Nine‐yr experience of 700 hand‐assisted laparoscopic donor nephrectomies in Japan
Clinical Transplantation
Volume 26, Issue 5, pages 797-807, 26 MAR 2012 DOI: 10.1111/j.1399-0012.2012.01617.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1399-0012.2012.01617.x/full#ctr1617-fig-0001
Organ Transplantation
Lloyd E Ratner MD MPH
Department of Surgery
Columbia University
New York-Presbyterian Hospital
New York, NY
Disclaimer:
I am a transplant
surgeon, not an ethicist
Topics
•
•
Brain death
Allocation
•
Transplant center interests versus patient interests
–
•
Patient selection
Living Donation
–
–
–
Risk acceptance/aversion
Misattributed paternity
Kidney paired donation
•
•
•
–
–
–
•
Living donor list exchange
Living organ donation in terminally ill patients
Donor/Recipient risk/benefit ratio
Utilization of vulnerable populations as donors
–
–
–
Transplant commercialism
Transplant tourism
Prisoners as donors
•
•
–
•
Compatible pair participation
Organ equity
Donor safety oversight
Living
Executed
Children as donors
Deceased donor experimentation
Brain Death: History
•
•
•
•
•
•
1954 Murray kidney transplant from an identical twin
1962 Murray first successful cadaveric kidney transplant
1963 Starzl first human liver transplant
1963 Hardy first lung transplant
1967 Barnard first heart transplant
Brain death donor was brought to the OR, ventilator was
stopped and everyone waited for the donors heart to stop,
therefore these donors were not brain death at the time of
organ retrieval
Brain Death: History cont.
•
•
•
•
•
•
•
•
1959 Wertheimer et al. characterized the death of the nervous system
1959 Mollaret and Goulon coined the term “coma depasse” (beyond coma) for
and irreversible state of coma and apnea
June 3,1963 Guy Alexandre introduced the first set of Brain Death Criteria based
on description of coma depasse and performed the first kidney transplantation
from a heart beating brain death donor
The recipient, who was maintained on PD, died of sepsis on post op day 87
1968 Ad hoc Committee at HMS defined irreversible coma and transplantation
from brain death donors begins in the US
1970’s only 20 stated had adopted the criteria
1981 the presidents commission for the study of ethical problems in medicine and
biomedical and behavioral research published its guidelines adopting “whole
brain” formulation
All 50 states accepted these guidelines
Brain Death
• Harvard Ad Hoc Committee 1968
– “ With its pioneering interest in organ transplantation, I believe the faculty of
Harvard Medical School is better equipped to elucidate this area than any
other single group” – Dean Robert Ebert
– 13 Members
• Technological progress
– “Life” support (e.g. mechanical ventillation)
– Diagnostics (e.g. EEG)
– Cardiac arrest & cardiopulmonary bypass in cardiac surgery
• Transplantation’s need for organs
– 1st heart transplant 1967
– Kidney procurement from heart beating donors 1960s
• Public distrust of the medical profession
– Fear of premature burial (ancient fear)
• Resource utilization of “comatose” patients
• Benefit to the donor
“Any modification of the means of
diagnosing death to facilitate
transplantation will cause the whole
procedure to fall into disrepute…….”
Discussion regarding establishing
brain death criteria 1966
Defining Brain Death:
4 Major Questions
1.
Under what circumstances, if ever, shall extraordinary means of
support be terminated, with death to follow? (Answer: When the
criteria of irreversible coma described above have been fulfilled.)
2.
From the earliest times the moment of death has been recognized
as the time the heartbeat ceased. Is there adequate evidence now
that the "moment of death" should be advanced to coincide with
irreversible coma while the heart continues to beat? (Answer: Yes.)
3.
When, if ever, and under what circumstances is it right to use for
transplantation the tissues and organs of a hopelessly unconscious
patient? (Answer: When the criteria of irreversible coma described
above have been fulfilled.)
4.
Can society afford to discard the tissues and organs of the
hopelessly unconscious patient when they could be used to restore
the otherwise hopelessly ill but still salvageable individual?
(Answer: No.)
Renewal:
Finds Living Kidney Donors In the Orthodox Jewish
Community
Directed Donation
• Donor or decedent’s family stipulate who the
organs will go to
– Individual
– Specific group of people
• Race, Religion, Ethnic group, Geographic location, etc
• Non-directed donation
• Living donor giving purely altruistically without a
connection to any individual recipient
Organ Allocation
Structuring
• Analytic discussion that spells out a variety of
conflicting ethical principles in order to isolate
and ultimately clarify the pivotal concepts
involved in the decision
Rationing
Goal: Maximize # of lives saved
1 Produce the greatest benefit
2 Give the most deserving
3 Give to those who make the greatest
contribution to society
4 Give to individuals who have the greatest
responsibility to others
5 Assign by random choice
6 (Select those willing to pay the most)
Distributive Justice
Goal: Maximize quality-adjusted life years saved
1 Utility (length & quality of life produced)
2 Neutral queuing (first-in-first-out)
3 Principle of rescue
– Absolute – save life above all else
– Modified – triage for expected length of survival
or quality related issues
– Modified Utility Principle
Value-Based System
1 Urgency
– Pro or Con
– Saving the most lives vs Longest possible
functional period per organ
2 Loyalty to patient
– Influences judgement
3 Fairness
Medical Considerations
•
•
•
•
•
•
Age
Potential for recurrent disease
Retransplantation
Non-adherence
Immunologic compatibility
Waiting time
United States Organ Allocation
• National Organ Transplant Act
– Sponsored by Al Gore
• Governed by OPTN
– UNOS is the OPTN contractor
• Membership organization
– Transplant centers
• Public members (e.g. patients, organ donors, etc.)
• Organ specific differences in allocation
United States Organ Allocation
• Sickest patients prioritized
– Liver
– Heart
– Lung
• Post-transplant outcomes not included in
allocation
• Kidney largely based on waiting time &
longevity matching
Unbalanced System Components

