The ethics of organ donation, donation after circulatory determination of death, and xenotransplantation from an Islamic perspective

Ethical considerations in xenotransplantation of thoracic organs - a call for a debate on value based decisions

Xenotransplant covers a broad ethical territory and there are several ethical questions that have arisen in parallel with the technological advances that have allowed the first porcine transplants to occur. This brief communication highlights ethical considerations regarding heart and lung xenotransplantation, with an emphasis on unresolved value-based concerns in the field. The aim of this text is therefore to encourage the readers to consider the vast potential of this emerging technique to do good, but also the risk of doing harm, and to participate in a discussion. The list of questions presented here is not exhaustive but hopefully represents some of the questions that appear to be most pressing as the field advances. The focus is on the value-based, or ethical questions, not the questions related to the practical medical procedures.

Moral approval of xenotransplantation in Egypt: associations with religion, attitudes towards animals and demographic factors

Xenotransplantation has great potential as an alternative to alleviate the shortage of organs for donation. However, given that the animal most suited for xenotransplantation is the pig, there are concerns that people in Muslim countries may be more hesitant to morally approve of these procedures. In this study, the moral approval of xenotransplantation was assessed in a group of 895 participants in Egypt. The results showed that religiosity itself does not predict moral approval of xenotransplantation, but religious identity does, as Muslims are less likely to approve of xenotransplantation than Christians. However, the strongest predictor of moral approval of xenotransplantation was gender, with women displaying less approval. A partial mediating factor in this association was concern for animal welfare. Based on these results, some implications for public policy are discussed.

Evaluation of knowledge, attitude, and awareness of liver transplant patients toward xenotransplantation

BACKGROUND

Xenotransplantation (XTx) is an alternative treatment for organ scarcity. Investigating the acceptance of XTx among patients from diverse cultural and religious backgrounds is essential. This study aimed to evaluate the knowledge, attitudes, and awareness of XTx among patients undergoing liver transplant (LT).

METHODS

This descriptive study was conducted between November 2022 and August 2023. The study population comprised LT patients aged ≥18 years who were admitted to the hepatology clinic of a university hospital in Turkey. Of the 360 patients (n = 360) interviewed, 351 were deemed eligible for inclusion. A questionnaire was used to collect data. The Kolmogorov-Smirnov test, median, standard deviation, minimum-maximum, number, percentage, and Pearson's chi-square test were used for statistical analysis.

RESULTS

Of the patients, 78.3% were religious and adhered to religious requirements, and 87.2% considered their religious beliefs when making important decisions. In all, 41.3% of the participants believed that organ or tissue transplantation from animals to humans is ethical, while 70.1% of the participants believed that organ and tissue transplantation from non-halal animals to humans was impossible. Specifically, 56.7% would not allow organ or tissue transplantation from a non-halal animal to themselves or a relative. Knowledge and attitude towards XTx were not affected by transplantation type (p > .05), but were affected by sex and educational level (p < .05).

CONCLUSION

This study found that LT patients generally oppose XTx. To enhance knowledge and awareness, religious leaders and healthcare professionals should organize comprehensive and effective seminars on this topic.

The view of the three monotheistic religions toward xenotransplantation

Xenotransplantation, transplanting animal organs into humans, may offer a solution to the shortage of organs for transplantation. This would increase the chances for scheduled, elective transplantation, even for patients currently ineligible for receiving a human organ. However, xenotransplantation raises specific ethical and philosophical issues, that is, a personal identification of the body parts with the soul and spirit, the relationships between humans and animals, and challenges related to issues of medical and social ethics. The three monotheistic religions have laws and perspectives pertaining to xenotransplantation. This scholarly review examines the theology and viewpoints of the three monotheistic religions and their concerns regarding xenotransplantation (interspecies) in terms of religious-legal rulings, the ethical considerations related to the procedure, through religious scriptures and rulings of scholars of the three faith communities. This review should be viewed as a continuation of an extensive investigation of these issues, as the field of transplantation advances toward clinical trials. It was found that there are no fundamental religious reasons presented by any of the three religions to prohibit the use of animal organs as a means of treating severe and life-threatening conditions. However, there are certain limitations prescribed by each religion relating to the treatment of the animals and the choice of organs to be transplanted.

