BTS 2012 Report – How risky is too risky? The ethical landscape of Challenging Transplants

by Maria Dalby – The Ethics Symposium at this year’s BTS Annual Congress was held in a highly interactive format and dealt with the ethical aspects of particularly challenging donation scenarios. The symposium was led by Vassilios Papalois, a consultant transplant surgeon from Hammersmith Hospital in London, and consisted of two hypothetical patient cases that were presented to the audience in a step-by-step layout with increasing amounts of detail provided at each step. The audience was invited to vote on different options at each step using interactive key pads, and the voting session was followed by an interactive discussion of the different options.

The first scenario involved an 18-year old student, Maria, who would like to donate a kidney to her 73-year old grandfather. In an initial statement, Maria, who is in good physical health, said that she was ‘messed up’ earlier in life but had since settled down with her college studies, a part time job, and a boyfriend and a good network of friends. Her grandfather had been on dialysis for 6 years for renal failure due to high blood pressure; he also had a history of CABG surgery and a minor stroke, but is independent. The grandfather had no contact with Maria’s mother and no other living relatives.

At the first step of this case presentation, only 20% of the audience voted that they would be happy for the donation to go ahead, and 37% were unsure. In the discussion that followed, several delegates expressed concerns over the age difference, and also possible psychological factors that may be behind the fact that there was no contact between the grandfather and the rest of his family, except for Maria – the fear was that this may indicate some level of coercion. At the next step of the case presentation it transpired that Maria felt very close to her grandfather after he had supported her during a difficult time in her younger years, and that she had done extensive research on the internet to inform herself; furthermore, her grandfather stated that he had initially felt uncomfortable about the idea of Maria donating a kidney to him, but that her clear determination to help him had convinced him. After this step, 55% of the audience voted in favour of the donation; this rose to 84% when told that the donation had been approved by the transplant team, the trust’s clinical ethics committee, and an independent assessor. Ten per cent remained unsure at this stage and only 6% remained opposed to the donation.

The second donation case involved two brothers, the older of whom, John, received a kidney from his younger brother Richard 10 years ago at the age of 33. John underwent coronary artery stenting 2 years ago but is otherwise healthy, is married with two children and works as a supermarket checkout assistant. Richard has remained single and has a successful career as a lawyer; however, he was diagnosed with hepatitis C 3 years ago at the age of 38 and has now developed liver failure and needs an urgent transplantation. There are no other siblings or living relatives. Based on this information, the audience was clearly divided: 31% voted in favour of the donation, 36% voted against it and 33% were unsure. The next piece of information revealed that Richard had said that he would ‘really help’ John and his family if all went well, whereas John had said he felt it was his duty to help Richard since he had helped him 10 years previously, and that it was God’s will that John should help his brother; this swung the audience opinion against the donation with 62% voting against. Several delegates were concerned about the very strong suggestion of financial coercion, and the possibility of a religious motif was also considered risky.

Although the cases discussed in this session were hypothetical, they illustrate the sometimes very complex situations transplant teams all over the country are faced with on an almost daily basis. There are clearly no simple answers to these issues and the debate is set to continue both on an individual level and within the transplant community as a whole.