Organ Donation and Procurement

Organ Procurement and Donation

• Organ donation involves transplanting healthy organs and tissues from one person to another.
• It is done to replace organs that are diseased or not functioning normally.
• Most donated organs come from people who are brain dead while on life support.
• Non-heart-beating donors (NHBD) or those with cardiac death may also be sources in some countries.
• Living people can also donate organs.

Agree or Disagree Statements

• Statements are presented concerning the ethics of organ donation, prompting discussion.
• Topics include repeat transplants, lifestyle factors, donor registry rights, family objections, and financial incentives.
• The statements also cover transplants for parents with young children and prisoners serving life sentences.

Timeline of Transplant History

• 348 AD: Cosmos and Damian
• 1550: Tagliacozzi performs skin grafting.
• 1902: Alexis Carrel pioneers vascular anastomosis.
• 1905: First corneal transplant performed.
• 1940s: First living related kidney transplant (identical twins).
• 1954: Medawar acquires immunological tolerance knowledge.
• 1962: Murray performs first kidney transplant from a deceased donor.
• 1967: Christiaan Barnard performs the first heart transplant in South Africa.
• 1983: Cyclosporine approved for commercial use in USA.
• 1998: First successful human hand transplant in France (later removed).
• 2005: First successful partial face transplant in France.
• 2014: First baby born to a womb transplant recipient in Sweden.

Transplant Patient Survival Rates

• Heart transplant survival rate: 90.4% at 1 year, 83.3% at 3 years, and 76.8% at 5 years.
• Liver transplant survival rate: 90.5% at 1 year, 83.4% at 3 years, and 77.8% at 5 years.
• Kidney transplant survival rate: 97.2% at 1 year, 93.3% at 3 years, and 87.7% at 5 years.
• Lung transplant survival rate: 85.2% at 1 year, 67.3% at 3 years, and 55.2% at 5 years.

Irish Transplant System

• Ireland has three transplant centers: Beaumont Hospital (renal), St. Vincent's Hospital (liver and pancreatic), and the Mater Hospital (heart and lung).
• Temple Street Paediatric Kidney transplants exist.
• UK referrals are made for heart, lung and liver transplants when necessary.
• Organ Donation and Transplant Ireland (ODTI) operates under the HSE, with a national team of Donor Coordinators.
• Specialist Organ Donation Personnel work in hospital intensive care units nationwide.
• Ireland uses an opt-in system where individuals can express their wish to donate via a donor card or driver's license.
• There is no national organ donor register in Ireland.
• Relatives are always asked for consent, even with a donor card; donation requires next-of-kin consent.

Facts & Figures

• There was a 20% decrease in transplants performed in 2020 compared to 2019 because of COVID-19.
• 21 patients died each day while waiting for a transplant in 2020.
• Transplants experienced a 30% reduction in 2020 due to COVID-19.
• 829 people were on the organ transplant list in 2020.
• The average waiting time for a kidney transplant was 19 months in 2020.
• Kidney living & deceased transplants: 28
• Liver transplants: 37
• Pancreas transplants: 5
• Lung transplants: 16
• Heart transplants: 9
• There is a predicted increase from 2000 people on dialysis to 3000 by 2026, costing €50 million per year.

Organ Allocation Principles

• According to the Declaration of Istanbul, organs are equitably allocated to suitable recipients, regardless of demographics or financial status.
• WHO Guiding Principles state that clinical criteria and ethical norms should guide organ allocation.
• Allocation rules should be equitable, externally justified, and transparent.
• Eurotransplant uses an objective, transparent, reproducible, and valid allocation system based on expected outcome and urgency.
• National organ balance and waiting time are considered, and Eurotransplant aims for a balanced organ exchange.
• Ireland's allocation policies are dependent on donor/recipient match, age, and clinical status.
• AI’s role in organ allocation aims to avoid discrimination.

Process of Selection for Transplant

• It involves medical and psychological assessments and a multi-disciplinary meeting.
• Allocation is based on medical urgency, waiting time, blood type, and body size.
• A National waiting list for elective and emergency transplants is maintained.
• Donors cannot select recipients, and donation is unconditional.
• In Ireland, transplantation is free for all recipients, regardless of health insurance or medical card status.

Increasing Donor Pool - Scientific Developments

• Regenerative medicine seeks to generate organs via tissue engineering using autologous cells, embryonic and induced pluripotent stem cells, and 3D organ printing.
• Small amounts of cardiac heart tissue have been recreated to match donor patient physiological characteristics.
• 10 people had bioprinted bladders grown from their own cells.
• A main challenge is vascularisation.
• Xenotransplantation involves transplanting organs or tissues from animals into humans.
• In 1984, Baby Fae received a baboon heart but died 21 days post-transplant due to rejection.
• 2016 experiments created human-pig chimeric embryos to grow human organs.
• Orthotopic pig xenografts survived in baboons for over 6 months in German experiments (2018-2020).
• In 2021, pig kidneys were transplanted, in first Human Studies, into brain-dead people in the US.
• First pig-to-human cardiac transplant.