Organ Donation and the Dead Donor Rule: A Synopsis of Pressing Ethical Controversies and Practical Questions

OBJECTIVES

As a result of recent biomedical advancements, organ donation continues to save and enhance countless lives globally.Yet,the gap between the organ supply and demand persists, leading to approximately 17 people dying each day waiting for an organ transplant and another person being added to the transplant waiting list every 9 minutes. This gap persists, in part, because of ethical and practical concerns arising from ambiguities surrounding death determination before donation and the dead donor rule. In this study, we discuss challenges related to defining death in the context of organ donation, critical and tolerant views on the dead donorrule, and possible avenues by which some of the ambiguities and ethicaltensions related to organ donation may be resolved.

MATERIALS AND METHODS

We reviewed literature opinions and data pertaining to cultural and religious influences affecting societal attitudes toward death determination and organ donation and examined the future of deceased organ donation.

RESULTS

Cultural and religious influences affect societal attitudes toward death determination and organ donation. There is a plurality of views on the matter that may be assuaged to an extent by standardized death determination criterion that could be implemented globally or by identifying alternative therapies other than human organ transplant.

CONCLUSIONS

The debate regarding death and the acceptability of dead donor organs fortransplant does not have a straightforward solution, and efforts are needed to overcome social, cultural and religious objections.

Organ Donation in the Emergency Department: Awareness and Opportunities

Background The only cure for end-organ failure is transplantation. Unfortunately, there are fewer organ donors than patients. Currently, the majority of organ donations come from live or brain-dead donors. In order to expand the pool of potential organ donors, the emergency department should be utilized effectively. Objectives The primary goal of this research is to determine emergency physicians' knowledge, awareness, and attitude about organ donation. Methodology A cross-sectional study was conducted through different hospitals in Saudi Arabia. It includes 106 physicians in the adult emergency departments. Results The majority (84.9%) of the participants never reported any case in the emergency department as a potential case for organ donation. In addition, 54.8% of the participants report having little to no knowledge of the ethical issues of organ donation. Furthermore, 66.1% of respondents claim to have little to no knowledge of the goals and duties of the SCOT (Saudi Center for Organ Transplantation). It was interesting to see that 96.2% of the participants reported that their organizations do not have any policies or procedures in place regarding organ donations. Regarding education, 99 (93.4%) physicians did not participate in any organ donation course, training, or teaching program about organ donation. At the same time, 67 (63.2%) physicians concurred that participation in a training program is essential. Moreover, 68 (64.2%) physicians believed that organ donation should be a part of every end-of-life case. In order to improve the donation process in the emergency department, 88 (83%) physicians would want a well-established program with defined policies and procedures. Conclusion According to our findings, the emergency physician has inadequate expertise and information on organ donation rules and procedures, which has resulted in a missed opportunity to recruit more potential donors. We recommend instituting clear policy and procedures and educating the physicians and all emergency medicine staff to have better outcome.

Xenotransplantation: A historical-ethical account of viewpoints

Formal clinical trials of pig-to-human organ transplant-known asxenotransplantation-may begin this decade, with the first trials likely to consist of either adult renal transplants or pediatric cardiac transplant patients. Xenotransplantation as a systematic scientific study only reaches back to the latter half of the 20th century, with episodic xenotransplantation events occurring prior to that. As the science of xenotransplantation has progressed in the 20th and 21st centuries, the public's knowledge of the potential therapy has also increased. With this, there have been shifting ethical stances toward xenotransplantation in key areas, such as religious and public viewpoints towards xenotransplantation, animal rights, and public health concerns. This review provides a historical-ethical account of xenotransplantation and details if or how viewpoints have shifted over time.

