Ethical Complexities in Public Solicitation for Organ Donors

Rebecca Greenberg RN, PhD is a Bioethicist at SickKids and an Assistant Professor in the Department of Paediatrics at University of Toronto.

SickKids’ Bioethics Week presents the organization with an opportunity to reflect on prominent ethical issues that have arisen over the past year. In recent months there have been a number of public solicitations for an organ in the media. This spring, the story of the Ottawa Senators owner Eugene Melnyk, or the parents of three-year-old twins, who made public pleas for someone to donate a liver have drawn significant media attention and raised a number of ethical issues.

The stories of the many people who receive living donor organs never hit the media as most individuals seeking a living donor do so in a stepwise private manner. Some are fortunate to find a suitable donor amongst their family and friends. For those who are not, public solicitation affords them the opportunity to try to find a donor. When these stories do go public it is important to remember that not all details are shared about the process, donor or recipient, due to concerns about privacy and confidentiality. As well, there are often inaccuracies in media reports regarding how organs are actually allocated and the assessment process. Maintaining confidentiality between the donor and recipient has been a longstanding practice in transplantation; for both deceased and anonymous living donation. Public solicitation raises new issues as the donor’s identity is not known to the recipient but the donor knows the recipient’s identity (i.e. a partially anonymous donation). This imbalance of information and power can leave the recipient potentially vulnerable to being approached by the donor with a desire to meet the donor, or with requests for compensation for their donation. Additionally, if the transplant does not go well, the donor and family may want to grieve privately.

With increasing media coverage and the explosion of social media, maintaining confidentiality is becoming increasingly challenging. To address some of these issues, recipients of a partially anonymous donation must be aware of the imbalances and what may ensue as a result. Some transplant centres will facilitate donor and recipient communication, but usually six months or a year post transplant. Cases of high profile patients and families can leave people with a sense of discomfort or concern about the legitimacy of the process. As a result some transplant centres will not do transplants with anonymous living donors. They find difficulty understanding the benefit to the donor such that it can justify the risk of the donation. Additional concerns that are raised include whether or not the donor is acting without undue influence or incentives to donate. It can be comforting to know that living donor transplant programs that do these donations have thorough processes to screen for coercion and optimize the voluntariness of donations.

Questions have been raised in the media about the fairness and justice of organ allocation. These cases suggest that that those who have financial and social means are most likely to be successful with solicitation while those who are less savvy, don't speak English or have social networks will be at a disadvantage. Acknowledging this disparity is an opportunity to call for education and supports for patients and families who require assistance in finding a living donor. Additionally, while it is true that living donor organs are not given to those most medically in need, it is often overlooked how many potential recipients benefit from one individual’s solicitation efforts. Firstly, many people on the waiting list will receive an organ faster as the recipient of the living donation will no longer be waiting for a deceased donor organ. Secondly, these appeals often draw many people to come forward to donate to a specific individual, of those who do not donate to the individual others go on to donate anonymously to others on the wait list. Thirdly, solicitations serve as a means of public education and increase awareness of the need for organs, which results in an increase in both living and deceased donations.

Public solicitation for organs can draw large numbers of people calling a transplant hospital offering to donate. This requires adequate staff to screen these requests. With such surges hospitals may be ill-equipped to deal with the inquiries and consideration must be given to adequately resourcing these departments, especially with the increasing trend of public solicitation. Additionally, public education could be offered to limit inquiries to those who understand the process and are truly interested.

While public solicitation of living donors certainly raises challenges, it's an opportunity to educate the public about the bigger picture - that the need for organs far outweighs the supply. Moreover, as the primary source of organs are deceased donors we must focus our efforts on increasing this pool and welcome the by-product of public solicitation as it increases both living and deceased organ pools.