Running Head: ETHICS OF ORGAN TRANSPLANTATION
Ethical Issues Surrounding Organ Transplantation and Donation
Auburn University
Madeleine Holmes
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ETHICS OF ORGAN TRANSPLANTATION AND DONATION
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Abstract
With high-stress procedures such as organ transplantation and donation, many
ethical issues arise. The aim of this paper is to explore the various aspects of organ
transplantation and donation that nurses face, including role conflict between healthcare
providers and donor patients and its impact on care, the ethics of accelerating the death of
a patient in order to preserve organ function, treatment of the donor body,
retransplantation, and training nurses to deal with organ transplantation and donation
patients. Nurses can better care for patients undergoing organ transplantation and
donation with ample amounts of education and teaching in the difficult topic of organ
donation. Nurses also must decide where they stand on such complicated ethical issues.
Communication is also a beneficial characteristic for a nurse to have when mediating
between the donor families, physicians and other members of the healthcare team. From
the data gathered, it was clear that nurses need to have the ability and knowledge to
educate others on organ transplantation and donation and must know their ethical
standpoint in order to better care for these patients.
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What is perhaps one of the most potentially beneficial, but risky surgical procedures
performed today, organ transplantation presents numerous ethical challenges. According
to the United Network for Organ Sharing (UNOS), there are 118,199 people in the United
States on the waiting list for organs, including kidney, pancreas, kidney/pancreas, liver,
intestine, heart, lung and heart/lung (2013). Most of these organs come from deceased
donors, or people who have sustained the irreversible cessation of circulatory and
respiratory functions, or all functions of the entire brain, including the brain stem (Day,
2009). Nurses, must consider not only the patient who is to receive the organs, but also the
patient who is donating the organs. Patients who are clinically dead and their families can
be ethically difficult to deal with because of the implications of organ donation and what it
medically entails for the status of a cadaver. An interesting ethical factor in organ donation
and transplantation is whether those needing retransplantation should receive the same
status of classification in the organ donation registry as those needing their first transplant.
Furthermore, there is a national shortage of organs for transplantation and an evergrowing number of patients that need transplants. This brings about the ethical dilemma of
how to best distribute organs in order to maximize the most benefit for patients. The aim of
this paper is to explore the various aspects of organ transplantation and donation that
nurses face, including role conflict between healthcare providers and donor patients and its
impact on care, the ethics of accelerating the death of a patient in order to preserve organ
function, treatment of the donor body, retransplantation, and training nurses to deal with
organ transplantation and donation patients.
Hart, Kohn, and Halpern studied the views of nurses and physicians dealing with organ
donation to better understand their opinions on possible role conflict between a healthcare
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professional and donor patient, and its impact on care given to a patient at the end of life. The
main patient population used in this article were patients classified as “donors after circulatory
determination of death” or DCDD (2012). These patients have undergone life-threatening
neurologic or pulmonary damage, but do not qualify for the neurologic criteria of death.
Recovery of organs from these patients can be difficult because upon withdrawal of life support,
some patients die after the window of opportunity for organ donation has passed. This can pose
an ethical dilemma for nurses. Many are torn between giving quality end-of-life care and
“fostering the interests of potential organ recipients” (Hart, Kohn & Halpern, 2012, p. 2595). The
authors conducted a survey of ICU physicians and nurses regarding their experiences and ethical
beliefs regarding DCDD patients. The majority of those surveyed reported having a DCDD
protocol in place at their hospitals and also had received educational training on DCDD.
Furthermore, most physicians (72.5%) and nurses (74.3%) strongly agreed that it was acceptable
for ICU healthcare professionals to participate in DCDD, and agreed that encouraging organ
donation did not create a conflict of interest. Interestingly, more nurses (55.1%) than physicians
(33.8%) believed that organ donation would improve end-of-life care. Things such as signed
donor cards and other indication of organ donation made it easier for nurses and physicians to
garner more support for organ donation, and they reported feeling ethically better about the
situation because they knew the patient had their wishes honored. As a recommendation for
future practice, the authors stated that more communication would be beneficial between DCDD
physicians, nurses and staff. Nurses in this situation can help by becoming more educated, and
informing others of DCDD.