The Need to Adjust the Informed Consent for Jewish Patients for Treatments Involving Porcine Medical Constituents

In order to obtain full informed consent for medical treatments, it is imperative to provide patients of diverse ethnic backgrounds with all relevant information. Since the pig is considered an impure animal in Judaism, Jewish patients may wish to be informed of porcine-derived substances used in treating. The present study is the first to explore the level of knowledge of Jewish participants as to whether the medical use of pig is permitted by their religion, and the extent to which they believe it should be permitted. 714 Jewish participants completed a study questionnaire that included 15 medical uses of pigs. Findings indicated that the knowledge of Jewish law regarding these uses is a significant mediator in predicting the attitude toward the permissibility of these uses. I conclude with practical recommendations as to how to enhance cultural competence and improve the informed consent process when treating Jewish patients with porcine-derived constituents.

An Interpretive Approach to Religious Ambiguities around Medical Innovations: The Spanish Catholic Church on Organ Donation and Transplantation (1954-2014)

How do institutionalized religions solve moral ambiguities around controversial medical innovations and public health issues? Most religions have moral guidelines about what can and cannot be done to people's bodies, but these guidelines are not always straightforward and, when faced with certain scientific advances, can come into contradiction with other doctrinal principles. I address this theoretical puzzle through the empirical case of the Spanish Catholic Church's discourse on organ donation and transplantation during the second half of the twentieth century. Drawing on an interpretive analysis of official statements by the Spanish Catholic Church, and of the media coverage of the religious debate over organ donation and transplantation in Spain from 1954 onwards, I show that the first experiments in organ transplantation faced the Church with a contradiction between its altruistic teachings and its beliefs in the sacredness of human life. Faced with an interpretive dilemma, the Church produced a context-specific version of its official doctrine friendly to organ donation and transplantation. It did so by activating its altruistic elements and suppressing sacralized meanings of the body, thus aligning organ donation with Catholic values of generosity and fraternal love. My study theorizes this moral alignment as a semantic overlap realized through historically situated institutional discourse. Additionally, it incorporates 24 primary and secondary sources on comparative cases to propose three facilitating factors that enabled and encouraged the Spanish Catholic Church to embrace a controversial medical practice.

Practical ethical concerns in allocation of pig kidneys to humans

The fundamental ethical question of whether pig organs should be transplanted into humans has been settled, as recent surgeries demonstrating proof of concept demonstrate. Other issues need to be considered and reconciled before xenotransplantation of pig kidneys becomes a solution to the organ shortage for people waiting for a kidney transplant or as a viable alternative to the deceased donor or living donor human kidneys. Human trials will be needed beyond brain-dead individuals to show that xenotransplantation is safe from immunologic and infectious standpoints. Transplant centers will need to show that xenotransplantation provides a long-term benefit to recipients and is financially viable. If trials are successful and receive regulatory approval, pig xenotransplants may become another option for people waiting for a kidney. Before patients are discharged with a functioning xenograft, practical issues with ethical implications remain.

The Use of Porcine-Derived Materials for Medical Purposes: What do Muslim and Jewish Individuals Know and Opine About It?

Porcine-derived medical products represent an effective solution for a wide range of human suffering, yet this may contradict Muslim and Jewish religious prohibitions against consuming pig. The present study evaluated the level to which Muslim and Jewish participants are knowledgeable about the conditions permitting porcine-based treatments and explored their attitudes toward the permissibility of these treatments. A questionnaire that presented fifteen medical uses of porcine-derived products was completed by 809 Muslims and 714 Jews. Neither Muslim nor Jewish participants are knowledgeable about the religious rulings of their religions which permit the use of pig for life saving. Participants of both groups objected to the view that porcine-derived materials should be permitted. The findings imply that the attitude toward porcine-derived materials for medical use is contingent upon the knowledge or lack thereof that individuals have regarding the permissibility of such use. We offer useful recommendations to improve the informed consent process before conducting porcine-based treatments.

