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  • One Life Saved. Two Lives Transformed.

  •   Health Talk: Organ Donation

    Abigail Trafford
    Host: Abigail Trafford
    Hosted by The Post's Health Editor
    Tuesday, June 15, 1999

    Increasingly healthy people are offering kidneys or part of their liver to people in need. Is this the future of organ donation?

    Our guest this week for "Health Talk" was Jeffrey Kahn, director of the Center for Biomedical Ethics at the University of Minnesota.

    Abigail Trafford: Welcome to health talk. Would you give part of your liver or one of your kidneys to someone you've never met--but who desparately needed a life-saving organ? Joining us today is Jeff Kahn, medical ethicist who will take us into this uncharted territory. Send us your questions.

    Abigail Trafford: Jeff, what are the main ethical issues involved in the so-called stranger to stranger transplant?

    Jeffrey Kahn: Abbie--I think there are a few main issues:

    1. whether anything of value changes hands--making sure that the donation is totally voluntary
    2. being confident that the motivations of the donor are "pure"--that there are no psychological issues
    3. making sure that the risk being undertaken by the donor is not so great as to outweigh the benefit to the recipient. For instance we wouldn't allow someone to give their heart to another--related or stranger

    Abigail Trafford: The main increase in living unrelated donors has occurred with kidney transplants Are there special risks and ethical hurdles involved with kidney transplants? Do you think this trend in organ donation will increase significantly?

    Jeffrey Kahn: I think that unrelated donation occurred first in kidneys is that:

    1. people can live very well with one kidney, and removing a kidney is relatively uncomplicated.
    2. the risk of kidney donation is not too great--risk of general anesthesia, risk of complications from surgery like infection; but not great enough for us to say the risk is too great to allow someone to give a kidney for the benefit of someone else.

    The list of organs for which living donors is possible is growing--livers, as reported in the story in today's Health section, pancreas, even partial lung transplants. But each of these carries significantly more risk than does kindney donation.

    Washington, D.C.: Is the procedure more risky with a donor who is unrelated to the recipient?

    Jeffrey Kahn: It's not more risky for the donor--the risk of giving a kidney for your brother is no more risky than it would be for a stranger. And with matched donors and recipients, and the drugs that are now used to prevent rejection, the risk to recipients is more or less the same than if the donor were related.

    Washington, DC: What are the risks in a man donating a kidney? Will he still be able to start a family?

    Jeffrey Kahn: Donating a kidney should not affect a man's ability to father children. People who live with one kidney (instead of the normal two) have no ill effects.

    Washington, D.C.: Are there any restrictions as to who can or cannot donate organs?

    Jeffrey Kahn: People are not allowed to donate for money, or if they don't meet certain medical criteria. They also must be screened with a battery of pscyhological tests, and they are not allowed to donate if giving an organ will jeopardize their health.

    Washington, D.C.: What risks are involved in donating an organ? How can a donor be assured that the procedure is safe?

    Jeffrey Kahn: The risks (and benefits) are all carefully explained in a process called informed consent, where the donor is giving all the information he or she needs or wants to know regarding the safety of the process, how it will be carried out, it's risks, etc. All transplant centers use this process, and it assures that donors have a full understanding or what they're getting into.

    Mt. Rainier MD: The article in the Post today talked about a risk -to the donor- of death of about 3 in 10,000. Pretty good odds. Is there any way they can be improved or is this the basic risk involved in surgery and anesthesia? Are less risky anesthetics being developed?

    Abigail Trafford: The main risk does come from the surgery and anesthesia, but because donors are so carefully selected, the general risks of surgery and anesthesia are probably lower. But there is always a risk. How do you make sure that a prospective donor understands the risks?

    Jeffrey Kahn: The process of informed consent (see my most recent post) should address how we make sure people know what they're getting into. But at base, we're asking people to undertake a risky procedure that will not have any direct medical benefit to them, but will only medically benefit someone else. I think that splitting apart risk and benefit this way is the most serious ethical issue in living donor transplants.

    Washington, D.C.: Is it common for a donor to meet the recipient?

