The ethical complexities of online organ solicitation via donor-patient websites: avoiding the "beauty contest"

Recommendations for living donor kidney transplantation

This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.

Utilizing Social Media to Identify Potential Living Donors: Learning from US Living Donor Programs

Purpose of Review

Living donor transplantation provides the best possible recipient outcomes in solid organ transplantation. Yet, identifying potential living donors can be a laborious and resource intensive task that heavily relies on the recipient’s means and social network. Social media has evolved to become a key tool in helping to bring recipients and potential living donors together given its ease of utilization, widespread access, and improved recipient’s comfort with public solicitation. However, in the USA, formal guidelines to direct the use of social media in this context are lacking.

Recent Findings

To better inform the landscape and opportunities utilizing social media in living donation, the OPTN Living Donor Committee surveyed US transplant programs to explore programs’ experiences and challenges when helping patients use social media to identify potential living donors (September 2019). A large majority of survey participants (N = 125/174, 72%) indicated that their program provided education to use social media to identify potential living donors and most programs tracking referral source confirmed an increase utilization over time. The use of social media was compounded with program and recipient’s challenges including concerns about privacy, inadequate technology access, and knowledge gaps. In this review, we discuss the results of this national survey and recent literature, and provide suggestions to inform program practices and guidance provided to patients wishing to use social media to identify potential living donors.

Summary

Transplant programs should become competent in the use of social media for potential living donor identification to empower patients interested in using this tool. Social media education should be provided to all patients regardless of voiced interest and, when appropriate, revisited at multiple time points. Programs should consider developing a “team of experts” that can provide focused education and support to patients embarking in social media living donor campaigns. Care should be taken to avoid exacerbating disparities in access to living donor transplantation. Effective and timely guidance to patients in the use of social media could enhance the identification of potential living donors.

The Impact of Primary Liver Disease and Social Determinants in a Mixed Donor Liver Transplant Program: A Single-Center Analysis

Organ allocation in liver transplantation (LT) remains imperfect. Periodic center reviews ensure programs transparently evaluate the impact of practice on access to transplantation, reflecting, in particular, patient (primary disease, social determinants) and program (deceased versus live donation) factors. Adult Ontario residents waitlisted for first LT at Toronto General Hospital from November 2012 to May 2019 were reviewed. Analyses were performed between distance to transplant center, income, education level, population density and primary liver disease, with LT, deceased donor liver transplant (DDLT), living donor liver transplant (LDLT), and delisting. Of 1735 listed patients, 549 were delisted (32%), while 1071 were transplanted (62%), with 819 DDLT recipients (76%) and 252 LDLT recipients (24%), while 115 (7%) remained actively listed at data census. On univariate analysis, DDLT recipients lived 30% closer (median 39.7 versus 60.6 km; P < 0.001), lived in more populous areas (median 8501.0 versus 6868.5 people in a 1-km radius; P < 0.001), and resided in households that annually earned 10% less (median $92,643.17 versus $102,820.89 Canadian dollars; P < 0.001) compared with LDLT recipients. These findings with population density and income differences between DDLT versus LDLT receival remained significant on multivariate modeling even when accounting for primary liver disease. Primary liver disease was a statistically significant factor on multivariate analyses in LT receival (P = 0.001) as well as DDLT versus LDLT receival (P < 0.001). Of patients listed for end-stage liver disease, more patients with autoimmune cholestatic liver diseases received LDLT (34%-41%) than DDLT (27%-30%); this contrasted with patients with noncholestatic diseases LDLT (8%-19%) versus DDLT (37%-59%) receival (P < 0.001). Review of transplant allocation in a large mixed-donor North American liver transplant program demonstrates how patient social determinants and primary liver disease etiology continue to be significantly associated with ultimate transplantation.

Have we reached the limits in altruistic kidney donation?