Over time, waiting time has become the primary driver
of kidney allocation


Histocompatibility components have diminished over time
This overreliance led to a system that does not
accomplish any goal other than transplanting the
candidate waiting the longest


Doesn’t recognize that not all can wait the same length of time
Fails to acknowledge different needs for different candidates (e.g., speed
over quality)
Proposed Policy Objectives

Make the most of every donated kidney without
diminishing access

Promote graft survival for those at highest risk of
retransplant

Minimize loss of potential graft function through better
longevity matching

Improve efficiency and utilization by providing better
information about kidney offers
Proposed Policy Objectives

Provide comprehensive data to guide transplant
decision making

Reduce differences in access for ethnic minorities and
sensitized candidates
Kidney Donor Profile Index (KDPI)
KDPI Variables
•Donor age
•Height
•Weight
•Ethnicity
•History of Hypertension
•History of Diabetes
•Cause of Death
•Serum Creatinine
•HCV Status
•DCD Status
KDPI values now displayed with all organ offers in
DonorNet®
Sequence A
Sequence B
KDPI <=20%
KDPI >20% but <35%
Highly Sensitized
0-ABDRmm (top 20%
EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
Highly Sensitized
0-ABDRmm
Prior living donor
Local pediatrics
Local adults
Regional pediatrics
Regional adults
National pediatrics
National adults
Sequence C
KDPI >=35% but
<=85%
Highly Sensitized
0-ABDRmm
Prior living donor
Local
Regional
National
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm
Local + Regional
National
*all categories in
Sequence D
are limited to adult
candidates
Proposed Classification:
Longevity Matching

Estimated Post-Transplant Survival

Candidate age, time on dialysis, prior organ transplant, diabetes status

Top 20% of candidates by EPTS to receive kidneys
matched on longevity

Applies only to kidneys with KDPI scores <=20% not
allocated for multi-organ, very highly sensitized, or
pediatric candidates
Sequence A
Sequence B
KDPI <=20%
KDPI >20% but <35%
Highly Sensitized
0-ABDRmm (top 20%
EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
Highly Sensitized
0-ABDRmm
Prior living donor
Local pediatrics
Local adults
Regional pediatrics
Regional adults
National pediatrics
National adults
Sequence C
KDPI >=35% but
<=85%
Highly Sensitized
0-ABDRmm
Prior living donor
Local
Regional
National
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm
Local + Regional
National
*all categories in
Sequence D
are limited to adult
candidates
Proposed Classifications:
Very Highly Sensitized

Candidates with CPRA >=98% face immense biological barriers

Current policy only prioritizes sensitized candidates at the local
level.

