Public preferences for the allocation of donor organs for transplantation: Focus group discussions

Abolishing age criterion to determine organ transplant recipients in Israel: A qualitative study of medical staff perceptions

INTRODUCTION

Since April 2014 the age limitation on candidates listed for organ transplantation in Israel was abolished following the recommendations of a Public Committee. In this research the new policy was examined in light of scarce medical resources and the increased rate of aging in Israel.

METHODS

The opinions of twelve medical staff regarding the policy change were analyzed by a qualitative methodology, using semi-structured interviews.

RESULTS

Interviews with medical staff members revealed three main themes: 1. positive acceptance of the new policy; 2. concerns and problems regarding the change; and 3. the influence of the policy change on the organ transplant allocation system and patient-doctor relationships.

DISCUSSION AND CONCLUSIONS

The medical staff expressed positive views towards the new policy, based on age-free, individually determined admission to transplant waiting lists. However, some concerns were raised regarding the medical implications of this policy, thus potentially hindering its full application.

Patients' perspectives on ethical principles to fairly allocate scarce surgical resources during the COVID-19 pandemic in the Netherlands: a Q-methodology study

OBJECTIVES

During the COVID-19 pandemic, healthcare professionals were faced with prioritisation dilemmas due to limited surgical capacity. While the views of healthcare professionals on fair allocation have been given considerable attention, the views of patients have been overlooked. To address this imbalance, our study aimed to identify which ethical principles are most supported by patients regarding the fair allocation of surgical resources.

DESIGN

A Q-methodology study was conducted. Participants ranked ordered 20 statements covering different viewpoints on fair allocation according to their point of view, followed by an interview. Principal component analysis followed by varimax rotation was used to identify subgroups who broadly agreed in terms of their rankings.

SETTING

The setting of this study was in the Netherlands.

PARTICIPANTS

16 patient representatives were purposively sampled.

RESULTS

Two perspectives were identified, both of which supported utilitarianism. In perspective 1, labelled as 'clinical needs and outcomes', resource allocation should aim to maximise the health gains based on individual patient characteristics. In perspective 2, labelled as 'population outcomes and contribution to society', allocation should maximise health gains as with perspective 1, but this should also consider societal gains.

CONCLUSIONS

There was a broad agreement among patient representatives that utilitarianism should be the guiding ethical principle for fair allocation of scarce surgical resources. The insights gained from this study should be integrated into policymaking and prioritisation strategies in future healthcare crises.

Religio-cultural facilitators and barriers in decision-making on organ donation: The experiences of families of brain-dead patients in Iran

This study aimed to explore the experiences of families of brain-dead patients regarding religio-cultural facilitators and barriers in decision-making for organ donation. This is a qualitative descriptive study, in which a total of eighteen families of brain-dead patients were recruited using purposive sampling. Data were collected using semi-structured face-to-face interviews. After recording and transcribing the interviews, concepts were extracted using conventional content analysis. The main theme was entitled "religio-cultural facilitators and barriers in decision-making on organ donation" and consisted of four main categories, including two facilitators of "life-giving culture" and "life-giving sacredness" and two barriers of "decision-making skepticism" and "opportunity-burning religiousization". Therefore, cultural and religious issues require further attention and a more realistic and logical cultural and religious perspective toward organ donation should be created at the societal level.

Am I my students' nurse? Reflections on the nursing ethics of nursing education

Despite having worked in higher education for over twenty years, I am still, first and foremost, a practicing nurse. My employer requires me to be a nurse and my regulator regards what I do as nursing. My practice is regulated by the Code and informed by nursing ethics. If I am nurse, practicing nursing, does that mean that my students are my patients? This paper considers how the relationship that I have with my students can be informed by the ethics of the nurse/patient relationship. After some initial theoretical preparation concerning argument from analogy, the paper identifies some areas for comparison between the two relationships. Areas of similarity and difference identify two areas of concern: Nurse education and educators regularly engage in coercion and surveillance in an attempt to increase student success, both of which would be considered outside nursing ethics. It is concluded that these coercive practices are not conducive to an environment where character is cultivated. Despite current financial and workforce pressures, nurse lecturers and more especially their managers would do well to return to the professional ethics of nursing to question and guide their practice.