All of the information known about organ donation is difficult to put into practice
when ethics are in question. In an article by Day (2009), the ethics of accelerating the death
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of a patient in order to procure organs in better condition are examined. The sooner organs
are taken from a patient, the less tissue death occurs, and the better condition the organs
are in. Currently in the area of organ donation, the “dead donor rule” is adhered to. This
rule states “the donor must be dead before unpaired vital organs can be taken for
transplant, and that the removal of organs cannot be the cause of death in the donor” (Day,
2009, p. 377). With the growing need for more organs, it is critical that healthcare professionals
maximize every opportunity for organ procurement. The author poses that taking organs from a
person who is presumed to die and has agreed to be an organ donor is another way of adhering to
the dead donor rule. In this situation, the ethical issue that presents itself is whether these
patients are 100% guaranteed to die. However, guaranteeing that a patient will die is
difficult to predict. When determining brain death, the accepted definition is the “irreversible
cessation of all functions of the entire brain, and brain stem” and in the case of cardiopulmonary
death, the accepted definition is “the irreversible cessation of circulatory and respiratory
functions” (Day, 2009, p. 377). Unfortunately, when considering irreversible cardiopulmonary
death, all organs cease being perfused and therefore, are not viable anymore. Day poses the
abandonment of the dead donor rule in favor of harvesting organs from those who are expected
to die, and have consented to donation. When looking at this situation from a utilitarian
standpoint, taking organs before death will ultimately provide the most patients with the most
life-saving benefits. Day poses that with the utilitarian view and the severe shortage of organs,
more organs procured means more people will benefit from this lifesaving procedure. Nurses
play a huge role in organ procurement. They may have to decide their views on whether they
believe that the patient should die before organs are harvested, or if harvesting organs before
definite cessation of cardiopulmonary or brain function has ceased is ethically acceptable.
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In terms of organ donation, many nurses have hesitations when it comes to the treatment
of the body. Monforte-Royo and Roque discuss the transition of caring for a living patient to
maintaining a cadaver’s organs. In these situations, many healthcare professionals including
nurses, can find themselves questioning the results, and whether they did all that was possible to
save this person’s life. It is now up to the healthcare professionals to break the news to the family
and broach the topic of organ donation. For many families, it can be difficult to realize that while
a loved one may still be breathing or have a heartbeat, they are clinically dead. In order to assist
the family in the realization that the “situation is definitive” nurses should stop calling the person
by name, instead favoring terms such as “the patient” (Monforte-Royo & Roque, 2012, p. 296).
Here, nurses are not only helping the family grieve, but are also detaching themselves from the
situation, decreasing the impact the situation will have on the nurse’s personal life. However, the
authors go on to stress that while it is important to detach oneself from a donor patient, it is also
important that the donor body always be treated with the same dignity and respect that a person
ethically deserves prior to death (Monforte-Royo & Roque, 2012). Nurses should still provide
privacy and hygiene to a body because ethics dictate that a cadaver was once a unique and
special being and any care inferior to that would be dehumanizing (Monforte-Royo & Roque,
2012). In these situations, it can be difficult for nurses to deal with the situation of keeping
organs viable. This can cause nurses to reexamine their own lives, and view death as a very real
and ever-present process.
Another common issue faced by health care professionals dealing with transplants is
whether it is ethical to list a patient for retransplant when there are still other patients waiting for
their first transplant. Dobbels, Hames, Aujoulat, Heaton and Samyn examine retransplantation in
patients who are non-compliant to transplant regimens, such as immunosuppressant drugs. A
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meta-analysis cited in the article states that 22.6 out of 100 patients do not take their
immunosuppressant drugs in the prescribed manner (Dobbels, Hames, Aujoulat, Heaton &
Samyn , 2012). The authors also report that 50% of adolescent transplant patients fail to take
immunosuppressant medications correctly (Dobbels, et al., 2012, p. 4). When medication
regimens are not followed, transplants are more likely to fail. Many of these patients who have a
failed organ are put on the list for a second transplant. So, herein lies the ethical dilemma.
The rate of graft failure is higher in those receiving retransplantation than those receiving
their first transplant. With an increased risk for failure in getting a second transplant, is it fair to
those on the list for their first transplant? In defense of retransplantation, the authors mention that
many patients were capable of changing their practices of medication adherence after the second
transplant. Around half of patients who had non-compliance with their first transplant were able
to learn from their mistakes and adhere to all medications with the second transplant (Dobbels, et
al., 2012, p. 5). The issue of withholding care to those needing retransplant was also voiced. Not
retransplanting a patient goes against the ethical ideas of benevolence and non-maleficence,
which are primary principles of both nursing and medical care. The argument in favor of
withholding retransplantation for non-compliant patients poses the concept of utilitarianism.