Proposed policy would give following priority
CPRA=100%
CPRA=99%
CPRA=98%

National
Regional
Local
To participate in Regional/National sharing, review & approval of
unacceptable antigens will be required
Sequence A
Sequence B
KDPI <=20%
KDPI >20% but <35%
Highly Sensitized
0-ABDRmm (top 20%
EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
Highly Sensitized
0-ABDRmm
Prior living donor
Local pediatrics
Local adults
Regional pediatrics
Regional adults
National pediatrics
National adults
Sequence C
KDPI >=35% but
<=85%
Highly Sensitized
0-ABDRmm
Prior living donor
Local
Regional
National
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm
Local + Regional
National
*all categories in
Sequence D
are limited to adult
candidates
Unmodified Classification:
Prior Living Organ Donor

Prior living organ donors receive the same level of
priority as current policy

Requirements remain the same for registering a prior
living organ donor


Policy proposal to allow priority with subsequent registrations to be
considered by Board in November 2012
Proposed policy will base qualification on date of
procurement not date of transplant

Would provide priority for prior donors whose organs were removed but not
transplanted
Sequence A
Sequence B
KDPI <=20%
KDPI >20% but <35%
Highly Sensitized
0-ABDRmm (top 20%
EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
Highly Sensitized
0-ABDRmm
Prior living donor
Local pediatrics
Local adults
Regional pediatrics
Regional adults
National pediatrics
National adults
Sequence C
KDPI >=35% but
<=85%
Highly Sensitized
0-ABDRmm
Prior living donor
Local
Regional
National
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm
Local + Regional
National
*all categories in
Sequence D
are limited to adult
candidates
Modified Classification: Pediatric

Current policy prioritizes donors younger than 35 to
candidates listed prior to 18th birthday

Proposed policy would



Prioritize donors with KDPI scores <35%
Eliminate pediatric categories for non 0-ABDR KPDI >85%
Provides comparable level of access while streamlining
allocation system
Sequence A
Sequence B
KDPI <=20%
KDPI >20% but <35%
Highly Sensitized
0-ABDRmm (top 20%
EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
Highly Sensitized
0-ABDRmm
Prior living donor
Local pediatrics
Local adults
Regional pediatrics
Regional adults
National pediatrics
National adults
Sequence C
KDPI >=35% but
<=85%
Highly Sensitized
0-ABDRmm
Prior living organ
donor
Local
Regional
National
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm
Local + Regional
National
*all categories in
Sequence D
are limited to adult
candidates
Modified Classification:
Local + Regional for High KDPI Kidneys