Mitigating Health Disparities in Transplantation Requires Equity, Not Equality

Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography. Mitigation of disparities is paramount to ensure fair and equitable access for those with end-stage disease and to preserve the trust of the public, upon whom we rely for their willingness to donate organs. In this overview, we present a summary of recent literature demonstrating persistent disparities by stage in the transplant process, along with policies and interventions that have been implemented to combat these disparities and hypotheses for why some strategies have been more effective than others. We conclude with future directions that have been proposed by experts in the field and how these suggested strategies may help us finally arrive at equity in transplantation.

Adding epitope compatibility to deceased donor kidney allocation criteria: recommendations from a pan-Canadian online public deliberation

BACKGROUND

The widening supply-demand imbalance for kidneys necessitates finding ways to reduce rejection and improve transplant outcomes. Human leukocyte antigen (HLA) epitope compatibility between donor and recipient may minimize premature graft loss and prolong survival, but incorporating this strategy to deceased donor allocation criteria prioritizes transplant outcomes over wait times. An online public deliberation was held to identify acceptable trade-offs when implementing epitope compatibility to guide Canadian policymakers and health professionals in deciding how best to allocate kidneys fairly.

METHODS

Invitations were mailed to 35,000 randomly-selected Canadian households, with over-sampling of rural/remote locations. Participants were selected for socio-demographic diversity and geographic representation. Five two-hour online sessions were held from November-December 2021. Participants received an information booklet and heard from expert speakers prior to deliberating on how to fairly implement epitope compatibility for transplant candidates and governance issues. Participants collectively generated and voted on recommendations. In the final session, kidney donation and allocation policymakers engaged with participants. Sessions were recorded and transcribed.

RESULTS

Thirty-two individuals participated and generated nine recommendations. There was consensus on adding epitope compatibility to the existing deceased donor kidney allocation criteria. However, participants recommended including safeguards/flexibility around this (e.g., mitigating declining health). They called for a transition period to epitope compatibility, including an ongoing comprehensive public education program. Participants unanimously recommended regular monitoring and public sharing of epitope-based transplant outcomes.

CONCLUSIONS

Participants supported adding epitope compatibility to kidney allocation criteria, but advised safeguards and flexibility around implementation. These recommendations provide guidance to policymakers about incorporating epitope-based deceased donor allocation criteria.

Ethics of allocation of donor organs

PURPOSE OF REVIEW

There is no widely accepted single ethical principle for the fair allocation of scarce donor organs for transplantation. Although most allocation systems use combinations of allocation principles, there is a particular tension between 'prioritizing the worst-off' and 'maximizing total benefits'. It is often suggested that empirical research on public preferences should help solve the dilemma between equity and efficiency in allocation policy-making.

RECENT FINDINGS

This review shows that the evidence on public preferences for allocation principles is limited, and that the normative role of public preferences in donor organ allocation policy making is unclear. The review seeks to clarify the ethical dilemma to the transplant community, and draws attention to recent attempts at balancing and rank-ordering of allocation principles.

SUMMARY

This review suggests that policy makers should make explicit the relative weights attributed to equity and efficiency considerations in allocation policies, and monitor the effects of policy changes on important ethics outcomes, including equitable access among patient groups. Also, it draws attention to wider justice issues associated not with the distribution of donor organs among patients on waiting lists, but with barriers in referral for transplant evaluation and disparities among patient groups in access to waiting lists.

Public values and guiding principles for implementing epitope compatibility in kidney transplantation allocation criteria: results from a Canadian online public deliberation

BACKGROUND

Epitope compatibility in deceased donor kidney allocation is an emerging area of precision medicine (PM), seeking to improve compatibility between donor kidneys to transplant candidates in the hope of avoiding kidney rejection. Though the potential benefits of using epitope compatibility are promising, the implied modification of deceased organ allocation criteria requires consideration of significant clinical and ethical trade-offs. As a matter of public policy, these trade-offs should consider public values and preferences. We invited members of the Canadian public to participate in a deliberation about epitope compatibility in deceased donor kidney transplantation; to identify what is important to them and to provide recommendations to policymakers.

