The approach to simultaneous consideration of each candidate’s profile of demographic and health characteristics advances a new framework for assessing donor candidate risk and for defensible shared decision making.