Psychosomatics 46:58-64, February 2005
© 2005 The Academy of Psychosomatic Medicine
Differences in Attitude Toward Living and Postmortal Liver Donation in the United States, Germany, and Japan
Marc H. Dahlke,
Felix C. Popp,
Nadine Eggert,
Ludwig Hoy,
Hideaki Tanaka,
Katsunori Sasaki,
Pompiliu Piso, and
Hans J. Schlitt
Received Jan. 22, 2004; revision received May 9, 2004; accepted June 15, 2004. From the Centenary Institute of Cancer Medicine and Cell Biology, University of Sydney; the Department of Hepatobiliary and Transplantation Surgery, Royal Prince Alfred Hospital, Sydney, N.S.W., Australia; the Department of Visceral and Transplantation Surgery, the Department of Sociology, and the Department of Biometrics, Hannover Medical School, Hannover, Germany; the Department of Anatomy, Shinshu University, Japan; and the Department of Surgery, University of Regensburg, Regensburg, Germany. Address reprint requests to Dr. Dahlke, Department of Surgery, University of Regensburg, 93042 Regensburg, Germany; mhdahlke{at}web.de (e-mail).
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ABSTRACT
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Living liver donation is a possible immediate option for decreasing the shortage of liver allografts worldwide. Risks related to the donation make this procedure ethically controversial. Study groups of medical students (N=330) from three different nations were analyzed with a complex questionnaire, and data were subjected to multiparameter analysis. The readiness for living liver donation was dependent upon the cultural background of the study groups. It was higher in the U.S. than in Germany and Japan, with a higher donation readiness for children as recipients than adults. Major differences among distinct sociodemographic groups need to be carefully addressed when setting up consensus guidelines for the clinical practice of living donation.
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INTRODUCTION
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Liver transplantation is the only definitive treatment available for end-stage liver disease caused by infections, metabolic or autoimmune disorders, and liver cancer. A considerable gap between the number of organ grafts needed for transplantation and those available from cadaveric donations results in long waiting lists and the imposition of narrow selection criteria.1,2 Living liver donation is an option that could increase the number of organs available for transplantation immediately. This could offer treatment to critically ill patients on waiting lists as long as no future therapeutic options, such as stem-cell-based techniques, bioreactors, or "liver dialysis" are available.3
Worldwide, many centers of excellence have established living liver transplantation programs in recent years, and the number of operations is increasing. The technical skills enabling these procedures have been developed over the last 15 years based on refinements in reduced-size-graft and split-liver techniques.4,5 In current practice, there is a broad range of technical modifications for living donor surgery. Depending upon the condition of the donor and recipient, either right or left lobe grafts are used. Orthotopic approaches as well as auxiliary transplantations are possible.
Ethical dilemmas behind living donation in general, and living liver donation in particular, arise in relation to postoperative donor morbidity and mortality.6–8 Performing major surgery on healthy donors to improve the well-being of another individual poses a number of ethical and sociological questions that have not yet been sufficiently addressed. What relationship criteria between the recipient and donor should be applied for donation? How should the expected outcome of the recipient’s treatment affect the advisability of donation? Where should lines be drawn and by whom? Under what general surrounding circumstances can living donation be considered acceptable? Answers to these questions require a careful appraisal of values, and no immediate solutions can be expected. However, international consensus is urgently needed to ensure that ongoing living donation programs can develop further.
The objective of the current study was to compare the attitude toward living liver donation of individuals from three different nations. Undergraduate medical students from the United States, Germany, and Japan were assessed by a complex questionnaire making use of a 5-point rating scale. Participants were asked about their willingness to receive a liver graft from a living donor as well as for their readiness to donate a part of their liver in a variety of hypothetical situations. We hope that data from this international collective will be useful for the generation of a consensus statement for living organ donation.
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METHOD
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Study Group
Overall, 330 undergraduate medical students took part in this study. This reflects approximately 50% of the questionnaires initially handed out. We could not exactly control the rate of response because participation in the study was not mandatory, and it could not be determined how many students de facto received their questionnaires, which were handed out in anatomy lessons, on campus, and in dormitory facilities. Although the uncontrolled rate of response of different groups might somewhat weaken comparability, the study conditions were as defined as possible in an open study analyzing subjects in a daily-life environment, which we consider to be essential for preventing bias by a highly artificial research setting (e.g., invited interviews). All research was carried out according to German federal law and approved by the participating universities.