Lebanese medical students' knowledge on and attitude toward xenotransplantation and its ethical issues: A cross-sectional study

INTRODUCTION

Xenotransplantation is the transplantation of animal parts into humans. This study's aim is to assess the Lebanese medical students' attitude toward xenotransplantation and their knowledge of its related ethical issues.

METHODS

A questionnaire was answered by 120 Lebanese medical students. Statistical analysis and ethical reflections were performed on the results.

RESULTS

Out of the 120 participants, 100 already knew about xenotransplantation, and 61.7% of the students believe that it is applied clinically. Only 25% trust that the animals need to be genetically modified for the organs to be eligible for transplantation. About 25.8% and 46.7% of the students, respectively, strongly agree that the patients' and physicians' beliefs play an important role in agreeing to the procedure. Students were likely to accept the animal organ for transplantation if the transplant could completely cure or improve the course of an untreatable disease (86.6% and 75.0%) or if the outcomes and risks were the same as with a human transplant with a shorter waiting period (71.7%). Students who agreed that animal rights and welfare/wellbeing should be respected tended to disagree with the statement that it is acceptable to use animals for human ends (p = .026).

CONCLUSION

Medical students proved to be knowledgeable on the ethical dilemmas related to xenotransplantation and showed a favorable attitude toward this procedure, which is crucial in its establishment as an absolute clinical reality in the near future and in the development and strengthening of research in this field.

Opinions of nursing and theology faculty students on Xenotransplantation

BACKGROUND

It is mentioned that students' opinions about xenotransplantation (XTx) have been explored in a limited manner. In particular, there is no literature in Turkey on Nursing and Theology students' perspectives on XTx. This research aimed to find out what Nursing and Theology students thought about XTx.

METHODS

This descriptive and cross-sectional study was conducted on students studying at the Theology and Nursing faculties. The study population consisted of 2.581 students educated in these faculties. Without using any sampling method, it was aimed to reach all students, and 1.780 (70%) students were reached. Data were collected using a participant identification form and questionnaire form, which the researchers developed.

RESULTS

The difference between the answers given by the Nursing and Theology students to the information statements about XTx was statistically significant (p < .001). Nursing and Theology students' attitudes to organ or tissue Tx from halal animals in case of necessity were positive (p < .001). While the nursing students' attitude toward organ or tissue Tx from non-helal animals in case of necessity was negative, Theology students had no idea (p < .001). In other attitude statements, while nursing students responded positively, Theology students responded as "I have no idea" (p ≤ .001).

CONCLUSION

Theology students tended to have the question about XTx and only positive attitude towards XTx from halal animals. Nursing students mostly had positive attitude, but negative when XTx is practiced out of necessity.

The double gender bias in parental kidney donation among Muslim Arab patients

Previous studies showed that it is usually the mother who agrees to donate her kidney to a child with an end-stage renal disease, while the fathers tend much less to donate. The present study sought to explore decision-making regarding which parent would donate a kidney to their child. Interviews were conducted with twenty-five mothers and six fathers who donated a kidney to their child. Analysis of the narratives reveals unwillingness to donate a kidney to a sick daughter and five reasons why mothers are more willing to donate than fathers. Our study shows that parents' patterns of kidney donation to their children powerfully demonstrate gender relations in Arab society and that culturally related matters have a significant impact on human organ transplantation, hence on quality of life and the chances of survival of nephrological pediatric patients. We recommend that the nursing staff enlist the help of Muslim clerics to increase the willingness of fathers to donate a kidney, for sons as well as for daughters. We call for designing education campaigns aimed at raising awareness and encouraging changes in the attitudes of the families of pediatric ESRD patients as well as of physicians.