METHODS

An online public deliberation was conducted with members of the Canadian public, in which participants were asked to construct recommendations for policymakers regarding the introduction of epitope compatibility to kidney allocation criteria. In the present paper, a qualitative analysis was conducted to identify the values reflected in participants' recommendations. All virtual sessions were recorded, transcribed, and analyzed using NVivo 12 software.

RESULTS

Thirty-two participants constructed nine recommendations regarding the adoption of epitope compatibility into deceased donor kidney allocation. Five values were identified that drove participants' recommendations: Health Maximization, Protection/Mitigation of Negative Impacts, Fairness, Science/Evidence-based Healthcare, and Responsibility to Maintain Trust. Conflicts between these values were discussed in terms of operational principles that were required for epitope compatibility to be implemented in an acceptable manner: the needs for Flexibility, Accountability, Transparent Communication and a Transition Plan. All nine recommendations were informed by these four principles. Participant deliberations were often dominated by the conflict between Health Maximization and Fairness or Protection/Mitigation of Negative Impacts, which was discussed as the need for Flexibility. Two additional values (Efficient Use of Resources and Logic/Rationality) were also discussed and were reasons for some participants voting against some recommendations.

CONCLUSIONS

Public recommendations indicate support for using epitope compatibility in deceased donor kidney allocation. A flexible approach to organ allocation decision-making may allow for the balancing of Health Maximization against maintaining Fairness and Mitigating Negative Impacts. Flexibility is particularly important in the context of epitope compatibility and other PM initiatives where evidence is still emerging.

Setting Organ Allocation Priorities: A Discrete Choice Experiment with German Patients and Their Relatives

PURPOSE

Organ transplantation systems benefit from guidelines that are harmonious with the preferences of the people involved. Discrete choice experiments are useful tools for eliciting preferences.

PATIENTS AND METHODS

This study evaluated the preferences of patients and their relatives (n=285) to identify their priorities in organ allocation using a discrete choice experiment. In eight hypothetical allocation decisions, the participants were asked to select the candidate they considered the most suitable The candidates differed in years of life gained after transplantation, quality of life after transplantation, waiting time until transplantation, age, compliance and social support.

RESULTS

The most important aspects for setting priority in organ allocation were lack of compliance (β= -2.5, p<0.001) and good quality of life after transplantation (β = +1.4, p<0.001). The lack of social support (ß = -0.8, p<0.05) and the more years of life gained after transplantation (β = +0.5, p<0.001) had less but still a significant amount of influence on this decision, while the waiting list was not considered significantly important (β = 0.1, p>0.05). The comparison of the different relations to transplantation showed that life years gained after transplantation was of high relevance to posttransplant patients (+10 years: β = +0.709, p<0.001 / +15 years: β = +0.700, p<0.001) and of no importance to waitlisted patients (+10 years: β = +0.345, p>0.05 / + 15 years: β = +0.173, p>0.05) and relatives (+ 10 years: β = +0.063, p>0.05 / +15 years: β = +0.304, p>0.05).

CONCLUSION

This study provides useful insights into the unique perspective of patients and their relatives on priority-setting in the allocation of donor organs that should be reflected in improved donor organ allocation rules.

Patient Perspectives on the Use of Frailty, Cognitive Function, and Age in Kidney Transplant Evaluation

BACKGROUND

The allocation of scarce deceased donor kidneys is a complex process. Transplant providers are increasingly relying on constructs such as frailty and cognitive function to guide kidney transplant (KT) candidate selection. Patient views of the ethical issues surrounding the use of such constructs are unclear. We sought to assess KT candidates' attitudes and beliefs about the use of frailty and cognitive function to guide waitlist selection.

METHODS

KT candidates were randomly recruited from an ongoing single-center cohort study of frailty and cognitive function. Semi-structured interviews were conducted, and thematic analysis was performed. Inductively derived themes were mapped onto bioethics principles.

RESULTS

Twenty interviews were conducted (65% contact rate, 100% participation rate) (60% male; 70% White). With respect to the use of frailty and cognitive function in waitlisting decisions, four themes emerged in which participants: (1) valued maximizing a scarce resource (utility); (2) prioritized equal access to all patients (equity); (3) appreciated a proportional approach to the use of equity and utility (precautionary utility); and (4) sought to weigh utility- and equity-based concerns regarding social support. While some participants believed frailty and cognitive function were useful constructs to maximize utility, others believed their use would jeopardize equity. Patients were uncomfortable with using single factors such as frailty or cognitive impairment to deny someone access to transplantation; participants instead encouraged using the constructs to identify opportunities for intervention to improve frailty and cognitive function prior to KT.

