Checklist: Passport, Plane Ticket, Organ Transplant

K. A. Bramstedt; Jun Xu

Disclosures

American Journal of Transplantation. 2007;7(7):1698-1701. 

In This Article

Ethics and Safety

Living donor transplants are associated with better outcomes when compared with deceased donor transplants.[18–20] Nonetheless, the success of living donation has brought forth concerns regarding the exploitation of living donors. Organ tourism programs highlight this concern because in countries where transplantation guidelines do not exist (or are not enforced), the source of donor organs can be people who have been expressly paid to donate, as well as those who are unable to give valid informed consent (e.g., forced spousal donation, prisoners).[21–23] The ethical implications of such practices are obvious.[24,25] Also, it is unclear whether organ tourism programs have provisions for or mandate formal Donor Advocate Teams to promote the safety and welfare of donors, including ascertaining their motivation for donation, as well as their functional capacity for decision-making.[26] Further, without a team that is distinctly separate from the recipient team, the clinical needs of the donor are potentially blurred or undervalued due to the overarching goal of saving the life of the recipient via transplant.

Because living organ donation is not without clinical risk[22,27] the concept of taking a US resident to a foreign country for the purpose of participating as a donor raises numerous concerns. In addition to the travel risks, donors potentially increase their risk of complications due to poor hygiene in some overseas hospitals,[28,29] as well as endemic communicable disease.[30] These risks as well as the impending financial bonus could tempt patients to offer a portion of their bonus to a US resident as a form of coercion to donate. Bonuses could also be used to pay living donors obtained in foreign countries. Both scenarios prey on humans to participate as live donors, exploiting those who are not financially secure, and potentially widening any existing socioeconomic health disparity.

Another matter is the long-term care of donors who experience late or lengthy complications. The experience of one of the authors [KAB] finds many US living donors lack personal health insurance and risk financial burdens when coverage from the recipient's policy ends (usually 6 months to one year after donation). Many Indian citizens who have participated as living donors have experienced medical complications such that 79% would not recommend the procedure to others.[22]

With regard to the organ recipient, the quality of the donor organ, as well as post-transplant care can be problematic. While not all overseas hospitals have problems with hygiene and post-operative quality of care, Kennedy at al reported Australian residents contracting fatal hepatitis B infection during their transplant quests in China and India.[8] Infections with CMV and Aspergillus have also been reported.[8,31] In another study, fungal sepsis was found in 9% of patients returning from overseases renal transplantation.[32] Infection with HIV, fatal postoperative bleeding, and over or under-immunosuppression after transplant have also been reported.[8,9,28,31,33] When infected patients return home for post-transplant care, it is possible that they could import organisms that could challenge the healthcare system due to issues of antibiotic resistance.[32] Upon returning home, patients' foreign medical records are often incomplete, in a foreign language, or unobtainable.[8,28,29] These matters can create ethical discomfort for medical teams[34] and some personnel might choose to abstain from giving post-transplant care to patients who have participated in transplant tourism.

US transplant practice and health insurance policies allowing living donor paired exchange/paired donation may prompt some to regard such as synonymous with transplant tourism because some US insurance companies allow foreign relatives to come to the US to be living donors with their workup expenses covered (even if the workup occurs in their home country). It is our view, however, that such practices are not a form of transplant tourism. First, the donor and recipient surgeries are performed in the US (not overseas). Second, live donors coming to the US participate in a transplant system that has identifiable (auditable, reportable) quality and safety parameters—this cannot be said for some countries (e.g., China) that refuse to allow transparency and disclosure of their organ transplant system. Third, we are unaware of any rebates paid to patients undergoing transplantation in the US. The rebates, as we reported, get paid to patients leaving the US to obtain a transplant abroad, potentially using a live donor in the foreign country (or a deceased donor in that foreign country). Further, live donors obtained in foreign countries can be exploited/harmed/forced in their participation—it is not necessarily the organized, relatively safe practice of that of the US (incorporating the use of a Donor Advocate Team).

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