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Murphy NB, Slessarev M, Basmaji J, Blackstock L, Blaszak M, Brahmania M, Chandler JA, Dhanani S, Gaulton M, Gross JA, Healey A, Lingard L, Ott M, Shemie SD, Weijer C. Ethical Issues in Normothermic Regional Perfusion in Controlled Organ Donation After Determination of Death by Circulatory Criteria: A Scoping Review. Transplantation 2024:00007890-990000000-00854. [PMID: 39192464 DOI: 10.1097/tp.0000000000005161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
Normothermic regional perfusion (NRP) is a surgical technique that can improve the quality and number of organs recovered for donation after the determination of death by circulatory criteria. Despite its promise, adoption of NRP has been hindered because of unresolved ethical issues. To inform stakeholders, this scoping review provides an impartial overview of the major ethical controversies surrounding NRP. We undertook this review according to a modified 5-step methodology proposed by Arksey and O'Malley. Publications were retrieved through MEDLINE and Embase. Gray literature was sourced from Canadian organ donation organizations, English-language organ donation organization websites, and through our research networks. Three reviewers independently screened all documents for inclusion, extracted data, and participated in content analysis. Disagreements were resolved through consensus meetings. Seventy-one documents substantively engaging with ethical issues in NRP were included for full-text analysis. We identified 6 major themes encompassing a range of overlapping ethical debates: (1) the compatibility of NRP with the dead donor rule, the injunction that organ recovery cannot cause death, (2) the risk of donor harm posed by NRP, (3) uncertainties regarding consent requirements for NRP, (4) risks to stakeholder trust posed by NRP, (5) the implications of NRP for justice, and (6) NRP's potential to benefits of NRP for stakeholders. We found no agreement on the ethical permissibility of NRP. However, some debates may be resolved through additional empirical study. As decision-makers contemplate the adoption of NRP, it is critical to address the ethical issues facing the technique to ensure stakeholder trust in deceased donation and transplantation systems is preserved.
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Affiliation(s)
- Nicholas B Murphy
- Department of Medicine and Philosophy, Western University, London, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Marat Slessarev
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - John Basmaji
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Laurie Blackstock
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Donor family partner, Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Michael Blaszak
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Mayur Brahmania
- Division of Gastroenterology and Hepatology, University of Calgary, Cumming School of Medicine, Calgary, AB, Canada
| | | | - Sonny Dhanani
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Pediatric Intensive Care, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Matthew Gaulton
- University of Western Ontario Faculty of Law, London, ON, Canada
| | - Jed A Gross
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Divisions of Emergency and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lorelei Lingard
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Mary Ott
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Faculty of Education, York University, Toronto, ON, Canada
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
- System Development, Canadian Blood Services, Ottawa, ON, Canada
| | - Charles Weijer
- Department of Medicine and Philosophy, Western University, London, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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Ott M, Murphy N, Lingard L, Slessarev M, Blackstock L, Basmaji J, Brahmania M, Healey A, Shemie S, Skaro A, Weijer C. Sowing "seeds of trust": How trust in normothermic regional perfusion is built in a continuum of care. Am J Transplant 2024:S1600-6135(24)00345-9. [PMID: 38825154 DOI: 10.1016/j.ajt.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/04/2024]
Abstract
Normothermic regional perfusion (NRP) is a promising technology to improve organ transplantation outcomes by reversing ischemic injury caused by controlled donation after circulatory determination of death. However, it has not yet been implemented in Canada due to ethical questions. These issues must be resolved to preserve public trust in organ donation and transplantation. This qualitative, constructivist grounded theory study sought to understand how those most impacted by NRP perceived the ethical implications. We interviewed 29 participants across stakeholder groups of donor families, organ recipients, donation and transplantation system leaders, and care providers. The interview protocol included a short presentation about the purpose of NRP and procedures in abdomen versus chest and abdomen NRP, followed by questions probing potential violations of the dead donor rule and concerns regarding brain reperfusion. The results present a grounded theory placing NRP within a trust-building continuum of care for the donor, their family, and organ recipients. Stakeholders consistently described both forms of NRP as an ethical intervention, but their rationales were predicated on assumptions that neurologic criteria for death had been met following circulatory death determination. Empirical validation of these assumptions will help ground the implementation of NRP in a trust-preserving way.
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Affiliation(s)
- Mary Ott
- Faculty of Education, York University, Toronto, Ontario, Canada; Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Nicholas Murphy
- Departments of Philsophy and Medicine, Western University, London, Ontario, Canada
| | - Lorelei Lingard
- Centre for Education Research and Innovation and Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Marat Slessarev
- Department of Medicine, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada; Trillium Gift of Life Network, Toronto, Ontario, Canada
| | - Laurie Blackstock
- Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada
| | - John Basmaji
- Departments of Medicine and Epidemiology & Biostatistics, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Mayur Brahmania
- Division of Gastroenterology, Department of Medicine, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Andrew Healey
- Trillium Gift of Life Network, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sam Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Canadian Blood Services, Ottawa, Ontario, Canada
| | - Anton Skaro
- Department of Surgery, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Charles Weijer
- Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada; Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, Western University, London, Ontario, Canada
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