Altruistic donation (unspecified donation) is an important aspect of living donor kidney transplantation. Although donation to a stranger is lawful and supported in many countries, it remains uncommon and not actively promoted. Herein, we ask the question if we have reached the limit in altruistic donation. In doing so, we examine important ethical questions that define the limits of unspecified donation, such as the appropriate balance between autonomous decision-making and paternalistic protection of the donor, the extent of outcome uncertainty and risk-benefit analyses that donors should be allowed to accept. We also consider the scrutiny and acceptance of donor motives, the potential for commercialization, donation to particular categories of recipients (including those encountered through social media) and the ethical boundaries of active promotion of unspecified kidney donation. We conclude that there is scope to increase the number of living donation kidney transplants further by optimizing existing practices to support and promote unspecified donation. A number of strategies including optimization of the assessment process, innovative approaches to reach potential donors together with reimbursement of expenses and a more specific recognition of unspecified donation are likely to lead to a meaningful increase in this type of donation.

Public Solicitation and The Canadian Media: Two Cases of Living Liver Donation, Two Different Stories

Supplemental Digital Content is available in the text.

Background

. Two stories of public solicitation for living liver donors received substantial Canadian media attention in 2015: The Wagner family, with twin toddlers, each needing transplants, and Eugene Melnyk, wealthy owner of a professional hockey team. This study compared the print media coverage of these 2 stories to understand how public solicitation was portrayed and whether coverage differed depending on the individual making the plea.

Methods.

We conducted a content analysis on 155 relevant Canadian newspaper articles published between January 1, 2015 and December 31, 2016. Articles were analyzed for their description of public solicitation, benefits and issues associated with public solicitation, and overall tone with respect to public solicitation.

Results.

The foregrounding of public solicitation and associated ethical issues featured heavily in articles focused on Melnyk but were largely absent when discussing the Wagner family. The fairness of Melnyk's solicitation was the most prominent ethical issue raised. Laws and policies surrounding public solicitation also featured in the Melnyk story but not in articles focused on the Wagners. Public solicitation was portrayed more negatively in the Melnyk articles, but overall, was portrayed positively in relation to both Melnyk and the Wagner family.

Conclusions.

Public solicitation was generally portrayed as a positive phenomenon in Canadian print media, yet there were stark differences in how these cases were presented. The Wagner story was largely portrayed as a human-interest piece about a family in dire circumstances, whereas Melnyk's wealth, status, and influence raised questions of the fairness of his transplant.

How altruistic organ donation may be (intrinsically) bad

It has traditionally been assumed that organ donation must be altruistic, though the necessity of altruistic motivations has recently been questioned. Few, however, have questioned whether altruism is always a good motive. This paper considers the possibility that excessive altruism, or self-abnegation, may be intrinsically bad. How this may be so is illustrated with reference to Tom Hurka's account of the value of attitudes, which suggests that disproportionate love of one's own good-either excessive or deficient-is intrinsically bad. Whether or not we accept the details of this account, recognising that altruistic motivations may be intrinsically bad has important implications for organ procurement. One possible response is to say that we should take further measures to ensure that donors have good motives-that they are altruistic is no longer enough. An alternative is to say that, since altruistic donation need not be intrinsically good, we have less reason to object to other motivations.

A Scoping Review of the Literature on Public Solicitations for Living Organ and Hematopoietic Stem Cell Donations

Introduction:

Evolving methods of communication have increased public appeals for living organ and hematopoietic stem cell donations from strangers, giving public solicitations more visibility. Within the academic literature, perspectives have been divisive, reflecting ethical justifications for and against appeals for living unrelated donors. Transplant programs and clinicians face a variety of ethical dilemmas when patients and their solicited donors present to the hospital.

Objective:

A scoping review methodology was designed to (1) explore the academic literature and (2) summarize and disseminate key research findings.

Methods:

We used the Arksey & O’Malley framework for conducting and reporting scoping reviews and to review the prominent ethical arguments, counterarguments, and policy implications in the literature. From 4616 articles identified through MEDLINE, EMBASE, PsycInfo, and CINAHL, we screened titles and abstracts to assess eligibility for full-text review.

Results:

We retrieved 280 full texts, extracted data from 61, and coded and analyzed 41 papers. Of these, 36 were from or based in the US context. Two articles originated from Canada. Three articles addressed public solicitations of hematopoietic stem cell donation. We mapped themes under 3 major headings related to public solicitations of living unrelated donors for organs and hematopoietic stem cells: (1) interpretations and modes, (2) ethical arguments for and against, and (3) policy implications and suggestions to address challenges for clinical practice.

