Utilization and allocation of organs for transplantation - medical and ethical aspects

Abstract: Great efforts have been made to find solutions to the shortage of organs, such as extending the donor pool by accepting so-called marginal donors and development of transplantation of organs from animals (xenotransplantation, xt). Due to the scarcity of organs, there is a long tradition of prioritizing among patients on the waiting list for transplantation. Rules for allocation of organs have been developed within organ exchange organizations, such as Scandiatransplant, the forum for exchange of organs within the Nordic countries. The overall aim of this thesis is to describe and analyze some of the medical and ethical aspects of utilization and allocation of organs and tissue for transplantation. The ethical considerations are discussed in relation to the studies reported in this thesis, using the four principles of autonomy, nonmaleficence, beneficence and justice as points of departure. The result of a study performed among (151/175) Baltic physicians with varying experience of organ donation and transplantation, indicated that they had generally similar attitudes toward organ donation and transplantation, though there were also some differences within the groups. However, the significance of these differences is difficult to estimate. This study seems to have promoted discussion of ethical aspects of transplantation in these countries, and paved the way for collaboration between the Nordic and Baltic countries. A study was performed among (53/61) patients awaiting kidney transplantation in the southern part of Sweden, on their views on informed consent on marginal donors. The result of this study indicates that patients accept information on donor-related risk factors and most patients want to be involved in the decision-making process concerning transplantation with a kidney from a marginal donor for themselves. The attitude to xt was surveyed among a random sample of the general public (596/1000) and all patients between the ages of 18 and 75 years who were awaiting kidney transplantation (398/460). The majority of patients and the general public would accept an animal graft provided that the outcome was the same as with a human graft. A life-threatening situation marginally increased the positive proportions. The overall impression is that the attitude to xt seems to be most influenced by whether the xenotransplant would involve whole organs or cells, and whether there would be uncertainty regarding the outcome. Questionnaires were used in all of these studies. Rules for allocation of kidneys from all 10 transplant units within Scandiatransplant were collected and interpreted. The allocation of kidneys seems to be a process of thoughtful weighing up of the factors: HLA-matching, children, waiting time, age-matching, and PRA-patients, although this is done somewhat differently at each unit.