    Abigail Trafford: This is a brave new world! In the health section Don Colburn writes about a man who gave part of his liver to a stranger. He had heard about her when her father pleaded that needed a donor. He had the same blood type: B-positive. He said to his wife: "I'd do that in a heartbeat." He and his wife met the woman and her husband before the operation and all had dinner together. Each case is unique. Are there any ethical guidelines on what is a healthy relationship between strangers who get involved in an organ transplant?

    Jeffrey Kahn: It's up to the individuals, but the common practice is that the donors and recipients do not meet. There are concerns that one or the other will infringe on the privacy of the other, or in extreme cases, that sometime in the future a donor may show up on the doorstep of the recipient and say "I helped you once, and now I need your help." Keeping the process anonymous prevents these situations.

    Charlottesville, VA: What is a donors family charged by both the hospital and doctors to donate an organ?

    Abigail Trafford: Does the donor have to pay anything in this transplant. That doesn't seem fair! How are these transplants financed? Who pays the costs for the donor? And the recipient?

    Jeffrey Kahn: The only costs are for the work done in obtaining the organ, such as hospitaltization costs of the donor, costs of surgery, etc. The organ itself must be free, and the donor cannot receive any kind of payment, or anything of value, for the donation.

    Washington, DC: What age was the oldest man to receive a liver transplant?

    Abigail Trafford: What if any is the age limit for a donor? And what other qualifications must a donor have to be considered?

    Jeffrey Kahn: Abbie--the limit is based more on the quality of the organ than the age of the donor. So a 50 year old in excellent health might be allowed to donate, but a 25 year old who didn't take care of his body might be rejected.

    Columbia, MD: Found this web site today by accident - - where someone claims to be selling a kidney for 30,000. Hard to say if it's for real, but I believe it's against the law, isn't it? And as a recipient who was on dialysis and may need another some day, I must say that while it seems appalling on the surface, if I needed one, it was a match, I had the $$$, I hate to say I would have to give it some thought. What are your thoughts?

    Abigail Trafford: I thought it was illegal to sell organs for money. But is there an underground trade in organs? A loophole that allows people to get some kind of fee for donating an organ?

    Jeffrey Kahn: It it against federal law to buy or sell organs, or to receive anything of value (another organ in trade?) for a donation. There are stories of organs being sold from Chinese prisoners, but it is difficult to know whether the stories are true. Living donation allows people to jump the queue, since if you show up at a transplant center with someone who agrees to donate to you, your wait is over.

    Abigail Trafford: Jeff, how frequent are transplants between patients and "friends" or "neighbors." The Health section story features the tale of two friends: Linda Cheatham who was heading into kidney failure. And her friend Robin Ward who offered one of her kidneys. The two have remained close after the operation. Cheatham said that her friend is "my sister, as far as I'm concerned."

    Jeffrey Kahn: Abbie--I think this is a growing trend. We've moved from donation between siblings, to donations within families between people who are not blood relatives, to donations between people who share nothing more than the same community--church members, classmates, co-workers, and so on. From the perspective of transplant centers, any new sources have a positive impact, because every person who comes off the waiting list is a victory. So even a few people donating to "friends" is a good thing.

    Abigail Trafford: Are there special issues involved when a transplant takes place between friends? In the Health section, two cases of friend-to-friend transplants deepened their relationship. But what burdens does a transplant place on friendship?

    Jeffrey Kahn: Abbie--that's a good question. Giving up a body part might be the ultimate expression of friendship. It would put friends in an awfully difficult position if a needy recipient asked a friend to donate. I don't think that's how it usually happens, but rather that friends come forward. In addition to creating a new and unique bond, it may make recipients feel that they owe an obligation that they probably can never repay.

    Washington, D.C.: Are organs from a living donor more likely to succeed than from a deceased donor?

    Jeffrey Kahn: In the case of kidneys, living donations have a higher success rate than do cadaveric donations, though I'm not sure anyone knows exactly why. It may be that their is often less time out of the body for the organ. . . .

    Abigail Trafford: Jeff, I still don't understand how transplants are financed and what the burden might be for a donor. What about time lost from work? How long is the recuperation? Who pays for home health services, if needed? And what about the recipient? How much does a transplant cost--for donor and then the recipient. And who generally pays?

