Is laparoscopic live donor hepatectomy justified ethically?

Live donor liver transplant (LDLT) was first reported in the 1990s and quickly raised ethical considerations, mainly related to the risk brought to the donor. The question of donor safety was even more accurate with the occurrence of laparoscopy, a technique which could allegedly increase the risk of severe intraoperative complications. Besides the questions of justice and autonomy, donor safety remains the main ethical debate of LDLT. Considering the lack of comparative assessment of postoperative outcomes, the Jury of the last Consensus meeting held in Japan in 2014 called for the creation of international registries to help to determine the benefit/risk ratio of laparoscopic donor hepatectomy. Since randomized studies are very unlikely to occur, benchmarking comparisons, between liver and kidney donors for instance, may also help to define standard practice. At last, donors' points of view should also be taken into account in the evaluation of those innovative procedures.

Live liver donation, ethics and practitioners: 'I am between the two and if I do not feel comfortable about this situation, I cannot proceed'.

This paper discusses the views of 17 healthcare practitioners involved with transplantation on the ethics of live liver donations (LLDs). Donations between emotionally related donor and recipients (especially from parents to their children) increased the acceptability of an LLD compared with those between strangers. Most healthcare professionals (HCPs) disapproved of altruistic stranger donations, considering them to entail an unacceptable degree of risk taking. Participants tended to emphasise the need to balance the harms of proceeding against those of not proceeding, rather than calculating the harm-to-benefits ratio of donor versus recipient. Participants' views suggested that a complex process of negotiation is required, which respects the autonomy of donor, recipient and HCP. Although they considered that, of the three, donor autonomy is of primary importance, they also placed considerable weight on their own autonomy. Our participants suggest that their opinions about acceptable risk taking were more objective than those of the recipient or donor and were therefore given greater weight. However, it was clear that more subjective values were also influential. Processes used in live kidney donation (LKD) were thought to be a good model for LLD, but our participants stressed that there is a danger that patients may underestimate the risks involved in LLD if it is too closely associated with LKD.

Preparing for the inevitable: the death of a living liver donor.

Living donor liver transplantation (LDLT) is associated with a low but finite and well-documented risk of donor morbidity and mortality, so organizations and individuals involved in this activity must accept the fact that a donor death is a question of when and not if. Studies in the field of crisis management show that preparing for the inevitable not only is critical in preparing institutions to better respond to catastrophic events but more importantly plays a crucial role in preventing them. This article describes the background of crisis management with specific reference to the death of a living liver donor and proposes a general framework that can be adopted by LDLT programs around the world.

[Dying with living donor transplantation]. / Sterbend mit Lebendspende.

A female patient with primary sclerosing cholangitis developed a cholangiocarcinoma (Klatskin tumor) at the age of 42 years. It was successfully resected by hemihepatectomy and hepaticojejunostomy. In the next 15 years she had recurrent episodes of bacterial cholangitis and had to be hospitalized several times a year for intravenous antibiotics. At the same time the sclerosing cholangitis progressed and she developed liver cirrhosis. The patient, who was never willing to give up, underwent liver transplantation by receiving the left liver lobe of her daughter (living donor). Postoperatively she suffered from severe complications including a biliary leak, sepsis, intraabdominal abscesses and cachexia. Soon after she was dismissed by the transplantation center, she was admitted to our hospital in a very poor condition. She refused any further intensive care and died, with the well functioning donated left liver lobe of the daughter dying with her.

Donor compensation: an ethical imperative!

The number of living organ donors is increasing worldwide, but donor needs are widely neglected in support of anticommodification policies. This article argues that the warrant of donor autonomy during the decision process to donate is only one requirement of adequate donor care. Another is the donor's protection against the systematic and institutional exploitation of his altruistic dispositions. People with the disposition to support those, who are in desperate need, with a nonrenewable part of their own body, despite a small but unavoidable risk of death or health impairment, do not deserve to be additionally burdened with further disincentives, such as financial risks and uncompensated costs of donation. And although the borderline between a morally required disincentive removal and a more controversial net incentive to boost donation might be vague and open to discussion, to disadvantage living donors by design constitutes a serious barrier to the fairness of living organ donation-a barrier that should be removed.

[Living donor liver transplantation from the perspective of the donor: results of a psychosomatic investigation]. / Die Leberlebendspende aus Sicht des Spenders: Psychosomatische Untersuchungsergebnisse.

OBJECTIVES: Living donor liver transplantation (LDLT) has been gaining importance in the treatment of endstage liver disease in adults. Thus far, only few empirical studies have been published on the psychosocial situation of donors who are faced with the risk of medical complications after resection of the right hepatic lobe. The aims were to describe the clinical problems before and after transplantation and to contribute to the discussion of ethical issues based on empirical findings. METHODS: In the present overview, the pre-/post-transplant and follow-up periods are characterized from a psychosocial point of view using actual psychosocial and medical findings in living donors of the right hepatic lobe. RESULTS: Before LDLT, 11 % of potential donors were not recommended for the transplantation due to marked ambivalence about the operation. After donation 26 % of donors showed high values for anxious depression and physical complaints despite low rates of surgical complications. CONCLUSIONS: For clinical psychosomatic evaluations of potential donors it is important to provide donors an opportunity to report any misgivings and anxieties as openly as possible. The psychosocial impairment and physical complaints of some donors after transplantation are yet not clearly understood. More psychosocial studies in this field will be necessary to investigate ethical questions and to develop criteria for an evidence-based medical care of living donors.

Ethical issues in split versus whole liver transplantation.

Technologic advances in split liver transplantation have resulted in an ethical dilemma. Although splitting a liver maximizes the number of patients receiving an organ transplant, it may increase the morbidity and mortality for the individual patient receiving the split liver. This essay explores the ethical issues involved in the allocation of split livers, and proposes general policy guidelines for the allocation of split versus whole liver transplants.

Harvesting liver fragments from living-related donors: a single-center experience.

The aim of the study was to estimate the risk of harvesting a liver fragment from a living-related adult donor. Liver fragments were harvested from 44 donors. Liver segments II and III were harvested from 36 donors. Liver segments II, III, IV were harvested from 6 donors, 2 donors gave segments V, VI, VII, and VIII. After preliminary donor selection volumetric assessment of liver segments by computed tomography and arteriography was performed to visualize the cenac trunk and superior mesenteric artery. None of the donors died. No complications were observed during the operation. Only one case, a bile collection, was observed after surgery. We treated this patient with a satisfactory result by sonography-guided drainage. We observed temporary elevation of bilirubin and transaminase levels and a decrease in prothrombin index value. Blood transfusion was not necessary during any of the procedures. Mean hospitalization time after the surgery was 9.4 days. Mean graft weight/recipient weight ratio was 2.54%. The risk of the harvesting liver fragment from a living-related adult donor seems to be minimal.