Informing American Muslims about living donation through tailored health education: A randomized controlled crossover trial evaluating increase in biomedical and religious knowledge

Biomedical and religious knowledge affects organ donation attitudes among Muslims. We tested the effectiveness of mosque-based, religiously tailored, ethically balanced education on organ donation among Muslim Americans. Our randomized, controlled, crossover trial took place at 4 mosques randomized to an early arm where organ donation education preceded a control educational workshop or a late arm with the order reversed. Primary outcomes were changes in biomedical (Rotterdam Renal Replacement Knowledge Test living donation subscale, R3KT) and religious (Islamic Knowledge of Living Organ Donation, IK-LOD) living kidney donation knowledge. Statistical analysis employed a 2 (Treatment Arm) X 3 (Time of Assessment) mixed-method analysis of variance. Of 158 participants, 59 were in the early arm and 99 in the late arm. A between group t test comparison at Period 1 (Time 1 - Time 2), demonstrated that the early arm had a significantly higher mean IK-LOD (7.11 v 5.19, P < .05) and R3KT scores (7.65 v 4.90, P < .05) when compared to the late arm. Late arm participants also had significant increases in mean IK-LOD (5.19 v 7.16, P < .05) and R3KT scores (4.90 v. 6.81, P < .05) postintervention (Time 2-Time 3). Our novel program thus yielded significant kidney donation-related knowledge gains among Muslim Americans (NCT04443114 Clinicaltrials.gov).

The impact of religiously tailored and ethically balanced education on intention for living organ donation among Muslim Americans

We tested the efficacy of religiously tailored and ethically balanced education upon living kidney organ donation intent among Muslim Americans. Pre-post changes in participant stage of change, preparedness, and likelihood judged efficacy. Among 137 participants, mean stage of change toward donation appeared to improve (0.59; SD ± 1.07, P < .0001), as did the group's preparedness to make a donation decision (0.55; SD ± 0.86, P < .0001), and likelihood to donate a kidney (0.39; SD ± 0.85, P < .0001). Mean change in likelihood to encourage a loved one, a co-worker, or a mosque community member with ESRD to seek a living donor also increased (0.22; SD ± 0.84, P = .0035, 0.23; SD ± 0.82, P = .0021, 0.33; SD ± 0.79, P < .0001 respectively). Multivariate ordered logistic regression models revealed that gains in biomedical knowledge regarding organ donation increased odds for positive change in preparedness (OR = 1.20; 95% CI 1.01-1.41, P = .03), while increasing age associated with lower odds of positive change in stage of change (OR = 0.98, 95% CI 0.96-0.998, P = .03), and prior registration as an organ donor lowered odds for an increase in likelihood to donate a kidney (OR = 0.22; 95% CI 0.08-0.60, P = .003). Our intervention appears to enhance living kidney donation-related intent among Muslim Americans [Clinicaltrials.gov number: NCT04443114].

The Development and Validation of the Islamic Knowledge of Living Organ Donation Knowledge Scale for Measuring Organ Donation Knowledge Among Muslim Communities

Introduction:

Studies around the world demonstrate that Muslim attitudes toward organ donation are closely tied to religion, but also that Muslim publics suffer from a lack of detailed knowledge about the Islamic perspectives on organ donation. Consequently, organ donation professionals and stakeholders are increasingly addressing knowledge gaps in the Muslim community through educational interventions. Yet, a measurement of Islamic knowledge of organ donation, and thereby the efficacy of such education, is not available.

Research Question:

To present the development and psychometric evaluation of the Islamic Knowledge of Living Organ Donation scale, designed to measure knowledge of the Islamic ethicolegal stances, and their underlying rationale, regarding living organ donation.

Methods:

Items were developed based on a review of Islamic juridical perspectives on organ donation, addressed knowledge gaps pervading Muslim communities, and pilot tested. The scale was statistically validated and psychometrically analyzed with a sample of 158 mosque-going Muslims in the United States.

Results:

The 9-item Islamic Knowledge of Living Organ Donation scale was found to be reliable (Cronbach α: 0.86), unidimensional, independent of religiosity, and predictive of social attitudes toward organ donation.