    Jeffrey Kahn: Abbie--you're right to point all that out. All health care costs are paid by the recipient. And there can be some help with travel costs, and time off from work. But no payment for the organ. Kidney donors can go home in a few days, and don't have too much recuperation time, unless you're talking about playing football or something!

    Most recipients have the transplant covered by insurance. The ongoing costs are related to the anti-rejection medications, which are not always covered long-term.

    Washington, D.C.: What do you think of Philadelphia's idea to have a reward system for organ donation?

    Abigail Trafford: What is "Philadelphia's idea" for a reward? How would it work?

    Jeffrey Kahn: The state of Pennsylvania is proposing to offer between $300 and $3,000 for funeral expenses to the families of people who donate their organs after they die. They hope it will encourage individuals and families to agree to donate. The question is whether it violates the law banning payment for organs--I think it comes awfully close, at least in spirit if not in letter of the law. And it runs the risk of commodifying the process and turning lots of people off to donation.

    Washington, D.C.: How can the medical field make living people more aware of the benefits of donating livers or kidneys?

    Abigail Trafford: First, Jeff, what are the benefits to the donor of giving up a kidney or part of another organ? What does the donor get out of it? How might that encourage other people to donate?

    Jeffrey Kahn: The benefits to the donor depend on his or her relationship to the recipient. If I donate to my sister or father, then I benefit by their continued good health (hopefully) and longer life (also hopefully). But if I donate to a stranger whom I never meet, then the only benefit to me is whatever benefit comes from doing a (very) good deed, from being altruistic. Those are real benefits, even though they aren't direct medical benefits to me.

    Silver Spring, MD: What exactly is a paired exchange? Are there further risks involved in this procedure?

    Jeffrey Kahn: Paired exchange is an idea by which people who aren't a match for a friend or loved one can "swap" organs. Say my brother needs a kidney transplant, but I don't match him; and your brother needs a kidney, but you're not a match. If I match your brother, and you match mine, we agree to swap. There is no more risk in the donation than in "normal" donation, but we'd have to guard against the possibility of one of us backing out. So we'd have to have our organs removed at the same time. Finally, we need to ask whether this swap qualifies as getting something of value in return for your donation--getting a kidney for my brother seems to qualify. . . .

    Abigail Trafford: When you screen potential "stranger" or "friend" donors, what do you look out for? Is there a personality type that rings alarm bells. Are you concerned that you would attract people with psychological problems that they are trying to work out by donating an organ?

    Jeffrey Kahn: There is a psychological battery administered to every living donor--friend, relative, or stranger. There are different concerns in each of the cases. For relatives, there are real concerns that donors feel pressured to donate, and an assessment needs to be made that assures everybody that the donor really wants to give up an organ. For friends or strangers, we're asking what motivates people to do this, since many of us wouldn't put ourselves at such risk for the good of someone we might not ever meet. So there are concerns that people might donate to atone for some sins in their lives, or to assure that they'll go to heaven, etc.

    Abigail Trafford: Jeff, what about a paired exchange between friends. What are the ethics of that? What would prevent somebody from "hiring" someone to make an organ donation as a paired exchange, or just to jump up on the waiting list?

    Jeffrey Kahn: That might be the next step. Of course we would need to make sure that people aren't being paid. There was a case here in Minnesota that shows the potential pitfalls of these complicated relationships: A woman's brother agreed to donate a kidney to the woman's fiance, in return for the fiance's taking out additional life insurance on the brother. After the transplant, the fiance broke off the engagement and ran off with one of his nurses, and the jilted woman and her brother filed suit for breach of contract!

    Washington, D.C.: What percentage of organ donors are living, as opposed to cadavers?

    Jeffrey Kahn: According to Don Colburn of the Post, UNOS (the national organ procurement organization), last year 43% of kidneys transplanted were from living donors.

    Abigail Trafford: We've come to the end of the show. Thank you Jeff for taking us down this novel road. And thank you all for your questions. See you next week, same time, same place.

    © Copyright 1999 The Washington Post Company

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