David Bennett Case

• David Bennett Sr., a 57-year-old with irreversible heart failure, was ineligible for a human transplant due to his health condition and medical advice disregard.
• The U.S. FDA authorized a transplant on compassionate grounds.
• The CRISPR-Cas9 system was used to modify the pig heart.
• Initial reports showed the pig heart functioning well.
• Bennett died 40 days later due to infection with porcine cytomegalovirus.

Ethical issues of Xenotransplantation

• Potential transmission of pathogens (retroviruses) from animal to human.
• Selection of patients should be limited to those with severe diseases lacking alternative therapies.
• It should only be considered for patients likely to experience a clinically significant quality of life improvement.
• Obtaining informed consent from patients.
• Addressing animal welfare concerns.
• Breaching what is normally inviolate is considered "unnatural".

Policy Developments for increasing donor pool

• Abandoning the dead donor rule.
• Donation after circulatory death.
• Opt-out model.
• Mandated choice.
• Required request.
• Solidarity model.
• Considering public attitudes.
• Increasing living donors.

Definition of Brain Death

• Before the 1960s, death was defined by cardiopulmonary criteria.
• Mechanical ventilation led to neurological criteria based on EEG activity.
• The first transplant using a heart-beating, brain-dead donor was performed in 1963.
• In 1968, a Harvard ad hoc committee proposed criteria for death based on irreversible coma and absent central nervous system activity.
• The 1979-1982 US President's Commission framed a uniform definition including cardiopulmonary and brain criteria: "An individual who has sustained either (1) irreversible cessation of circulatory and respiratory function, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead".
• The Academy of Medical Royal Colleges in the UK defines death as 'the irreversible loss of the capacity for consciousness, combined with irreversible loss of capacity to breathe'
• They state 'irreversible cessation of the integrative function of the brain-stem equates with the death of the individual'.
• There is no statutory definition of death in Ireland: brainstem death diagnosis is made according to the UK Academy of Medical Royal Colleges Code of Practice.

Controversies

• Concerns that whole brain/brain stem death does not meet definition of death.
• Some suggest removing organs from traumatic brain injury patients who are close to death but not yet dead.
• Transparency about organ donation would benefit patients and the public.
• Abandoning the dead donor rule may reduce public confidence and organ supply.

Donation after Circulatory Death (DCD)

• DCD has re-emerged as a strategy for securing more organs for transplant.
• "No touch time" ranges from 2-10 minutes, a period of heart stoppage after which irreversible brain is considered unavoidable
• Anticoagulants and vasodilators are routinely administered to ensure organ preservation.
• Controlled DCD involves family consent, which is not so for uncontrolled DCD.
• Maastricht classification includes controlled DCD (categories III/IV) with artificial life support withdrawal, and uncontrolled DCD (categories I/II and V), occurring in unexpected deaths due to heart arrest.

Opt-Out Model (Presumed Consent)

• Consent is assumed unless the deceased has expressed a wish not to donate.
• The weight given to relatives' wishes varies by country.
• "Hard" approaches give less weight to relatives' wishes, while "soft" approaches give them more weight.
• UK Human Tissue Bill provides that a deceased person would be deemed to have consented to donate their major organs unless they are objected lifetime
• The next of kin will be consulted, and if they object, the donation will not proceed, irrespective of wishes.

Pros and Cons of Opt-Out Model:

• Potential to increase the pool of donors.
• Stronger utilitarian arguments could save more lives.
• Model takes pressure off of families.
• Increases autonomy of donors.
• Same choice still presents itself, which would simply shift the default position.
• Can fulfill many people's wishes who are tacitly implicit towards donation
• May reduce autonomy.
• May affect vulnerable people more.
• Changes nature of the "gift" of donation, making it assumed.
• Has the potential to induce backlash.
• May possibly reduce the total donations.
• Mixed evidence is present on increasing the potential pool of donations..

Evidence on Opt-Out

• A Welsh opt-out law failed to increase organ donations.
• A study found no evidence that it increased transplant rates two years after implementation.
• There were 104 donors in the 21 months after the law versus 101 donors before.

Mandated Choice

• Competent adults are required to inform an authority whether or not they wish to donate post-mortem.
• It ensures personal preferences are known and respected and is less traumatic for relatives.
• It can be viewed as coercive and invasive, undermining autonomy

Required Request

• Hospitals must ensure health care professionals offer families of eligible donors donation opportunities.
• Health care professionals may be reluctant to approach grieving families.
• The manner of approach affects the family's willingness to donate.
• It increases attention and provides better success.