The median age in the U.S. group was 23.9 years (SD=2.2), in the German group, 21.5 years (SD=2.8), and 22.4 years (SD=2.7) in the Japanese group (see Figure 1). Gender distribution was different among the groups, with 51.5% women in the U.S. group, 64.8% in the German group, and 27.3% in the Japanese group. Nine percent of U.S. students were married, in contrast to 1.8% of German students and no Japanese students. Religious beliefs were different in the study groups, reflecting the religious traditions in the respective countries. The majority of students reported their current state of health as at least good (U.S.: 98.5%, Germany: 91.5%, and Japan: 73.7%). As expected, most of the students had completed the highest basic educational degrees of their countries, and 81.8% (U.S.), 66.3% (Germany), and 50.0% (Japan) of the students lived in major cities while studying.
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FIGURE 1. Age Distribution of Medical Student Groups From the U.S., Germany, and Japana
aUnited States students were from New York; German students were from Hannover, Germany; and Japanese students were from Shinshu, Japan. Circles represent outliers; stars represent extremes.
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Questionnaire and Database
The questionnaire used in this study consisted of 28 distinct questions. First, sociodemographic data were collected, including age, sex, marital status, religion, educational background, locality, number of children, current state of health, and possession of an organ donor card. In a second part, the participants could rate their willingness to donate or receive a liver graft under certain conditions on a 5-point scale. The general readiness for postmortal donation or living donation of kidneys and lungs was assessed in additional questions.
The questionnaire was provided to 165 German medical students in an undergraduate anatomy course at Hannover Medical School, Hannover, Germany, to 99 Japanese students at Shinshu University, Matsumoto, Japan, and to 66 U.S. students in a dormitory at the Medical Center of the State University of New York, Brooklyn, N.Y.
The questionnaire was collected 2 weeks after distribution. All students received questionnaires in their first language. Native speakers translated the questions. The questionnaire was accompanied by a brief introductory text about the state of worldwide organ donation, which described the current need for donor organs and the possibility of living liver donation. The problems of donor risks in general were introduced without further explanations regarding special complications or outlining risk–benefit arguments.
All questionnaires were introduced into a database generated for the study and computed with statistical software (SPSS for Windows, Version 11.5, 2002). The means of the point scales were compared with t tests. Sociodemographic variables were compared with the chi-square method. Statistical analysis was conducted within the Department of Biometrics at Hannover Medical School.
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RESULTS
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Willingness to Receive a Graft From a Living Donor
All study participants were asked under which circumstances they could imagine receiving a liver graft from a living donor. Most of the German and U.S. students stated that they would accept a living liver graft under all circumstances, whereas most of the Japanese students were undecided (Figure 2A), leading to significant differences among all of the groups. However, when a life-threatening need for an organ graft was proposed, this result changed dramatically, and the majority of participants from each country would agree to accept a graft (Figure 2B). When a living donation would shorten the waiting period, the willingness to accept a living liver graft was slightly greater in the U.S. and Japanese groups (Figure 2C). When it was suggested that the results for living donation would be worse than those from a cadaveric donation, the willingness to receive a living liver graft was decreased in all groups (Figure 2D). If the results of living donation would be better than that for cadaveric donation, the attitudes were much more positive (Figure 2E), even if compared with the first general question (Figure 2A). Suggesting that there was a significant risk for the donor during the procedure greatly decreased the will to accept the donation in all groups, with most students being either undecided about, or opposed to, the transplantation (Figure 2F). Finally, the participants were asked whether they would accept a graft from a cadaveric donor. Here, U.S. and German participants expressed a higher will to receive a cadaveric graft (Figure 2A) than a living graft (Figure 2G). This difference was not as high in the Japanese group.
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FIGURE 2. Willingness to Receive a Liver Graft of Medical Student Groups From the U.S., Germany, and Japana
aColors correspond to 5-point Likert scale ratings, which ranged from "absolutely no" (black) to "yes, of course" (white) for each group. Questions for each potential situation were asked seperately (A–F), as indicated. Brackets indicate significant differences between groups (p<0.05).