Discussion:

The survey can be used to validly assess Islamic knowledge of living organ donation among Muslim communities in research, educational, and clinical settings.

The Moral Status of Organ Donation and Transplantation Within Islamic Law: The Fiqh Council of North America's Position

BACKGROUND

Muslim communities tend to hold more negative attitudes toward organ donation than other communities. These views, in part, reflect the diverse views of Islamic scholars who debate the conditions under which donation and transplantation is morally licit. In December 2018, the Fiqh Council of North America (FCNA) weighed in on the US context of donation and transplantation through an Islamic ethico-legal verdict (fatwa).

METHODS

Between 2016 and 2018, FCNA members engaged in multidisciplinary research using conventions of collective Islamic moral deliberation. They examined rulings on organ donation and transplantation issued by Islamic jurists and juridical councils abroad, convened with organ donation and transplantation professionals and stakeholders including families and patients, and consulted medical and bioethics experts.

RESULTS

FCNA judges organ donation to be morally permissible from the perspective of Islamic law and ethics, subject to several conditions. These include first-person authorization, that donation occur either while living or after circulatory declaration of death, harm to the donor is minimized, reproductive organs are not donated, among others. Organ transplantation, in general, was also deemed licit.

CONCLUSIONS

FCNA's verdict uniquely addresses American contexts and has several clinical practice implications. By sharing their perspective with academic and professional stakeholders, the council aims to provide nuanced guidance for assisting Muslims in making informed choices regarding these procedures and further societal dialogue on the ethics and practices of donation and transplantation.

Seven Faces of a Fatwa: Organ Transplantation and Islam

A new fatwa was announced by the British National Health Service (NHS) in June 2019 to clarify the Islamic position on organ donation. Additionally, the NHS promotional material presents brief arguments for and against organ donation in Islam. However, to date, research into the various fatwas on organ donation is required. This article goes beyond the dichotomous positions mentioned by the NHS and goes on to explore and summarise seven conflicting views on the issue extrapolated from an exhaustive reading of fatwas and research papers in various languages since 1925. Our discussion is circumscribed to allotransplant and confined to the gifting of organs to legally competent adult donors at the time of consent. These arguments include an analysis of the semantic portrayal of ownership in the Qur’an; considering the net benefit over the gross harm involved in organ donation; balancing the rights of the human body with the application of the rule of necessity; understanding the difference between anthropophagy and organ transplantation; understanding of death, and the conceptualisation of the soul. We argue that, given the absence of clear-cut direction from Muslim scripture, all seven positions are Islamic positions and people are at liberty to adopt any one position without theological guilt or moral culpability.

A Mosque-Based Qualitative Study on American Muslim Women's Organ Donation Beliefs

INTRODUCTION

Detailed studies on the associations between religious beliefs and organ donation attitudes among religious minorities remain wanting. Although Muslims appear to have low rates of support for donation, how these behaviors relate to religious frameworks requires further investigation.

METHODS

We sought to explore the relationship between religious beliefs (Islam) and organ donation attitudes through focus groups with 43 Muslim women from 5 Chicago-area mosques. Purposive selection of mosques generated near-equal representation of Arabs, South Asians, and African Americans, as well as diversity in education and income. Using the theory of planned behavior as our conceptual framework, we expanded the traditional normative domain to include religiously informed beliefs.

FINDINGS

We found that the relationship between religious beliefs and Muslim attitudes toward organ donation is more complex than commonly perceived. Regarding the Islamic ethicolegal permissibility of organ donation, participants expressed a range of normative beliefs. Furthermore, participants voiced concerns beyond religious permissibility, including anxieties over modesty violations during the donation process, as well as concerns about purported black market organ trade and medical risks to donors.

DISCUSSION

Given that participants raised religious, societal, and biomedical concerns regarding organ donation, our findings suggest that effective educational programs should involve nuanced curricula that teach to the plurality of Islamic ethicolegal opinions and discuss transplantation processes within the United States.