Solidarity Model

• Gives priority to those who have previously consented to be organ donors when they need a transplant.
• Highest priority to living donors if their second kidney fails.
• Allocating transplants based on anything other than medical need is morally ambiguous.
• Unjust against those who cannot donate for medical reasons or don't wish to donate.

Impact of Public opinion on Organ Donation

• Research shows positive attitudes toward organ donation, but the relationship between attitudes and actual donation is weak.
• Next-of-kin decisions are driven by executing the deceased's known or inferred wishes.
• Patient ethnicity, religious beliefs, sex, socio-economic status, and donation knowledge strongly affect consent.
• Consent is higher for brain death donation versus donation after circulatory death as stated by Curtis et al.
• Significant factors are the timing and setting of the request and the individual's approach.
• 8 in 10 people would donate their organs or donate their family's organs.
• Only half discussed organ donation with their family.
• Most people are happy to receive an organ, and fewer are willing to donate and not donate their own.
• 1/3 of general people are organ donors however less will carry the same
• One organ donation helps to save 5 lives in general
• Families should have the final say, but only 45% have discussed to their families .
• The causes not donate vary but less have any reason

Public Attitudes About Specifics

• Less known about motives for not donating.
• Distrust in the health care system.
• Misperceptions.
• Media and bodily integrity also sway results.

Living Organ Donation

• Involves removing an organ or part of it (kidney, liver segment, lung lobe, small intestine) from a healthy person.
• It is followed by transplanting it to someone with organ failure.
• The donor organ is better and produces better results.
• Ethical concerns relate to donor risk, lack of therapeutic benefit, and the need for informed consent and voluntariness.

Ethical Concerns

• Informed consent is vital for understanding the benefits and risks of donation
• Voluntariness reduces the change of coercion from family
• Those with commercial pool of organ donation are more prone to coercions.

Outcomes with Living transplant Patients

• Living kidney donors show similar or better survival compared to control groups
• This includes, healthier cohort, follow up
• Living kidney donors are relatively rear
• Those may cause long term more signicant issues than first thought.
• Prevalence of anxiety, depression, and regret is low among living kidney donors
• Between 4.7% and 9.6% of living liver donors reported impaired mental well-being at various time points
• Psycho socials monitoring shows the results .

Guidelines and Regulations

• Article 19 of the CoE Convention on Biomedicine states that organs from a living person are for the therapeutic benefit of the repipient.
• The recipient could benifit provided has no alternative person that has available.
• Donation should be genetically related
• The Netherlands, Cyprus, and Bulgaria outperform Kidney transplants overall.

Ethical Issues with Organ Donation

• From a minor donation, it can stream lines and potentially alter the concept.
• This shifts the ethical backbone in terms of how the utilitarianism can benefit one.
• This can be in rare circumstances due to those that benefit that are close to them,
• All donors must agree to the the terms of how things work .
• Only European countries allow such an act , such as the livers in some instances
• Unease with Exploitations and interests being sacrifieds
• Article does state that the organ needs to consent Incapaciated adults show that the organ donation from 2015 that they lack the ability to reach high court.

Transplations can only be done by these groups

• Volunteer Donors are know as anonymous, or other good samaritan groups that help those by being a good alruristic that bennfts others
• Some potential donors may have illnesses .
• Heroic actions require scrutiny.

Non Essential Transplantation

• First case to be recognized by the French was in 2005 with more 40 transplants available by 2018
• There can be emotional and psychological consequences due to some .
• Informed concent should be performed
• Cost varies for those that require one

Transplants have been showing some great results with some studies and more

• This is to improve certain features

• This also includes the value of birth from those types

• Consent of a dead corpse can easily be made, living more complex

• Can all access the same treatment with fair pricing One can solicit for more organs

• To help those in need

• Two central actions can be taken , can cause exploitation

• They might not be tested properly

• System seems undermined but all more from the one that wants to get to the donation

Who gets the transplants?

• It is up to the race of such person

• They should all be good for those donations

• Both are not as close as the related linked parts.

These transplantions are all important With an alrtuistic mindstate

• Should also add and see if that the generosity is all the time. And is valued
• And if those were needed, those shoud be offered to everyone.

Transplation should also be for commericializaiton instead of using what those can give at the end of the day. This may cause issues in the future

Organ Sales

• United Nations are against the the organ sales
• Can only to used when and if needed those organ purchases . Unconvential transplant must happen to be donated
• If one needs money, they should not have any incentive

Issues with donations

• It should all take what what is needed and used to the full potential

• Low class can start exploitation Denial to be put to help those that all need it. Their family also loses the ability to fully earn .

• May affect those the most

• Those can can be great for the donation and what causes the benefits .