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Table 3 Ethical issues

From: How is organ transplantation depicted in internal medicine and transplantation journals

Autonomy (almost exclusively in internal medicine journals)

Informed consent: research, minors, incapacitated adults, refusal, information provided, marginal organs

"Organs from donors with specified known infections may be considered for specific recipients—provided there is appropriate informed consent—based on the urgency of the need for transplantation and the availability of effective antimicrobial therapies" [29].

"Consent is an important issue and it is clearly in the doctor’s interest to make sure that it is based on complete and explicit discussion of known risks" [30].

"Hannah Jones persuaded Herefordshire Primary Care Trust that she was competent to make her own decisions about medical treatment and was making an informed choice not to have the operation that could have prolonged her life" [25].

"A clear and comprehensive informed consent process is necessary, including a thorough and easily understood informed consent document. To control for conflicts of interest, informed consent should be obtained by independent third parties and should include counselling on all aspects of the risks and benefits of the experimental study" [31].

Organ market: sellers’ and buyers’ autonomy

"Paying for a kidney donation is viewed as a potential win-win situation that can benefit both parties. Individual decision making and patient autonomy have become the final arbiters of medical and bioethical values" [28].

Beneficence (both types of journals)

Risks vs. benefits: assessment methods, pregnancy (only in IM journals), transplantation with marginal donor, choice of medication, HIV patients

"Physicians should discuss the risks and benefits of the various immunosuppressive regimens with respect to pregnancy and the fetus with their female patients and make decisions collaboratively" [32].

"Adequate graft function requires lifelong immunosuppressive treatment, and the resultant modification of the immune system is associated with an increased risk of various cancers, particularly those involving viruses" [33].

"In cases in which the need for transplantation is relatively less urgent, it is reasonable to avoid the use of organs from donors with unexplained fever, rash, encephalitis, or untreated infectious syndromes" [29].

"This knowledge raised the intriguing possibility that the immunosuppression used to prevent rejection might be beneficial for patients with HIV disease that had been successfully controlled by antiretroviral agents" [34].

Justice (both types of journals)

Organ allocation

"It is a relevant difference. You want to make sure you get the appropriate use of the appropriate resources. That is ethically not questionable at all. We do this rationalization of resources in health care every day" [35].

"Because transplantable organs are scarce, determining the most ethical allocation system requires simultaneous considerations of efficacy, urgency, and equity" [36].

"As stewards of a precious resource, the transplant community has a goal of achieving an equitable, transparent, and efficient system of organ allocation" [37].

Disparities in access to organ transplantation (gender, ethnicity, geography)

"We believe that the United States should end policies that permit geographic inequities and move quickly to determine the best use of data on the efficacy of outcomes to create a more equitable national system of distribution" [38].

"The federal government should expect dialysis programs to meet reasonable standards for equitable access to transplantation for all patients, regardless of race, sex, or social status" [39].

Personal responsibilities and organ transplantation

"Even though the issue of personal responsibility for organ failure is usually raised in the literature with regard to whether patients who abuse alcohol should be given a lower priority for an organ, a similar argument could be made that a woman who wittingly chooses to get pregnant when her graft is unstable (and who therefore has an increased risk of graft loss) should be given a lower priority for retransplantation" [32].

"A British liver transplant specialist last week accused colleagues of taking a decision on moral rather than medical grounds when they refused a transplant to a teenage girl with liver failure after she took half an ecstasy tablet" [40].