Teaching Ethics in Organ Transplantation

Cases and Movies

Silke Schicktanz, Claudia Wiesemann

• Publisher: University of Akron Press
• Year: 2011
• ISBN:
  9781937378110
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Organ transplantation allows modern surgeons to give "new life" to chronically ill patients. At the same time, the new opportunities raise ethical questions concerning human identity and the definition of the human body. These concerns do not play out the same in all cultures or in every situation. This collection of 30 case studies illustrates the range of global and local, ethical, social, and cultural problems associated with organ transplantation. The collection also provides a list of popular movies and websites to aid instructors and their students. This work is aimed at educators in medicine, health care, philosophy, and religious studies.

Part B: Case studies

I. Case: Living kidney donation – the right to refuse

Mr. A.B.⁴ is 57 years old. He is an Arab citizen, married and has three children: a 22-year-old son, a student; a 27-year-old son, married and father of two young children; and a 32-year-old daughter, unmarried.

Mr. A.B. has been suffering from acute chronic renal failure for two years and needs dialysis three to four times a week – nevertheless he is unable to work and live a normal life. For two years he has been living on social welfare.

His three children were medically examined and found to serve as potential kidney donors to their father. The question was: Which of the three children should be chosen as donor? They were sent to the psychologist for a psychological examination of their mental well-being – and the youngest son was diagnosed to be the most resilient for this purpose. However, the psychologist was later informed that the family had decided on choosing the 32-year-old daughter as donor. According to their ethnic background, the daughter as an unmarried female is considered to have an inferior family status. Moreover, the psychologist was informed in a face-to-face talk to her, that her right to refuse had not been considered by the family.

Moshe Zaki, Israel

Please discuss the alternatives and justify your answer!
How should the psychologist respond?

1. The psychologist informs the family and the father that their decision to choose their daughter as donor is ethically respected because it is culturally reasonable.
2. The psychologist pleads for a universal ethical code according to which the family has to respect the individual’s right to refuse to be a donor which also applies to their daughter.
3. The psychologist appeals to the local welfare services to offer the daughter legal and social assistance to convince the family not to force her.
4. The psychologist convinces the medical doctors that they should feign serious disease of the daughter which would exclude her as donor because of “medical reasons”.

⁴ Names of persons and places have been anonymized in order
to protect the privacy of the persons involved.

II. Case: Living liver donation and competent decision making

35-year-old Mrs. C.D., mother of a daughter aged six, is a patient of colitis ulcerosa and has developed cirrhosis of the liver as a result of cholangitis. In addition, a carcinoma of the intestine was detected a few years ago which led to the removal of the entire intestine. During the operation a lymph vessel was injured, which is why lymph now flows into her abdomen and has to be pumped off every other day. On account of the bad liver function, doctors advise against an operation and plead for transplantation. However, Mrs. C.D.’s liver function reading is too good for her to become a candidate for urgent transplantation on the waiting list. With no live-in partner to step in, both her mother and her aunt’s live-in partner Mr. B. have declared their willingness to function as donors.

For medical reasons (Mrs. C.D.’s mother is obese) the doctor in attendance favors Mr. E.F. as possible donor. Mr. E.F. is 46 years old and currently working as a construction worker, constantly away on a job. As a temporary worker he will have to stop working for some time if becoming a donor (at least three months, totally resting for the first eight weeks) and he may lose his job, which, according to him, he would not mind. Mr. E.F. attended elementary school for eight years.

During the required psychological examination he appeared to have limited intelligence. Other than most patients he has never sought information on living organ donation, either by reading about it or by looking it up on the internet. He completely trusts the doctors and expects full recovery with his liver renewing itself. The impression one gets is that Mr. E.F. has so far not quite realized the risks of the operation (mortality risk for living liver donors is approx. 1%). Neither has he been in a hospital before. Furthermore, he expresses towards the psychologists that Mrs. C.D. presses for something to be done and has pinned all her hopes on Mr. E.F. which he wants to fulfill.

Merve Winter and Oliver Decker, Germany

Please discuss the alternatives and justify your answer!
How should the psychologist respond?

1. The psychologist agrees to Mr. E.F. becoming a donor for Mrs. C.D. as it is Mr. E.F.’s expressed wish.
2. The psychologist rejects Mr. E.F.’s offer of becoming a donor, because the base condition of informed consent is not fulfilled.
3. The psychologist invites Mrs. C.D. as well as other relatives to discuss other alternatives for the donors.
4. The psychologist again discusses the case with the surgeon to convince him that the transplantation should be postponed until Mrs. C.D. be an official patient on the waiting list and has a higher chance as an emergency case to receive a post-mortem liver.

III. Case: Parental living kidney donation

Mrs. G.H. and Mr. I.H., parents of the four- year-old R., are both willing to undergo parental live kidney donation. They have explained that this is “natural” to them; it is a matter of “parental responsibility”. Mrs. G.H. has explicitly said that if one has brought a child to this world, one should do what one can for the child’s health and well-being. Both parents have also explained that they are more than happy to start the medical test and examination procedure, which will show whether they are medically acceptable as donors.

