Living related liver transplantation: a Japanese experience and development of a checklist for donors' informed consent

In the February 2002 issue of Gut, Broelsch et al argued for a controversial therapy of living related liver transplantation (Gut 2002; 50:143). The Japanese experience is somewhat different from those of other countries, as indicated in the article. Japan has long been the subject of sociocultural studies because of its delay in using the organs of brain dead persons for transplantation purposes. Since the Organ Transplant Law was enacted in 1997,¹ only 16 liver transplant operations using brain dead donors have taken place. In contrast, more than 700 cases of liver transplants (with both children and adults as recipients) using living donors have been performed at Kyoto University Hospital, and more than 1000 such transplants have taken place in Japan.²

The development of this medical procedure at our institute has entailed a strict self regulative process.

1. Each case is reviewed by an institutional professional committee that examines the medical indication. The transplant team prioritises the safety of donors, and no donor deaths have been reported so far.

2. Informed consent obtained by transplant teams is reassessed by the institutional ethics committee to check for the absence of coercion and guarantee the right to refuse surgery until the last moment. The ethics committee has developed a checklist (table 1 ▶) and basically all donors are interviewed by a member of the ethics committee before surgery. Donor candidates are restricted to a spouse or relatives within the third degree of blood relationship.

3. Information disclosure to media. In order to facilitate social acceptance of the procedure, relevant information continues to be disclosed to the press.

Table 1.

Checklist for interviews with donors for living related liver transplantation

(1) General profile of the recipient and the donor

(a) A brief medical history of the recipient

(b) Family tree

(2) Informed consent

(a) When and how did you come to know about living related donor liver transplant?

(b) Who explained the details of the transplant surgery, and how many times?

(c) Under what circumstances (one to one, or with others present)?

(d) Do you clearly understand the procedure of the surgery?

(e) Do you fully understand the risks and benefits of the treatment (including short term and long term risks for the donor, and the success rate of graft attachment for the recipient)?

(f) Have you been given information and explanations about alternative therapies?

(g) Have you been given enough time to ask questions? Have you been invited to ask questions?

(3) Decision making process

(a) Have you consulted with anyone?

(b) Was there any coercion by other family members or relatives? (For example, if you do not agree to be a donor, the patient will surely die.)

(c) Is your decision completely voluntary?

(4) Psychosocial aspects

(a) Do you have any anxiety about your surgery?

(b) Do you have any problems in your life (for example, business or social relationships)?

(c) Do you have any financial problems?

(5) Protection of the donor's right

(a) You have the right to refuse or withdraw your consent until the last moment.

(b) You will not suffer any disadvantage if you decide to refuse or withdrawal.

Interviewer's assessment

(1) The donor is well informed. □Yes □No

(2) The donor has a good understandings of the entire process. □Yes □No

(3) The donor is fully capable of making a decision. □Yes □No

(4) The donor's decision is completely voluntary and firm. □Yes □No

(5) The decision has been reached without any evidence of coercion. □Yes □No

(6) The donor's right has been fully protected. □Yes □No

(7) The donor is without significant psychosocial problems. □Yes □No

Time of interview min

Interviewer's signature (a member of ethics committee)

Date

While these institutional efforts are essential, we suppose there are more substantial reasons for the striking increase in this type of surgery. One obvious explanation is the hesitation in Japan to accept the concept of brain dead organ donors, but another may be the strong family bonds that are fundamental to Japanese culture. Traditionally raised in a family oriented society, Japanese people may not hesitate to give their organs to save a family member even if there is a small but perhaps fatal risk associated with the practice. This hypothesis needs further corroboration; however, on the other hand, many would assert that love for family is a universal value.

Hence we are faced with two academic questions: firstly, whether or not liver transplants using living donors will prevail to a similar extent in other countries where organ procurement from the brain dead is socially prohibited there; and secondly, whether or not this procedure can provide a solution to the lack of available organs in countries where organ procurement from the brain dead is permitted.

Japanese transplant surgeons are now going abroad to teach the living related liver transplant technique while patients and their family from countries where transplants from the brain dead are not permitted come to Japan to undergo living donor surgery. The situation described here clearly shows that while the world surgical community freely shares advancements in techniques, regional and sociocultural values greatly influence their implementation.