Discussion:

The academic literature contains divisive perspectives of public solicitations for organ and hematopoietic stem cell donation, each of which deserves further reflection for implications for policy and practice.

"What if this is my chance to save my life?" A semistructured interview study on the motives and experiences of end-stage renal disease patients who engaged in public solicitation of a living kidney donor

The increase in patients using public solicitation (PS) to find a living kidney donor has generated a debate about the ethical complexities of PS. To investigate why patients engaged in PS and what they experienced during PS, we conducted semistructured interviews with 20 Dutch patients with end-stage renal disease who had publicly solicited a living donor. Transcripts were thematically analyzed. We identified ten themes on patients' considerations preceding PS: cautiousness in discussing living donation within social network; reluctance to accept a kidney from loved ones; rejection/withdrawal of related donor candidates; moral objections to paid donation; the ease of social media; encouraged by others; ends justifying the means; despair and urge to take action; public disclosure of vulnerability; fear of being (perceived to be) selfish. We identified nine themes on patients' experiences: positive emotions and support generated by action; genuine and ulterior motives for donation; patients acting as educators and screeners; time- and energy-consuming process; emotionally taxing process; positive interactions with donor candidates; feeling of dependency and obligation; limited cooperation from health professionals; demands a proactive attitude and media strategy. These results can inform and complement (existing) policies on PS and provide content for education of patients who are considering PS.

Social media and organ donation: Ethically navigating the next frontier

As the organ shortage continues to grow, the creation of social media communities by transplant hospitals and the public is rapidly expanding to increase the number of living donors. Social media communities are arranged in myriad ways and without standardization, raising concerns about transplant candidates' and potential donors' autonomy and quality of care. Social media communities magnify and modify extant ethical issues in deceased and living donation related to privacy, confidentiality, professionalism, and informed consent, and increase the potential for undue influence and coercion for potential donors and transplant candidates. Currently, no national ethical guidelines have been developed in the United States regarding the use of social media to foster organ transplantation. We provide an ethical framework to guide transplant stakeholders in using social media for public and patient communication about transplantation and living donation, and offer recommendations for transplant clinical practice and future research.

KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.

Beyond the Billboard: The Facebook-Based Application, Donor, and Its Guided Approach to Facilitating Living Organ Donation

Living donor solicitation can raise ethical concerns, regardless of the medium used: newspaper, television, pulpit, billboard or Internet. Moving the search for a living donor into the social media realm introduces the risk of unguided and coercive patient narratives as well as decoupling or even total absence of information that could aid the consent process. The Facebook application (app) for living donors, called Donor (restricted to patient use), aims to address these concerns in several ways: (i) by directing the patient's initial appeal to friends and family; (ii) by guiding the patient's narrative; and (iii) by providing a library of clinical, ethical and regulatory information that informs the consent process. In this paper, we explored these features and contrasted them with billboard solicitation activities and current independent social media efforts. We concluded that the proactive ethical design of the Donor app is a permissible way to help satisfy the shortfall of deceased donor livers and kidneys.

Dealing With Public Solicitation of Organs From Living Donors--An ELPAT View

Although transplant professionals have initially been reluctant to perform transplants after public solicitation of organs from living donors, nowadays these transplants are increasingly being performed and reported. After clarifying the existing terminology, we elaborate an operational definition of public solicitation that is consistent with the Ethical, Legal, and Psychosocial Aspects of Transplantation classification for living organ donation. Our aim is to critically assess this phenomenon, from a legal, moral, and practical perspective, and to offer some recommendations. From a legal point of view, we analyze the current situation in the Europe and the United States. From a moral perspective, we evaluate the various arguments used in the literature, both in favor and against. Finally, we offer a set of recommendations aimed at maximizing the organ donor pool while safeguarding the interests of potential living donors.

Directed altruistic living donation: what is wrong with the beauty contest?