CONCLUSIONS

KT candidates' values mirrored the current allocation strategy, seeking to balance equity and utility in a just manner, albeit with conflicting viewpoints on the appropriate use of frailty and cognitive impairment in waitlisting decisions.

Israeli Medical Experts’ Knowledge, Attitudes, and Preferences in Allocating Donor Organs for Transplantation

Medical advancement has increased the confidence in successful organ transplants in end-stage patients. As the waitlist of organ demand is multiplying, the organ allocation process is becoming more crucial. In this situation, a transparent and efficient organ allocation policy is required. This study evaluates the preferences of medical experts to substantial factors for allocating organs in different hypothetical scenarios. Twenty-five medical professionals with a significant role in organ allocation were interviewed individually. The interview questionnaire comprised demographic information, organ donation status, important organ allocation factors, public preference knowledge, and experts’ preferences in different hypothetical scenarios. Most medical experts rated the waiting time and prognosis as the most important, while the next of kin donor status and care and contribution to the well-being of others were the least important factors for organ allocation. In expert opinion, medical experts significantly considered public preferences for organ allocation in making their decisions. Altogether, experts prioritized waiting time over successful transplant, age, and donor status in the hypothetical scenarios. In parallel, less chance of finding another organ, donor status, and successful transplant were prioritized over age. Medical experts are the key stakeholders; therefore, their opinions are substantial in formulating an organ allocation policy.

How Should Deceased Donor Organs Be Allocated? The Patient's Perspective Derived from Semi-Structured Interviews

PURPOSE

The gap between the supply and demand for deceased donor organs is increasing worldwide, while patients on waiting lists for organ transplantation die. This situation requires ethical donor organ allocation rules. The patients' perspective on donor organ allocation rules offers a highly relevant and unique perspective that may differ from the perspectives of physicians and the general public.

PATIENTS AND METHODS

Semi-structured telephone interviews were conducted with the regional group coordinators of the federal self-help organization for organ transplanted patients and their relatives in Germany in early 2021. Twelve interviews were conducted with patients and relatives of transplantation patients who received transplants for the affected organs including the lungs, heart, kidney, and liver. Transcripts were analyzed using the deductive framework method which was based on an earlier study. All criteria were reported following the COREQ statement.

RESULTS

Participants emphasized aspects of "medical urgency" and "effectiveness/benefit" of transplantation and associated trade-offs as well as the recipient's responsibility for organ failure ("own fault"), the appreciation for the gifted graft and the patient's capability of taking care of it ("appreciation/responsibility"). Patients acknowledged that urgent patients should be prioritized and they showed a clear preference toward allocation rules that strive to maximize both the life years and quality of life gained by transplantation.

CONCLUSION

The patients' perspective is unique in that patients agree on certain rules for allocation and share many preferences, but also have a hard time finding clear cutoff points when considering selecting a participant for allocation. Patient representatives should therefore be consulted in the debate on donor organ allocation rules.

'As a surgeon, I am obliged to every single patient': evaluation of focus group discussions with transplantation physicians on the allocation of donor organs

INTRODUCTION

Organ transplantation is the last resort for many patients. The ubiquitous shortage of suitable donor organs raises the question of best-justifiable allocation worldwide. This study investigates how physicians would allocate donor organs.

METHODS

Focus group discussions with a total of 12 transplant surgeons and 2 other transplant-related physicians were held at the annual conference of the German Transplantation Society (Oct 2019). Three groups discussed aspects of 'egalitarianism', 'effectiveness/benefit', 'medical urgency', 'own fault', 'medical background' and 'socio-demographic status'.

RESULTS AND DISCUSSION

It was observed that physicians often find themselves confronted with conflicts between (a) trying to advocate for their individual patients versus (b) seeing the systemic perspective and understanding the global impact of their decisions at the same time. The groups agreed that due to the current shortage of donor organs in the German allocation system, transplanted patients are often too sick at the point of transplantation and that a better balance between urgency and effectiveness is needed. The aspects of 'effectiveness' and 'urgency' were identified as the most challenging issues and thus were the main focus of debate. The dilemmas physicians find themselves in become increasingly severe, the larger the shortage of suitable donor organs is.