KDPI >85% kidneys would be allocated to a combined
local and regional list

Would promote broader sharing of kidneys at higher
risk of discard

DSAs with longer waiting times are more likely to utilize
these kidneys than DSAs with shorter waiting times
Sequence A
Sequence B
KDPI <=20%
KDPI >20% but <35%
Highly Sensitized
0-ABDRmm (top 20%
EPTS)
Prior living organ
donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
Highly Sensitized
0-ABDRmm
Prior living organ
donor
Local pediatrics
Local adults
Regional pediatrics
Regional adults
National pediatrics
National adults
Sequence C
KDPI >=35% but
<=85%
Highly Sensitized
0-ABDRmm
Prior living organ
donor
Local
Regional
National
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm
Local + Regional
National
*all categories in
Sequence D
are limited to adult
candidates
Organ Allocation – Other Countries
• Old for old (some European countries)
• Israel: Prioritization given to those individuals
who are designated organ donors
• Japan: Little acceptance of brain death,
therefore minimal deceased donation
Transplant Center Interests
Versus Patient Interests
Transplant Center Interests
Versus Patient Interests
• Patient selection
– Transplant center performance metrics
• Patient safety
– Use of hemostatic clips in living donor
nephrectomy
• Cost savings
• FDA contra-indication in US but not elsewhere
• Continued use in other countries
Transplant Volume Declined in Centers
With Low Performance
Schold JD et al: AJT 2013, 13(1):67-75
Living Donation
Living Donation
•
•
•
•
Risk acceptance/aversion
Misattributed paternity
Potential donor’s desire to back out
Kidney paired donation
– Compatible pair participation
– Organ equity
– Donor safety oversight
• Living donor list exchange
• Living organ donation in terminally ill patients
• Donor/Recipient risk/benefit ratio
Living Donation:
Risk Acceptance/Aversion
• Who determines the degree of risk a donor should take?
– Paternalism?
– Opportunity to do good
• What risk?
– Operative risk
– Long term risk
• Absolute minimal risk versus risk assessment and stratification?
• Risk based on what comparator group?
• Should the relationship between donor & recipient influence risk
tolerance?
– Coercion?
• Liver versus Kidney donation
LIVE DONOR MORTALITY RATES
Segev
Trotter/Ringe
Truthfulness?
• Misattributed paternity
– Medical implications
– Relationship dynamics
– Legal implications
• Potential donor’s desire to back out
– Coercion
– Medical excuse
• Ability to donate at a later date
ABO Compatibility
Random Pairs of Individuals
A to O 21%
B to O 4%
AB to O 1.3%
AB to A 1.1%
B to A 5%
AB to B 0.6%
A to B 3%
ABO Identical
39%
ABO Compatible 25%
Kidney Paired Donation
History of Kidney Paired Donation
•
1986
–
•
1991
–
•
–
Rees removes logistical constraint of simultaneous operations with Nonsimultaneous, Extended, Altruistic-Donor
Chain
Utilization of compatible donor/recipient pairs to facilitate KPD for incompatible donor/recipient pairs
2008
–
•
Antibody Working Group 3rd Meeting – Focus on KPD to overcome immunologic incompatibility
2007
–
•
Establishment of Dutch “Crossover Transplantation Program”
2004
–
•
First KPD Johns Hopkins U – Legal Dept. requirement to anesthetize donors simultaneously
2003
–
•
First KPD in U.S. NEOB
2001
–
•
Successful use of Plasmapheresis/IVIg to overcome immunologic incompatibility – Johns Hopkins Univ. – February
First international presentation of Korean PKE Program – ASTP - May
2000
–
•
First Laparoscopic Donor Nephrectomy – Johns Hopkins Univ.
1998
–
–
•
Establishment of KPD program at Yonsei Univ in S. Korea
1995
–
•
Rapaport first proposes KPD to overcome immunologic incompatibility with live kidney donors
National Kidney Registry established
2010
–
UNOS Pilot Project commences
A Conventional Paired Exchange
Donor 1
Blood Group A
Donor 2
Blood Group B
X
X
Recipient 1
Blood Group B
Recipient 2
Blood Group A
An Unconventional Paired Exchange
Donor 1
Blood Group 0
Donor 2
Blood Group A
Positive Crossmatch
X
Recipient 1
Blood Group A
(DSA)
X
ABO Incompatibility
Recipient 2
Blood Group B
A Nonsimultaneous, Extended, Altruistic-Donor ChainBrief
Report:Michael A Rees, Jonathan E Kopke, Ronald P Pelletier, Dorry L Segev, et al. The New
England Journal of Medicine. Boston: Mar 12, 2009. Vol. 360, Iss. 11; pg. 1096
Compatible Pair Participation
