Kidney donation: Clinical practice and ethical dilemmas

Recently, we examined a 30-year-old female with borderline intelligence, who wanted to be a donor for her brother who was struggling with end-stage renal disease. She was completely dependent on her brother, and loss of her brother could bring her life to a standstill. However, she was unaware of the physical risks or consequences of such donation. For her, it was a kind of duty as a sister, which she had to perform anyway. This was obviously not an isolated or rare instance. Clinicians encounter similar circumstances quite frequently and are embroiled in ethical dilemma. Resolution of such ambivalence and subsequent decision to a large extent depends on their attitudes.

Eagly and Chaiken had defined attitude as “a psychological tendency that is expressed by evaluating a particular entity with some degree of favor or disfavor.”[1] Attitude might be either positive or negative depending on the intensity and the direction of the affective valence associated with it. Attitude could also influence the attention, information processing, interpretation, and judgment toward attitude-relevant object or event. All these together are going to determine the action or behavior of an individual.[1] Hence, attitude has a direct relevance to the outcome of any situation. Measurement of attitude as a psychological construct could be done either by direct self-reports or by indirect observational methods known as the explicit and implicit measurement of attitudes, respectively.[2] Explicit attitude is conscious, thus is subjected to “censoring,” and is more likely to be knowledge-information based and socially appropriate. On the other hand, implicit attitude is assumed to be automatic and semi-conscious, thus more valid and reliable. Implicit attitude could predict future action of an individual.[3] In the context of kidney donation, decision of selecting or rejecting a donor by a physician is not always uniform and unambiguous. Controversy rather than consensus is expected. Hence, in an attempt to eliminate the personal “attitude bias,” a standardized guideline needs to be formulated.

The next issue which is relevant for organ donation is the ethical dilemma of the physicians while decision-making. The four guiding principles of “Medical ethics” proposed by Beauchamp and Childress in their textbook Principles of biomedical ethics are autonomy, beneficence, nonmaleficence, and distributive justice.[4] Among them, perhaps, “autonomy” and “justice” are the most common ethical dilemmas encountered during organ donation. The principle of autonomy recognizes the rights of individuals to self-determination. This is rooted in society's respect for individuals’ ability to make informed decisions about personal matters. Now, in our example above, the donor sister was absolutely convinced about her decision to donate her kidney to her ailing brother. However, she was found to be intellectually challenged, had poor knowledge, thus was likely to take “wrong” decisions. This label of “wrong” decision reflects the “paternalistic” side of medicine, which in stark contrast with “autonomy” upholds the supremacy of the professional. It would not be imprudent to speculate that in countries such as India, personal choice might not be grounded on scientific evidence; rather, it could be based on other social, environmental, and family circumstances. Therefore, the scale with which rational decision-making is to be determined must be calibrated on practical ground realities. In this example, when she wished to express her gratitude, do her duty as sister, and made an attempt to keep her brother alive (indirectly ensuring her survival which was contingent upon her brother's life) and hence decided to donate her kidney, she appeared to be quite rational despite having a scientifically proven poor knowledge. The second important ethical issue, especially for our country, is distributive justice. Because of the scarce resources and increasing demand for organs, the optimum usage of the same needs to be considered.[5] Fair and equal distribution of the existing resources underlies the principle of justice. However, in case of organ donation, kidney transplantation in patients with HIV or liver transplantation in patients with substance use disorders might raise questions regarding the applicability of equal justice.

In the study by Almeida et al., majority of the professionals seem to have divergent opinion about a few areas, namely organ donation in patients with HIV, need for incentive for the donors, compulsory kidney donation after death, and necessary possession of a donor card.[6] The first issue raises the concern regarding distributive justice. Interestingly, although the existing scientific knowledge has demonstrated beyond reasonable doubt that transplantation in patients with HIV has equivalent outcome, professionals are yet to be convinced.[78] Thus, the agreement or disagreement might be based on the clinician's attitude toward persons with HIV infection. The other three issues are related to individual's autonomy which would ultimately determine their decision of organ donation. Now, professional's attitude toward “autonomy” might explain the divergence. These divergent areas which could be colored by “attitudinal bias” are needed to be streamlined in future. In other areas such as nonlegalization of kidney donation, no particular preference to any social strata, and preference for future transplantation for the donors, a consensus has been achieved. These are quite nondubious situations where ethical principles could be directly applied without exercising any explicit attitude.

This study could have informed us regarding the respondents’ sociodemographic and clinical background that could have helped us in understanding any association of these with their explicit attitudes. Although more studies are required on much larger and representative samples to understand attitudes of medical professionals regarding transplantation, this study is a small but important step in that direction.