However, when Mrs. G.H. underwent the procedure, the doctors found that she could not be accepted as donor since she has a cyst on one of her kidneys. For Mrs. G.H., these were “just terrible” news. The medical professionals turned to Mr. I.H. Had he considered parental live kidney donation? Mr. I.H. explained that he really wanted to donate.

Today, however, Mr. I.H. gets the response that he is medically unacceptable as donor because he has rheumatic fever. Mr. I.H. already knows this and he gets upset. He explains that, in his view, it is better that he donate now, while both of his kidneys are ok. They may get destroyed later on in life, he says, and “it is better that my daughter gets one of them, while they’re healthy, and she lives.” He adds that he thinks he has the right to decide on his own what happens to his body.

The ethical committee and physician involved are unsure how to decide as the surgeons do not want to harm the donor which means exposing the father to serious health risks. On the other hand the parents insist in their “parental responsibility”.

Kristin Zeiler, Sweden

Please discuss the alternatives and justify your answer!
How should the doctor respond?

1. The doctor rejects Mrs.G.H. and Mr. I.H.’s offer of becoming donors, because the risk in the future is too high.
2. The doctor agrees to Mr. I.H. becoming a donor for his child, because of Mr. I.H.’s expressed decision to give his life for the life of his daughter.
3. The parents should reconsider what they mean by “parental responsibility” and how this risk will also affect their daughter psychologically. The transplantation will be postponed and the father will not be allowed to donate, because his ability to make an autonomous decision seems to be seriously weakened by an overstated understanding of “parental responsibility”.

IV. Case: Living liver donation – the right to refuse

K.L. is a nine-year-old girl. She was referred to the paediatric clinic with symptoms of acute hepatic failure. The clinical signs suggest that she might be suffering from Morbus Wilson which has not been diagnosed so far since she was asymptomatic and perfectly healthy until now. However, she was initially treated for influenzal infection, and then suddenly had fallen into a coma due to acute and irreversible liver failure. The patient also developed renal failure being already anuric due to a hepatorenal syndrome. Her condition has actually become so severe that liver transplantation turns out to be the only available therapy. The parents are spontaneously willing to donate a part of their liver. However, the computed tomography reveals that only the mother can donate due to size match and anatomical reasons. During the preoperative interview, she has to be informed about the possible risk of major surgical complications and the unlikely worst-case scenario of even dying due to hepatic failure related to the procedure (<0.5 mortality risk, post-operative complications in about 40% of donors; serious complications (i.e. lasting disability or death) occurs in up to 5% of postoperative complications). This, quite unexpectedly to herself, causes a major conflict because of her own history: when she was ten years old, her own mother had to undergo liver surgery because of a haemangioma and did not survive the intervention. She therefore grew up as a half-orphan. She is now afraid that she might not survive partial liver donation and that her daughter would have to grow up without her mother. Moreover, she fears that in this worst case her daughter would be affected by the knowledge that the operation rescuing her own life had cost her mother’s life. She is reluctant to consent to the surgical procedure.

Gabriele Werner-Felmayer, Manuel Maglione and Gerald Brandacher, Austria

Please discuss the alternatives and justify your answer!
How should the surgeon proceed?

1. The surgeon informs the mother about the improvement in surgical techniques in the last 20 years as well as about the donor’s and recipient’s outcome in the planned procedure. He explains that in a renowned transplant center like the one where she and her daughter are being treated, complications with fatal outcome for donors are most unlikely (the overall statistics show <0.5% mortality; moreover, the clinic has a reputation as an excellent hepatobiliary and transplantation center with about ten living-donor liver transplantations per year and a high number of liver resections in which so far none of the donors have died).
2. The surgeon explains the alternative to living liver donation: the daughter could be listed as a top priority recipient which would ensure post-mortem donor transplantation. Yet, the time frame and the chance to receive an organ of appropriate size and quality are uncertain because no brain-death donor is at the moment available. Certainly, because of the daughter’s medical condition, her chances of survival would be much higher in case of a living liver donation as this would save valuable time in the limited span available for intervention.
3. The surgeon explains that other relatives could donate. This, however, would be a time-consuming procedure with the possibility that no suitable donor will easily be found among them.
4. After having informed the parents about all the facts mentioned in points 1-3, the surgeon suggests to take a break giving them a chance to discuss and reconsider the situation either alone, or, if they wish, together with a psychologist. He also suggests to register the daughter for deceased donor transplantation immediately as a back-up in case the mother wants to refuse donation.

V. Case: Living organ donation – legal limits to non-family related donations

In Martínez, near Buenos Aires, Mrs. M.O. required judicial authorization for an ablation of kidney to be performed on her, to implant it in Mr. N.P. As the two were not relatives, the national Law of Transplants requires a court decision.

Mr. N.P. is on the waiting list because of chronic terminal kidney failure. He needs three sessions of dialysis per week. The only recommended therapy is renal transplant. Statistics show a 20% mortality rate for patients with his condition on dialysis, and 2% for those with renal t...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Part A: Introduction
• Part B: Case studies
• Part C: Movies as teaching material – ethical issues in organ transplantation
• Table of movies
• List of Contributors