LIVER TRANSPLANTATION 20:S14–S15, 2014
SUPPLEMENT
Expanding the Bounds of Liver Transplantation Robert S. Brown Jr. Departments of Surgery and Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY Received September 22, 2014; accepted September 29, 2014.
Key Points: 1. Living donation involves respecting donor autonomy and informed consent. 2. Donors will likely be satisfied with a lower expected survival rate for recipients. 3. We can expand the limits of transplantation in an ethical manner. 4. To be successful we must redefine program metrics to allow innovation. Primum non nocere. First do no harm. Opponents of living donor liver transplantation argue that putting a healthy donor at risk goes against this sacred principle of medicine and is, therefore, unethical. True, there are myriad ethical issues embedded in the concept of living donor transplantation: but the eligibility for a Model for End-Stage Liver Diseaseallocated deceased donor graft has been considered a prerequisite. The concept of living donation was born out of a need for more liver grafts for donation; in the absence of a shortage of livers, there would be no need to turn to healthy donors. The major ethical principles in living donation are the principles of autonomy and informed consent. The elements of autonomous decision-making include acting with understanding, without influence that determines the action and with intentionality. Informed consent requires people to understand and articulate the risks, benefits, and alternatives to the procedure in question. Potential donors go through an intensive educational process that includes all members of the transplant team, from surgeons, hepatologists, psychiatrists, and nurse practitioners to social workers. The process is designed to provide prospective donors with the necessary information such that they can make a decision that enhances their utility.
This underlies the principle of autonomy; people will make decisions that bring them a certain benefit. A beneficial action is not necessarily risk-free. To be clear, living donation carries the risk of harm to the donor. This risk varies with individual donors and with center experience but definitely exists. This small but finite risk of harm to the donor must be weighed against the potential gain to the donor, that is, satisfaction and the potential to provide gain to the recipient. Thus much of the donor gain is quantified by recipient benefit of guaranteed transplantation. For the recipient, the alternative to transplant is death, although not necessarily imminently, particularly if the recipient is deemed not to be a candidate for deceased donor liver transplantation. The relative benefit may be the greatest if the recipient is not eligible for a deceased donor graft, because the likelihood of death without liver transplantation approaches 100%. If after an extensive donor evaluation such that the partial hepatectomy is anticipated to be routine, the survival benefit to the recipient far outweighs quantitatively the potential risk to the donor. Thus, with an autonomous decision, all ethical principles have been upheld. Donor satisfaction is a major component of living donation and should not be underestimated. Rewards include the ability to have their loved one enjoy extended life, and the psychological benefit derived from knowing that they helped save a life important to them. Literature suggests that living donors are overall satisfied with their donation process. In fact, most studies indicate that donors would undergo the process again if given the opportunity. Interestingly, the decision to donate again is correlated with recipient outcome, not with donor complications, supporting the notion that donors’ benefits are intricately related to recipients.
Conflict of interest: Nothing to report. Address reprint requests to Robert S. Brown Jr., M.D., M.P.H., Department of Surgery, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH-14-Center, New York, NY 10032. Telephone: 212-305-0662; FAX: 212-305-9139; E-mail: [email protected], [email protected] DOI 10.1002/lt.24012 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
LIVER TRANSPLANTATION, Vol. 20, No. S2, 2014
The practice of living donor liver transplant does raise several ethical issues. It is imperative that donors are given accurate and complete information and that they make their decision with complete autonomy. It remains to be determined which patients are the best
S15
candidates for living donation. Transplant teams, and surgeons in particular, are charged with the difficult task of weighing donor risks with recipient benefits. The only unethical aspect of living donation would be withholding it from appropriate patients in need.
SUPPLEMENT
Expanding the Bounds of Liver Transplantation Robert S. Brown Jr. Departments of Surgery and Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY Received September 22, 2014; accepted September 29, 2014.
Key Points: 1. Living donation involves respecting donor autonomy and informed consent. 2. Donors will likely be satisfied with a lower expected survival rate for recipients. 3. We can expand the limits of transplantation in an ethical manner. 4. To be successful we must redefine program metrics to allow innovation. Primum non nocere. First do no harm. Opponents of living donor liver transplantation argue that putting a healthy donor at risk goes against this sacred principle of medicine and is, therefore, unethical. True, there are myriad ethical issues embedded in the concept of living donor transplantation: but the eligibility for a Model for End-Stage Liver Diseaseallocated deceased donor graft has been considered a prerequisite. The concept of living donation was born out of a need for more liver grafts for donation; in the absence of a shortage of livers, there would be no need to turn to healthy donors. The major ethical principles in living donation are the principles of autonomy and informed consent. The elements of autonomous decision-making include acting with understanding, without influence that determines the action and with intentionality. Informed consent requires people to understand and articulate the risks, benefits, and alternatives to the procedure in question. Potential donors go through an intensive educational process that includes all members of the transplant team, from surgeons, hepatologists, psychiatrists, and nurse practitioners to social workers. The process is designed to provide prospective donors with the necessary information such that they can make a decision that enhances their utility.
This underlies the principle of autonomy; people will make decisions that bring them a certain benefit. A beneficial action is not necessarily risk-free. To be clear, living donation carries the risk of harm to the donor. This risk varies with individual donors and with center experience but definitely exists. This small but finite risk of harm to the donor must be weighed against the potential gain to the donor, that is, satisfaction and the potential to provide gain to the recipient. Thus much of the donor gain is quantified by recipient benefit of guaranteed transplantation. For the recipient, the alternative to transplant is death, although not necessarily imminently, particularly if the recipient is deemed not to be a candidate for deceased donor liver transplantation. The relative benefit may be the greatest if the recipient is not eligible for a deceased donor graft, because the likelihood of death without liver transplantation approaches 100%. If after an extensive donor evaluation such that the partial hepatectomy is anticipated to be routine, the survival benefit to the recipient far outweighs quantitatively the potential risk to the donor. Thus, with an autonomous decision, all ethical principles have been upheld. Donor satisfaction is a major component of living donation and should not be underestimated. Rewards include the ability to have their loved one enjoy extended life, and the psychological benefit derived from knowing that they helped save a life important to them. Literature suggests that living donors are overall satisfied with their donation process. In fact, most studies indicate that donors would undergo the process again if given the opportunity. Interestingly, the decision to donate again is correlated with recipient outcome, not with donor complications, supporting the notion that donors’ benefits are intricately related to recipients.
Conflict of interest: Nothing to report. Address reprint requests to Robert S. Brown Jr., M.D., M.P.H., Department of Surgery, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH-14-Center, New York, NY 10032. Telephone: 212-305-0662; FAX: 212-305-9139; E-mail: [email protected], [email protected] DOI 10.1002/lt.24012 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
LIVER TRANSPLANTATION, Vol. 20, No. S2, 2014
The practice of living donor liver transplant does raise several ethical issues. It is imperative that donors are given accurate and complete information and that they make their decision with complete autonomy. It remains to be determined which patients are the best
S15
candidates for living donation. Transplant teams, and surgeons in particular, are charged with the difficult task of weighing donor risks with recipient benefits. The only unethical aspect of living donation would be withholding it from appropriate patients in need.