This paper explores the specific criticism of directed altruistic living organ donation that it creates a 'beauty contest' between potential recipients of organs. The notion of the beauty contest in transplantation was recently used by Neidich et al who stated that '[a]ltruism should be the guiding motivation for all donations, and when it [is], there is no place for a beauty contest'. I examine this beauty contest objection from two perspectives. First, I argue that, when considered against the behaviour of donors, this objection cannot be consistently raised without also objecting to other common aspects of organ donation. I then explore the beauty contest objection from the perspective of recipients, and argue that if the beauty contest is objectionable, it is because of a tension between recipient behaviour and the altruism that supposedly underpins the donation system. I conclude by briefly questioning the importance of this tension in light of the organ shortage.

Solicited kidney donors: Are they coerced?

Most non-directed donors (NDDs) decide to donate on their own and contact the transplant centre directly. Some NDDs decide to donate in response to community solicitation such as newspaper ads or donor drives. We wished to explore whether subtle coercion might be occurring in such NDDs who are part of a larger community. One successful organization in a community in Brooklyn, NY, provides about 50 NDDs per year for recipients within that community. The donors answer ads in local papers and attend donor drives. Herein, we evaluated the physical and emotional outcomes of community-solicited NDDs in comparison to traditional NDDs who come from varied communities and are not responding to a specific call for donation. An assessment of coercion was used as well.

Content Analysis of Social Media Related to Left Ventricular Assist Devices

BACKGROUND

Social media have the potential to offer important benefits for patient education, support, and shared decision making. Despite the proliferation of social media use during the past decade, little is known about the scope and quality of available information, or the purposes that social media sites serve for patient decisional and support needs.

METHODS AND RESULTS

We conducted a mixed method study, including content analysis of social media and principal components analysis analysis of data sites discussing left ventricular assist device treatment for heart failure. This study explored aspects of interactivity, user-friendliness, appeal, medium, purpose, audience, and accuracy of information. Higher levels of interactivity (eg, posting comments) seem to enhance the appeal and usability of available information but also introduce greater potential for inaccuracy and inconsistency. The current lack of oversight into the content and quality of available information constitute a challenge for the reliable use of social media as forums for information-seeking and social network-based support.

CONCLUSIONS

We conclude that social media outlets constitute a promising source of informational and psychosocial support for patients, caregivers, and candidates, and if used in conjunction with patient-provider dialog, can contribute to informed decision making by facilitating reflection and discussion of personal concerns, values, and informational needs.

Ethical issues regarding related and nonrelated living organ donors

The ethics of the clinical practice of transplanting human organs for end-stage organ disease is a fascinating topic. Who is the "owner" of the transplantable organs of a deceased, brain-dead patient? Who should have a right to receive these organs? Who set the boundaries between a living donor's autonomy and a "paternalistic" doctor? What constitutes a proper consent? These questions are only some of the ethical issues that have been discussed in the last 60 years. All of these ethical issues are intensified by the fact that supply of human organs does not match demand, and that, as a consequence, living-donor organ transplantation is widely utilized. The aim of this article is not to be exhaustive but to present the general ethical principles of beneficence, nonmaleficence, and justice as applied to organ transplantation. Moreover, the topic of reimbursement for organ donation is also discussed.

"I want your kidney!" Information seeking, sharing, and disclosure when soliciting a kidney donor online

OBJECTIVE

This study investigates how people use the Internet to search for an altruistic kidney donor. Although many opinion pieces on this phenomenon have been written, this is the first qualitative study focused on online kidney solicitation from the potential recipient's point of view.

METHODS

Eight participants - four who successfully found donors and four who were still searching - were interviewed, and inductive content analysis was performed.

RESULTS

Three themes appear in our data: choosing to go online to find a donor, information hubs, and information flow. These themes emphasize the process of information seeking and disclosure when using the Internet to find an altruistic kidney donor.

CONCLUSION

The benefits from searching online are not limited to the possibility of finding a kidney donor. Our participants also experience a wide variety of socially supportive activities from their online networks. Additionally, our participants felt that the potential benefits of finding a donor online outweighed risks to their privacy.

PRACTICE IMPLICATIONS

Not all potential recipients will find a kidney donor online. Participants indicated that through sharing educational information, staying positive, and actively maintaining their online solicitation efforts they received numerous social benefits even if they did not find a kidney donor.