For Living Donors, Many Risks to Weigh

September 4, 2007
Personal Health

For Living Donors, Many Risks to Weigh

By JANE E. BRODY
NEW YORK TIMES

Linda Fox of Brooklyn donated a lobe of her liver to save her husband, whose own liver had failed. The transplant took, and Ms. Fox said although recovery from the surgery was no picnic, she would willingly do it again.

Will Maloney, also of Brooklyn, donated a kidney to his brother, who was struggling to survive with the aid of dialysis. The operation was anything but simple, and Mr. Maloney suffered significant complications. Worse yet, the transplanted organ quickly failed, and his brother was again in need of a donated kidney, which he eventually received from a deceased donor.

In 2004 and 2005, the number of organ donations from living donors surpassed those from dead donors. And although dead donors are once again more common, many people risk surgery and the loss of an organ to save the lives of people they love — and increasingly of strangers, as well.

In addition to a kidney and lobe of a liver, living donors can give the lobe of a lung and bone marrow. Almost half of all kidney donors in the United States are living donors, a total of 6,434 last year. Living donors last year also provided lobes of the liver to 288 recipients and lobes of a lung to five recipients. Transplants between unrelated donors are now highly successful, thanks to improved methods of immune suppression that reduce the need for close tissue matching to prevent rejection.

But many problems can complicate transplants from live donors. It is important that potential donors know about them and take the time to resolve them before deciding whether to go ahead with a donation, which carries the potential for serious physical and emotional risks.

Ethical Concerns

Dr. Robert D. Truog, professor of medical ethics and anesthesia at the Harvard Medical School, lists three categories of living organ donation: directed donation, to a loved one or friend; nondirected donation, in which the organ goes to the general pool to be transplanted into the recipient at the top of the waiting list; and directed donation to a stranger, in which a donor gives to a specific person with whom there is no emotional connection.

And, Dr. Truog added in an essay in The New England Journal of Medicine in August 2005, “Each type of donation prompts distinct ethical concerns.”

When, as with Ms. Fox and Mr. Maloney, the donated organ is destined for a loved one or friend, there is the possibility of coercion — intense pressure on the potential donor to risk the surgery, as well as the chance that the transplant will not succeed. For those who do not want to go forward with a living organ donation and say so to the doctors involved, transplant teams are typically willing to provide a reasonable medical excuse to enable the person to bow out gracefully.

But, Dr. Truog noted, there are “situations in which people feel compelled to donate regardless of the consequences to themselves.” He told of a case in which a child was dying of respiratory failure. Both parents “insisted on donating lobes of their lungs in a desperate but unsuccessful attempt to save her life.”

He maintains that in such cases it is not enough to obtain informed consent from the potential donor. Rather, he said, “physicians are obligated to prevent people from making potentially life-threatening sacrifices, unless the chance of success is proportionately large.”

In nondirected donations to the general transplant pool, it is important to explore what has motivated the person to make such a sacrifice for an anonymous recipient.

The possibilities include personality or emotional disturbances like depression, low self-esteem, an abnormal desire for attention or a desire to become involved in the recipient’s life. Or the person may simply want to repay a kindness to society, perhaps because a loved one’s life was saved by an organ from a deceased donor.

But when the motive is suspect, transplant teams are supposed to assess the reasons and prohibit donations that raise serious concerns.

Helping Strangers

Recently, there has been an increase in organ donations directed to strangers who may advertise their need for transplants through the news media, the Internet and even on billboards. Although there is nothing illegal about soliciting a donor organ, the practice is inherently unfair and raises the possibility of buying and selling organs, which the medical community considers highly unethical. Donated organs are considered a “gift of life,” not a commodity to be bought and sold.

There is a national list of people awaiting transplants, and those who are the sickest, though rarely the wealthiest, are at the top. But when donations are directed to strangers, potential recipients “who have the most compelling stories and the means to advertise their plight tend to be the ones who get the organs, rather than those most in need,” Dr. Truog said.

There are other possible wrinkles in donations directed to strangers. The donor may insist that the donation not go to a recipient of a particular race, religion or ethnic group. One case, in which a white brain-dead donor specified that his organs go just to white recipients, prompted Florida to pass a law prohibiting patients and families from restricting donations in this way.

Another case was less clear-cut. A Jewish man in New York learned of a Jewish child in Los Angeles who needed a kidney and said he would donate a kidney to help this child. This is clearly a discriminatory donation, even though it would enable those below the child on the transplant list to move up a notch. On the other hand, if the donation was not allowed, no one would benefit, because the man would not offer his kidney to anyone else.

Live Donor Swaps

Pressure is mounting to establish a national registry of live donors, people who were willing to donate organs to relatives or friends but were not good matches.

Through such a registry, patients anywhere in the country could “swap” one of their donors who is not a match for a donor who is. Such programs have the potential to increase significantly the donor pool and the success of transplants, because the surgery can be done before the patient is deathly ill. In recent years, small donor exchange programs have been established by the Johns Hopkins Medical Center, the New England Organ Bank and the Ohio Paired Donation Consortium.

http://www.nytimes.com/2007/09/04/health/04brod.html?_r=1&adxnnl=1&adxnnlx=1188939805-qgZeGnMe21amZCwqgCJdcA&oref=slogin