Beyond the Transplanted: Who Should Inform Attitudes Toward Xenotransplantation?

To the editor,

We read with interest the study by Başkiran et al., [1]. on the views of living donor liver transplant (LDLT) recipients toward xenotransplantation. Qualitative inquiry into this emerging field is much needed, and the authors offer a valuable window into how transplanted patients reason about animal‐to‐human organ sources. We would like to highlight a few considerations regarding the study's sampling approach in relation to its stated objectives and conclusions.

The significance and scope of the findings rest, in part, on the claim that they emerged from an information‐rich and heterogeneous sample. Indeed, the benefit of maximum variation sampling is that it allows researchers to identify cross‐cutting patterns across a widely diverse population. However, while maximum variation sampling typically includes cases as different from each other as possible, the study ultimately draws on a fairly homogeneous group of 20 recipients (17 Muslim men and three women), all otherwise healthy and cared for at a single hospital. The authors' claim of maximum variation thus sits uneasily with the demographic homogeneity of the sample. In addition, the relatively brief interviews (11–23 min) and limited iterative engagement may constrain the depth of phenomenological insight achievable.

Likewise, while the authors frame xenotransplantation as a response to organ scarcity, waitlist attrition, and the loss of those who never reach liver transplantation (LT), the sample consists exclusively of patients who have already been transplanted, mostly from living donors. The phenomenon the authors set out to understand, namely how the lived experience of scarcity and waiting shapes acceptance, is thus explored among those who survived and escaped it. Notably, the authors' own analysis identifies the “attrition of the waiting process” as a central driver of acceptance, yet those currently enduring that attrition, and the families of those who died waiting, are absent from the sampling frame. Their perspectives seem essential to the question at hand.

This skew also carries a fairness dimension relevant to xenotransplantation's purpose. The capacity to furnish a living donor is itself patterned by social and relational resources: an available, healthy relative and the means to support their surgery [2]. In a setting where, as the authors note, the great majority of transplants rely on living donors, those who reach transplantation are disproportionately the already‐advantaged [3]. Since the patients who would benefit most from xenotransplantation are precisely those without such resources [2], a sample drawn from “successful” LT recipients risks leaving the patients with the greatest stake unheard.

Taken together, these considerations raise questions about participant representativeness and appropriateness; that is, whether the participants sampled were optimally positioned to illuminate the phenomenon under study [4]. Supporting this concern, a qualitative study of Turkish patients awaiting kidney transplantation found that most participants accepted xenotransplantation unconditionally [5], suggesting that urgency and vulnerability may attenuate the conditionality observed among recipients. Those still awaiting LT may similarly view xenotransplantation more readily as a necessary option. Claims of maximum variation derived from a largely homogeneous sample may therefore overstate the representativeness of the findings, which cannot reflect the full range of perspectives shaped by organ scarcity, including those of individuals least able to secure a donor [4].

We recognize that interviewing currently listed candidates or bereaved families raises real ethical and logistical challenges, and we do not mean to imply that the recipients' accounts lack value; rather, they reflect the retrospective views of a fairly homogeneous group who successfully reached transplantation. Future qualitative work recruiting these underrepresented groups would capture how last‐resort reasoning forms before the LT outcome is known, offering a fuller account of attitudes toward xenotransplantation.

Author Contributions

Jenny L McDonnell and Tony O Pomales contributed equally to the appraisal and draft of the manuscript and provided content expertise in qualitative methods. Tomohiro Tanaka conceived and initiated the drafting of the paper, supervised the work, and critically revised the manuscript for important transplant‐related content. All authors reviewed and approved the final version.

Funding

Tomohiro Tanaka is supported by AHRQ Mentored Clinical Scientist Research Career Development Award (K08): K08HS029195‐01A1.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The authors have nothing to report.