Many are worried that previously non-compliant patients would revert back to earlier states and
reject another organ. The wasting of this organ is inadvertently preventing another first-time
transplant candidate from getting an organ that they would possibly be able to maintain
successfully. The utilitarian view would be to prevent retransplantation and give all viable organs
to those needing a first transplant, thus providing the “greatest amount of good for the largest
number of people” (Dobbels, et al., 2012, p. 8). Nurses can greatly contribute to the area of
medication adherence in transplant patients. They can educate patients in the importance of
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adherence to immunosuppressant drugs and continue to remind them of the risk of rejection at
anytime after a transplant is performed. If more patients are educated about the risk of organ
rejection due to lack of medication adherence, the number of patients needing retransplant can
hopefully be reduced.
The question that remains is how to train nurses to deal with organ donation and
transplantation. A study conducted in Norway by Meyer, Bjork, and Eide focused on educating
nurses to better approach this topic. They argue that because nurses come in such close contact
with patients and families, they can be of assistance when determining eligible patients for organ
donation. Nurses need this education because families of patients who understand their family
member’s situation are more likely to have a positive experience with organ donation, despite
losing a loved one, and are more likely to consent to organ donation. As in the study by
Monforte-Royo and Roque, these authors discuss the need to treat the patient’s body with
dignity. Meyer, Bjork and Eide argue that this will also make the family more likely to consent
to organ donation. After the patient’s family has consented to organ donation, the nurse’s focus
shifts to the family. In fact, many nurses saw care of the family and catering to their needs
instead of the patient’s “emotionally and professionally satisfying” (2011, p. 106). While caring
for a transplant patient can be ethically complicated, the more education a nurse is prepared with,
the less difficult it can be.
While this only covers a small list of ethical issues in relation to organ transplant, the
issues of retransplantation, treatment of the donor body, and the nurses’ responsibility to the
patient and the education required to deal with transplants, still remain key issues. Recently in
the news, the parents of a 10 year old with cystic fibrosis campaigned to have their daughter
placed on the adult list for transplants, where she would have a much higher chance of receiving
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a lung transplant, instead of the pediatric list (Martinez & Almasy, 2013). Perhaps with renewed
interest in transplants in the media, many of these ethical issues, can be brought forward and new
policies can be developed accordingly. The role of the nurse in transplantation and donation
situations is crucial. Nurses must educate the public about organ donation and the benefits it can
have to patients in dire need of organs like hearts, lungs, kidneys, and livers. Nurses can also
educate themselves in areas such as care of a patient’s family for whom organ donation is a
possibility. Knowledge of one’s position on issues like retransplantation is also of the utmost
importance. With all of this knowledge and education of transplants, nurses can be better
prepared to take on the ethical dilemma that is organ transplantation.
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References
Day, L. (2009). Questions on organ donation and hastening death. American Journal of Critical
Care, 18(4), 377-380.
Dobbels, F., Hames, A., Aujoulat, I., Heaton, N., & Samyn , M. (2012). Should we retransplant a
patient who is non-adherent? a literature review and critical reflection. Pediatric
Transplantation, 16, 4-11. doi: 10.111/j.1399-3046.2011.001633.x
Hart, J., Kohn, R., & Halpern, S. (2012). Perceptions of organ donation after circulatory
determination of death among critical care physicians and nurses: a national survey.
Critical Care Medicine, 40(9), 2595-2600. doi: 10.1097/CCM.0b013e3182590098
Martinez, M., & Almasy, S. (2013, June 03). Family of girl desperate for transplant says she
can't wait for policy to change. Retrieved from
http://www.cnn.com/2013/06/02/health/pennsylvania-girl-lungs/index.html
Meyer, K., Bjork, T., & Eide, H. (2011). Intensive care nurses' perceptions of their professional
competence in the organ donor process: a national survey. Journal of Advanced Nursing,
68(1), 104-115. doi: 10.111/j.1365-2648.2011.05721.x
Monforte-Royo, C., & Roque, M. (2012). The organ donation process: a humanist perspective
based on the experience of nursing care. Nursing Philosophy, 13, 295-301.
U.S. Department of Health and Human Services, Organ Procurement and Transplantation
Network. (2013). Data of waiting list candidates. Retrieved from website:
http://optn.transplant.hrsa.gov/data/