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Attitude Toward Donating Organs After Death
When asked for their readiness to donate organs after death, there were no striking differences among the groups (Figure 3A). The majority of students from all three countries stated that they would donate their livers after their deaths (U.S.: 65.2%, Germany: 56.4%, and Japan: 52.5%). Although there tended to be more positive answers in the U.S. group, this did not lead to a statistically significant difference ( 2=4.37, df=4, p=0.36). The possession of a valid organ card was declared by fewer students than were motivated to donate (U.S.: 30.8%, Germany: 41.8%, Japan: 31.3%) (2=4.09, df=2, p=0.13).
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FIGURE 3. Willingness to Donate Different Organs as a Live Donor of Medical Student Groups From the U.S., Germany, and Japana
aColors correspond to 5-point Likert scale ratings, which ranged from "absolutely no" (black) to "yes, of course" (white) for each group and each respective organ or for postmortal donation in general (here, only three different answers could be given). Brackets indicate significant differences between groups (p<0.05).
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Attitude Toward Potential Living Donation of Liver, Kidney, or Lung
The study participants’ general attitude toward donation of various organs was assessed by asking about their willingness to donate a part of the liver, one kidney, or a part of the lung without specifying the potential recipient. Answers were measured on a 5-point scale. Most of the U.S. students showed a high donation readiness for parts of their liver, whereas this inclination was lower in German students and even lower in Japanese students (Figure 3B). A different result was obtained when attitudes toward potential living kidney donation were examined. German and U.S. students showed an equally high donation readiness, whereas the Japanese students’ readiness level was significantly lower (Figure 3C). It should be noted that the overall motivation to participate in living liver donation was not lower when compared with kidney donation. Asking about the potential donation of a part of the lung, which is not a common clinical reality, all groups expressed a significantly lower disposition (Figure 3D). In this case, only the difference between the U.S. and German group was statistically significant (p=0.031, t test).
Donation for Own Children Compared to Donation for Parents
To compare whether the designated recipient of a liver graft would influence the donation readiness, the study participants were asked under which circumstances they could imagine donating for either their parents or children. When asked about donation for parents over age 75, the willingness to donate was much lower than for parents over 50 years (Figure 4A and 4B). If the parent’s hypothetical disease was liver cancer, this resulted in higher donation readiness than for liver disease caused by alcohol (Figures 4C and 4D). A potentially life-threatening situation produced the highest readiness to donate (Figure 4E), especially when the results of the procedure would be promising (Figure 4F) when compared with "a last attempt" (Figure 4G). A higher potential risk to the donor resulted in lower donation readiness (Figure 4F).
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FIGURE 4. Willingness to Donate Part of a Liver for One’s Parents of Medical Student Groups From the U.S., Germany, and Japana
aColors correspond to 5-point Likert scale ratings, which ranged from "absolutely no" (black) to "yes, of course" (white) for each group. Questions for each potential situation were asked separately (A–H), as indicated. Brackets indicate significant differences between groups (p<0.05).
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When asked about donation to their own children, the overall donation readiness was extremely high in all groups. It was the highest in cases in which disease would be curable by transplantation (Figure 5A), the child’s status would be life threatening (Figure 5C), and the chances of a successful outcome were likely to be good (Figure 5D). In the situation of recipient liver cancer, the donation readiness was extraordinarily high (Figure 5B), and it was only slightly decreased in a situation with uncertain recipient outcome (Figure 5E) or increased donor risk (Figure 5F).
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FIGURE 5. Willingness to Donate Part of a Liver for One’s Children of Medical Student Groups From the U.S., Germany, and Japana
aColors correspond to 5-point Likert scale ratings, which ranged from "absolutely no" (black) to "yes, of course" (white) for each group. Questions for each potential situation were asked separately (A–F), as indicated. Brackets indicate significant differences between groups (p<0.05).
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DISCUSSION
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In the present study, we assessed attitudes toward living organ donation with the objective of aiding policy development for living donor programs. Ethical guidelines for the clinical practice of both donor and recipient procedures are urgently needed because living donor programs are expanding worldwide.9–13 In this trial, we assessed subjects from three different societies. Undergraduate medical students were chosen for the study because it can be assumed that these individuals share a similar educational background in different industrial nations. Japan, Germany, and the United States were chosen as study nations because their socioeconomic structure can be considered generally comparable, whereas significant diversity can be observed in terms of cultural and traditional values, religion, and political attitude. Having chosen students with medical backgrounds for the present study may have influenced the overall donation readiness toward a more positive attitude compared to the basic population. The focus of this study, however, was not to select cohorts representative of the respective nations but to compare the influence of cultural background on comparable groups.