Compatible Pair Participation:
Background
• Living Kidney Donor:
– a private resource for the recipient since first LD Tx in 1954
• “Good Samaritan” or “Undirected” Donors:
– Used with increasing frequency
– Public resource (center limited?)
• Kidney Paired Donation (KPD):
– Incompatible donors are relinquished
• Compatible Pair Participation (CPP):
– Compatible donors exchanged to enable more incompatible
patients to be transplanted
Compatible Pair Participation
Compatible
Donor 1
Blood Group 0
Recipient 1
Blood Group A
Donor 2
Blood Group A
Recipient 2
Blood Group B
X
ABO Incompatibility
Compatible Pair Participation
• Major paradigm shift: donor from private resource
to public or shared resource
• Potential large impact on organ supply
• Regional or national sharing networks not
necessary to achieve AUPKEs
• Easily performed at any center
• Ross et al – ethical concerns due to potentially
coercive nature
– Transplantation. 2000 Apr 27;69(8):1539-43.
Altruistic Kidney Exchange
Live Donor Renal Transplants Columbia University
January 2005 – July 2006
n = 163
Donor
Recip
A
A
B
O
AB
29
2
21
0
B
3
9
6
0
O
9
4
74
0
AB
2
2
2
0
THE POTENTIAL FOR 2005-2006
DONOR
A
B
O
AB
RECIPIENT
A
X
X
868
B
X
X
403
O
X
X
78
55
X
AB
43
Total # of Living Donor Transplants in the UNOS data base 2005-2006:
Total # of Transplants that had the Potential to Participate in AUPKE:
Blood group O donors:
1314 (90.8%)
6,565
1,447 (22%)
Compatible Pair Participation:
Areas of Ethical Concern
•
Coercion
Opportunity to Participate in AUPKE Would Place Unwanted Pressure
20
Number of Patients Responding
18
16
Recipient
Donor
14
12
10
8
6
4
2
0
e
re
Ag
ee
or
N
e
re
ag
is
D
r
Ag
ly
ng
ro
St
e
re
Ag
er
th
ei
N
ly
e
re
ng
ag
is
D
ro
St
D
gr
a
is
ee
Coercion
• Recipient: opportunity to obtain an organ
with likelihood of a superior outcome
• Donor: primary goal of altruism fulfilled by
facilitating more transplants
Altruistic Unbalanced Paired Kidney Exchange:
Areas of Ethical Concern
•
•
Coercion
Donor equity or “trading up”
Compatible Pair Participation:
Areas of Ethical Concern
•
•
•
Coercion
Donor equity or “trading up”
Donor/recipient age matching
Compatible Pair Participation:
Areas of Ethical Concern
•
•
•
•
Coercion
Donor equity or “trading up”
Donor/recipient age matching
Disparity in donor/recipient attitudes
Disparity in Donor/Recipient Attitudes Towards
CPP
Donor - Yes
Donor - No
Recipient - Yes
Yes/Yes
Yes/No
Recipient – No
No/Yes
No/No
Donor & Recipient Attitudes Towards Decision Making Responsibility for Participation in AUPKE
Recipient-Joint Decision
Donor-Joint Decision
Recipient-Donor Decision
Donor-Donor Decision
Recipient-Recipient Decision
Donor-Recipient Decision
ee
r
Ag
r
No
ee
e
ee
gr
sa
Di
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Ag
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ro
St
r
Ag
th
i
Ne
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ag
s
Di
ly
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St
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Di
Potential Recipients' Willingness to Participate in an AUPKE
35
# of Recipients Responding
30
25
20
15
10
5
0
0
1
2
3
4
Likert Scale
No advantage
Better match
Other recipient a relative
Donor strongly supports AUPKE
5
6
Potential Donors' Willingness to Participate in AUPKE
30
# of Donors Responding
25
20
15
10
5
0
0
1
2
3
4
Likert Scale
No advantage
Advantage to the recipient
Younger donor
Better match
Other recipient someone I knew
Other recipient a relative
Other recipient a child
Recipient strongly supports AUPKE
5
6
Compatible Pair Participation:
Areas of Ethical Concern
•
•
•
•
•
Coercion
Donor equity or “trading up”
Donor/recipient age matching
Disparity in donor/recipient attitudes
Donor selection based on willingness to
participate in AUPKE
Compatible Pair Participation:
Areas of Ethical Concern
•
•
•
•
•
•
Coercion
Donor equity or “trading up”
Donor/recipient age matching
Disparity in donor/recipient attitudes
Donor selection based on willingness to
participate in AUPKE
Anonymity
Anonymity
• Dislike
• Coercion
• Poor outcomes
First Compatible Pairs Participation
Columbia University 8/30/07
Recipient
Donor
Relationship
O
AB
A
X
AB
Spouse
A
Acquaintance
O
Spouse
Compatible Pairs Participation:
Complex Exchange
Recipient
Donor
Relationship
AB
O
B
X
X
O
Spouse
B
