Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Allied Health Professionals’ Corner
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Commentary : Patient’s Voice
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guideline
Guidelines
Image in Nephrology
Images in Nephrology
In-depth Review
Letter to Editor
Letter to the Editor
Letter to the Editor – Authors’ reply
Letters to Editor
Literature Review
Nephrology in India
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Allied Health Professionals’ Corner
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Commentary : Patient’s Voice
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guideline
Guidelines
Image in Nephrology
Images in Nephrology
In-depth Review
Letter to Editor
Letter to the Editor
Letter to the Editor – Authors’ reply
Letters to Editor
Literature Review
Nephrology in India
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
View/Download PDF

Translate this page into:

Commentary
26 (
6
); 391-392
doi:
10.4103/0971-4065.179200

Kidney donation: Clinical practice and ethical dilemmas

Department of Psychiatry, Drug De-Addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Address for correspondence: Prof. D. Basu, Drug De-Addiction and Treatment Centre, Department of Psychiatry, PGIMER, Chandigarh, India. E-mail: db_sm2002@yahoo.com

Read COMMENTARY-ARTICLE associated with this -

Licence

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

Disclaimer:
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher.

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.

References

  1. , , . The Psychology of Attitudes. San Diego, California: Harcourt Brace Jovanovich College Publishers; .
  2. , , . Attitudes and attitude change. Annu Rev Psychol. 1993;44:117-54.
    [Google Scholar]
  3. , , . Associative and propositional processes in evaluation: An integrative review of implicit and explicit attitude change. Psychol Bull. 2006;132:692-731.
    [Google Scholar]
  4. , , . Principles of Biomedical Ethics. London: Oxford University Press; .
  5. , , . End-stage renal disease in India and Pakistan: Burden of disease and management issues. Kidney Int. 2003;63:115-8.
    [Google Scholar]
  6. , , , , . Attitude of medical professionals regarding controversial issues in kidney donation/transplantation. Indian J Nephrol. 2016;26:393-7.
    [Google Scholar]
  7. , , . Review of solid-organ transplantation in HIV-infected patients. Transplantation. 2003;75:425-9.
    [Google Scholar]
  8. , , , , , . HIV-positive renal recipients can achieve survival rates similar to those of HIV-negative patients. Transplantation. 2006;81:1658-61.
    [Google Scholar]

    Fulltext Views
    464

    PDF downloads
    399
    View/Download PDF
    Download Citations
    BibTeX
    RIS
    Show Sections