One general conclusion from this study is that the sociological surroundings of a distinct study group determine donation readiness, independent of the need for organ donation within a group. In 2002, the rate of cadaveric donations per million inhabitants was 21.5 in the U.S., 12.2 in Germany, and below 1.0 in Japan. In addition, the prevalence of hepatitis and hepatic carcinoma is significantly higher in Asia, increasing the number of potential recipients.14,15 Therefore, it might have been expected that where the need for liver grafts was higher, there would also be a greater willingness to donate. Data from the present trial show that this is certainly not true for living donations of the liver or kidney, with the lowest donation readiness among Japanese students. The particular situation for organ donation in Asia is described in a recent article by De Villa et al.16 Here, the authors stressed that living liver donation is prevalent because of the lack of cadaveric organs. In our study, the Japanese cohort exhibited a lower inclination for organ donation in general, and postmortal donation in particular, than the other groups.17–19 This is especially notable because Japan has one of the world’s largest living liver transplant programs, with many excellent centers. In the present study, the groups’ cultural background was a more relevant predictor of the attitude of the potential donor than was the actual need for organ grafts in the respective society.
Data from this study also emphasize that there is no clear difference between the willingness to donate a kidney or parts of one’s liver. Although no data are yet available describing the long-term detriment of live kidney versus liver donation, the risk of immediate postoperative donor death in living kidney donation is estimated to be lower than that in living liver donation. Therefore, it could have been expected that potential donors would be more doubtful about participating in living liver donation. This was untrue for the groups of students analyzed in this study.
The state of living liver transplant programs in the United States was recently reviewed by an article by Brown et al.8 They analyzed 449 adult-to-adult living liver transplantations performed in the U.S. from 1997 to 2000. The overall postoperative donor mortality predicted from this study and others was between approximately 0.2% and 1.0%. Given that the underreporting of donor deaths and adverse events cannot be excluded, it is likely that the value was closer to 1.0%. In this study, the U.S. students showed the highest inclination toward living liver donation as well as for receiving a graft from a living donor themselves. This might reflect a greater trust in modern medicine in general or transplantation medicine in particular. It might also well be that the willingness to accept risk is greater in the U.S. than in other areas. The overall benefits of living liver donation were recently emphasized by Pascher et al.20 They reported a single center’s experiences for adult living liver transplantation in Germany. The procedure is described as safe and efficient, with survival and complication data comparable to that in the U.S. article. Of interest, the self-assessed quality of life in donors increased after donation in this study, indicating that living liver donation is a procedure that can be ethically justified regarding donor well-being.
One of the most obvious fears in living donation is the incremental decrease of ethical standards over time, allowing for an unintended change of principle values.21,22 Albeit, this threat must be considered real and needs to be carefully addressed; it must again be pointed out that a categorical decision that is applicable to all possible donation situations is highly unlikely.23–25 Therefore, widely accepted guidelines for the everyday procedure of clinical living organ donation need to be set up and strictly followed. The Consensus Statement of the Transplantation Society26 and the American Society of Transplant Surgeons’ Position Paper27 were recent steps in this direction upon which worldwide agreement might be based.
In conclusion, the ethics behind living organ donation is complex and needs further open discussion. No definitive immediate answers can be expected in the near future. This strengthens rather than diminishes the need for a trade-off consensus statement for clinical practice. From the current study, we conclude three major points contributing to future guidelines:
- Donation readiness depends upon the cultural surroundings and was obviously different in our three study groups with comparable educational and socioeconomic backgrounds
- Willingness to donate a living organ did not depend upon the need for organ grafts in a given society
- There was no obvious difference in the willingness to donate a kidney or a part of the liver
Achieving consensus within a heterogenous structure such as the Transplantation Society can sometimes be difficult.28,29 Nevertheless, it is desirable that policy recommendations by the international forum are informed by local reactions and values. Therefore, data from this study contribute to the description of cultural diversity in living organ donation.
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ACKNOWLEDGMENTS
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Supported by a grant from Roche Germany, Grenzach and additional support by Fushisawa Germany. Dr. Dahlke is currently supported by a personal grant from the Deutsche Forschungsgemeinschaft (DA 572/1-1).
The authors thank all study participants; Prof. R. Pabst, Hannover Medical School, for his support in organizing the study; and Ms. I. Kucuk for her work on the database.
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ABSTRACT
INTRODUCTION