Daughter
AB
Brother
Ethical Considerations
CUMC Ethics Committee &
University of Pisa Symposium:
Ethically Sound & Acceptable
Compatible Pair Participation
• Definition of :
– Compatible
– Incompatible
• Immunologically incompatible
• Blood type
• Donor specific antibodies
– Quasi-compatible
• Some advantage may be obtained in either survival (patient
or graft) or risk if participate in KPD
• Age
• Serology
Safety Oversight in KPD
• What responsibility does the recipient center
have to the donor?
• What responsibility does the donor center
have to the recipient?
• Each patient has their own physicians to
assess and counsel regarding risk
• What if different centers have different risk
tolerances?
• What if organ is lost or damaged in transport?
Living Donor List Exchange
• Deceased donor organ is used to initiate a KPD
chain
• Opportunity to increase the number of
transplants by utilizing more live donors
• Some patients advantaged while other
disadvantaged
– Blood group O patients without live donor are
disadvantaged
– Blood group A patients will be advantaged
ABO Compatibility
Random Pairs of Individuals
A to O 21%
B to O 4%
AB to O 1.3%
AB to A 1.1%
B to A 5%
AB to B 0.6%
A to B 3%
ABO Identical
39%
ABO Compatible 25%
Living Organ Donation In Terminally Ill
Patients
• Question has come up in patients with ALS
(Lou Gehrig’s Ds)
• More and better quality organs for
transplantation if taken from living donor
• Able to give informed consent and express
individual’s wishes
• Decision for withdrawal of life support and
subsequent donation
Utilization Of Vulnerable Populations
As Donors
• Transplant commercialism
– Black market
– Regulated system (Iran)
• Transplant tourism
• Prisoners as donors
– Living
– Executed
• Children as donors
– Child conceived as donor for ill sibling
– Court as guardian
Transplant Commercialism
• US NOTA prohibits “valuable consideration” for organs
• Regulated system of organ sales
– Government establishes non-negotiable price and pays
donors
– Proposal for US $100,000
– Iran only country with this system
• Black market
• How to prevent in US?
• What is the role of the transplant center/physician?
– Suspicion
– No investigative powers
Transplant Tourism Definition:
Declaration of Istanbul
“Travel for transplantation is the movement of organs,
donors, recipients or transplant professionals across
jurisdictional borders for transplantation purposes.
Travel for transplantation becomes transplant tourism if it
involves organ trafficking and/or transplant
commercialism or if the resources (organs, professionals
and transplant centers) devoted to providing transplants
to patients from outside a country undermine the
country's ability to provide transplant services for its own
population.”
Transplant Tourism
• Stewardship of a scarce resource
• Potential for exploitation of vulnerable
populations
• Poor follow-up care
• Transplant service may not be available in all
localities (countries)
Prisoners As Donors
• Living prisoners
– Mississippi case
– Free will and informed consent?
– Quid pro quo?
• Executed prisoners
–
–
–
–
–
–
Ethics of capital punishment?
Main source of donated organs in China
Justice of the legal system
Consent
Donor donation part of repaying debt to society
Transplant tourism in China
Children As Donors
• Ability to give informed consent
• Coercive nature of parental relationship
• 18 yo age of consent
– Mature 17 yo
• Independent
• Understands risks and consequences
• Child conceived as donor for ill sibling
• Court serves as guardian for decision
Deceased Donor
Experimentation
Deceased Donor Experimentation
• Necessary to move the field of transplantation
forward
– Organ supply
• Number of organs per donor
• Quality of organs
• Multiple potential recipients with competing
needs
– When in relation to organ allocation
– Consent?
– Which organ takes priority?
• Who provides oversight?
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Summary & Conclusions
• Finite resource (organs) brings transplantation to
the fore for ethical considerations
• Everyday part of transplantation
• Plethora of interesting and vexing ethical issues
• Acceptance of various ethical issues in
transplantation have evolved and will continue to
do so
• As demand increasing and technology advances
we can expect new challenging issues