A world-wide survey on kidney transplantation practices in breast cancer survivors: The need for new management guidelines

Kidney transplantation reduces mortality in patients with end stage renal disease (ESRD). Decisions about performing kidney transplantation in the setting of a prior cancer are challenging, as cancer recurrence in the setting of immunosuppression can result in poor outcomes. For cancer of the breast, rapid advances in molecular characterization have allowed improved prognostication, which is not reflected in current guidelines. We developed a 19-question survey to determine transplant surgeons' knowledge, practice, and attitudes regarding guidelines for kidney transplantation in women with breast cancer. Of the 129 respondents from 32 states and 14 countries, 74.8% felt that current guidelines are inadequate. Surgeons outside the United States (US) were more likely to consider transplantation in a breast cancer patient without a waiting period (p = .017). Within the US, 29.2% of surgeons in the Western region would consider transplantation without a waiting period, versus 3.6% of surgeons in the East (p = .004). Encouragingly, 90.4% of providers surveyed would consider eliminating wait-times for women with a low risk of cancer recurrence based on the accurate prediction of molecular assays. These findings support the need for new guidelines incorporating individualized recurrence risk to improve care of ESRD patients with breast cancer.

French People's Views on the Allocation of Organs for Transplantation

BACKGROUND

French laypeople's views on the allocation of organs for transplantation were examined.

METHODS

A total of 199 adults make judgments of priority for a liver transplant in 48 realistic scenarios composed of all combinations of 4 factors: 1. probability of success, 2. life expectancy without transplant, 3. level of responsibility for liver failure (eg, substance abuse in the past), and 4. social situation (eg, young mother with 2 young children). In all scenarios, the patients were in need of liver transplant. The ratings were subjected to cluster analysis and analyses of variance.

RESULTS

Six qualitatively different positions were found that were termed Probability of Success and Life Expectancy (6%), Family Responsibilities (8%), Family Responsibilities and Risky Behavior (28%), Risky Behavior and Family Responsibilities (22%), Risky Behavior (11%), and Always a Priority (25%). Regular church attendees expressed more often the Risky Behavior and Family Responsibilities position and less often the Always a Priority position than atheists. Female participants expressed more often the Risky Behavior position than male participants.

CONCLUSIONS

The French laypeople in our sample think that when assessing priority for transplant, criteria additional to medical urgency or the estimated utility in terms of expected life span after transplant should be taken into account. These criteria are the patient's lack of responsibility for the liver failure (ie, not causing it by drinking or using drugs) and the extent of the patient's social responsibilities (with active employment and dependents to care for).

Public preferences for the allocation of donor organs for transplantation: Focus group discussions

BACKGROUND

Deceased donor organs are scarce resources because of a large supply-and-demand mismatch. This scarcity leads to an ethical dilemma, forcing priority-setting of how these organs should be allocated and whom to leave behind.

OBJECTIVE

To explore public preferences for the allocation of donor organs in regard to ethical aspects of distributive justice.

METHODS

Focus groups were facilitated between November and December 2018 at Hannover Medical School. Participants were recruited locally. Transcripts were assessed with content analysis using the deductive framework method. All identified and discussed criteria were grouped according to the principles of distributive justice and reported following the COREQ statement.

RESULTS

Six focus groups with 31 participants were conducted. Overall, no group made a final decision of how to allocate donor organ; however, we observed that not only a single criterion/principle but rather a combination of criteria/principles is relevant. Therefore, the public wants to allocate organs to save as many lives as possible by both maximizing success for and also giving priority to urgent patients considering the best compatibility. Age, waiting time, reciprocity and healthy lifestyles should be used as additional criteria, while sex, financial status and family responsibility should not, based on aspects of equality.

CONCLUSIONS

All participants recognized the dilemma that prioritizing one patient might cause another one to die. They discussed mainly the unclear trade-offs between effectiveness/benefit and medical urgency and did not establish an agreement about their importance. The results suggest a need of preference studies to elucidate public preferences in organ allocation.