Living Related / Unrelated Organ Donation
and Ethics 
by Dr Lily Ng  

Transplantation is the most cost-effective form of renal replacement therapy. Transplantation saves lives in the case of endstage liver and heart failure. In the meantime, disparity between supply of organs and need for organ transplants is increasing everywhere in the world. No country is able to meet their organ needs.

Despite the support of major religions, low cadaveric organ donation rates prevail because among other things, there is distaste among people, thinking about their mortality, and fears of dismemberment after death. Hospital staff hesitate to burden grieving relatives with a request for organ donation from their dead loved one. Relatives may be too shock at the time of death and simply incapable of making any decision. The public understanding of brain death is also limited. While on artificial respiratory support, the deceased’s heart continues to beat for a time, the body feels warm and looks as if alive. This makes it difficult for relatives to accept that their loved one is actually dead. Preferences about organ donation may not have been discussed beforehand among family members making it difficult for those remaining to decide.

In western world, donation rates have decreased due to reduction in deaths from road traffic accidents and strokes with better medical treatment. Presumed consent is practiced in 14 European countries. Australia is at present debating on implementing the law. Singapore practices presumed consent. or “opting out” law. This means legislation allows organ procurement from all citizens if they had not specifically said they did not wish to be an organ donor.

Organ donation can be from cadaveric donors ie. donation after death or from living donors. Living donors are either related genetically or emotionally (LRD); or are unrelated (LUD). Donation from spousal or friend represents emotionally related but genetically unrelated living donation. Unrelated living donation (LUD) can also be for commercial reasons.

Living donation has the advantages of better quality organs and better results with the shorter ischaemic time. Timing of transplantation also can be scheduled to suit the convenience of both donor and recipient, as opposed to cadaveric donation. As society is not too willing to part with their organs upon death, recipients face a long, long wait ahead. The number of patients dying from liver disease is increasing. Living liver donation could benefit patients who are likely to die or deteriorate before a cadaveric donor becomes available. However there are a number of disadvantages and issues with living organ donation. It is limited to some organs only eg. kidneys and a part of the liver, but not possible for the heart. Theorectically a person can donate one of his pair of eyes but that is not known to be done. Pregnancy is a contraindication to live donor organ donation until after delivery.

“First do no harm” is a tenet of medical practice from the time of Hippocrates. Living donation carries risk of morbidity and mortality to donor. Living donors have been known to either die immediately or later from complications, the immediate risks being those of having to undergo a major operation. Other donors have become vegetative or themselves needed a transplant later on, as reported in American Journal of Medicine. Overall the risk of death to living kidney donors is low ( 0.03 %), with a 2% risk of major illness from complications and a 10-20% risk of minor illness. 

For cadaveric donation, the graft is considered as a freely given gift and no stipulations are made by the donor; the donation is unconditional and not directed. In contrast, in living liver donation, the organ is given to a specific recipient. Living liver transplants are mostly from parent to child. The first living liver transplant was from an adult to a child and was performed in Australia in 1989. The procedure is now common at major pediatric centres.

What requires emphasis is that the ethics, risks of donation, and recipient outcome between paediatric and adult living transplantation are very different and need to be considered separately. In left lateral segment (of the left lobe of liver ) transplantation of children, the donors are invariably parents, donating only 20 – 25% of their liver mass. Significant morbidity is approximately 5% and the risk of donor death is currently 0.1.%. 

If donating to another adult of similar or lesser size, all of the left lobe is taken, and if donating to a larger adult, the right lobe is removed. Splitting of livers to share between two adults whether donor organ be living or cadaveric, could have an impact – but at the expense of lower recipient survival rates. Right lobe graft survival is inferior to that observed for cadaveric whole livers.

The risk of illness such as bile duct leaks and massive bleeding to liver donors is 40-60%, and risk of death is 0.5-1%. (BMJ Volume 327, pp 676-9). Biliary complications also play a part in the increased graft loss observed and prolonged hospital stay associated with this procedure. The long term physical and psychological consequences of living liver donation are not established, unlike for living kidney donation. Living liver donors ought to be followed up for life for long term consequences and a registry set up for them.

Hence, living unrelated liver donation, with the exception of emotionally related, is generally not encouraged. Depicting young living unrelated donors as “heroes” by the press can have disastrous results. The body intervention inflicted on a live donor is generally justified by the significant relationship between the donor and the recipient but is it justified where the donor is a stranger? It can be argued that well informed donors have an absolute right to determine whether they will give tissue to benefit a recipient and that society (be it government, the courts, or professional bodies) has no right to obstruct an altruistic decision. A survey of 2000 adults in Great Britain in 2003 found that half of respondents thought that a risk of death of 1 in 200 (0.5%) was acceptable for donation to a family member, and 14% thought this was acceptable for donation to a friend. In general, doctors have an obligation to act in the individual's best interests and an individual's rights can be curtailed for the individual's benefit (such as the enforced wearing of seat belts in cars).

Cadaveric organ donation on the other hand, is totally risk free to the donor who has no need of his organs anymore, and should be strongly encouraged. Living donors must fully understand the risks and benefits. Consent must be voluntary and not coerced but how can we be sure that the autonomy of individuals is maintained?  In Pakistan for instance, as a result of coercion, more unmarried females donate than married females. Later these unmarried donors are not accepted for marriage. Males are generally spared from donation.

Living unrelated ( “ Altrustic”,  “Good Samaritan” or “Stranger” ) donation has given rise to fears that the donors are motivated by mental illness ( as evidenced by  emotional lability, impulsivity, series of failed relationships) or material gains. Survey carried out in the USA cited also other reasons for living unrelated donation. The multitude of reasons include “spiritual reasons”, “does not recognize the enormity of donation”, “increases self-esteem”, “wants accolades and public recognition”, “repay the good others have done for them”, “as a sense of obligation”, “as recompense for past wrongs”, “as a statement against his family”, “personal experience with medicine”, “set an example for others”, and “improve the quality of life for someone else”.

Living unrelated donation increases the risk of financial commercialization. Market system of organ donation will lead to unacceptable and unethical practices such as class distinctions, exploitation of the poor, infringement on life and liberty, blackmailing and coercion of prisoners on the death row and their execution expedited, murder, kidnapping and organ theft.  Incidents about doctors having  been “duped “ by false claims about relationships between donors and recipients have been reported.

In commercial transplantation centres in some countries, the standards of care for both donor and recipient may not be ideal. Testing for Hepatitis B, C and AIDs may not be stringent enough and a number of Malaysians going abroad for organ transplants have contracted these diseases. They may also not have been forthright about the age of donor from whom the organs came. Mismatch and organ rejection later may occur due to taking shortcuts.

Knowing all the difficulties surrounding living organ donation, we should all the more practice cadaveric donation being risk free. A change in mindset is much needed. Society need to view organ donation as a collective responsibility. It is time that health professionals consider organ donation as a standard aspect of patient care. With that hopefully, it will become the custom for Malaysians to donate organs after death to save others rather than let them go to waste. 

****References are from British Medical Journal, Journal of American Medical Association and New England Journal of Medicine.

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