Public solicitation for organ donors: a time for direction in Canada

The disparity between supply and demand for transplantable solid organs has resulted in strategies to drive increased organ donation, including public solicitations for living donors. Public organ solicitation occurs when a recipient or their representative solicits an organ for transplantation by public broadcast (e.g., social media or a public notice). The intended donor and recipient may not have a prior relationship. Lack of regulation of public solicitations for organ donation in Canada is a cause for concern. We call for careful screening of altruistic donors within a well-organized system that links willing donors with a maximum number of beneficiaries.

Public solicitation for organs offers an opportunity to find a living donor for potential recipients who do not have one within their social or familial network. Thus, solicitations are a way to redress a somewhat natural injustice, whereby some people have more friends or family members who are willing to donate than others. Accepting these donations does not discriminate¹ nor does it disadvantage those on the waiting list.² Solicitation leads to access to an organ that would not otherwise have been available for donation.³ In addition to being a benefit to the direct recipient, every transplant reduces the demand on the waiting list.² Solicitation can also increase the awareness of organ shortages and may elicit more donors for other recipients.³

However, there are concerns. Organ solicitations have been criticized as unfair, because they enable donation to identified recipients rather than to a recipient on a waiting list. Celebrity status and access to resources clearly provide increased opportunities to find a donor. A person with a high profile or more appealing story may be perceived as getting ahead in the transplant system, which could influence the public against organ donation.⁴ Recipients who are computer literate, social media savvy or English-speaking have enhanced access to potential donors beyond their local community and are more likely to find a donor than those without these characteristics.² Publicity surrounding personal stories involving organ solicitation can be misleading and encourage offers to the solicitor, without considering donations to those with greatest need.⁵ However, all living donation is inequitable in that the donor chooses to whom to donate — generally someone they know — without any requirement to donate to the wait-list recipient with the greatest need.

One concern with public solicitations for organs is the potential for exposure of the recipient to harms from a donor who is unknown to them, which may in turn damage the reputation of transplant programs.³ Canadian law requires a minimum donor age for living donors, voluntary consent and no exchange of goods for an organ.⁶ Public solicitation may increase the potential for exchange of valuable considerations for an organ, because the donor is unknown to the recipient.

Two recent, well-publicized Canadian cases focused attention on these issues. The owner of the Ottawa Senators hockey team, who needed a new liver, used his public profile to solicit an anonymous donor.⁷ In the other case, the family of a young girl who needed a liver transplant made a public appeal through a Facebook page.⁸ The solicitation was fuelled by media attention surrounding this touching story, whereby the child’s twin had received liver tissue donated by their father, who could only donate once. The solicitation received more than 500 responses from people willing to donate.⁸ These two public solicitations for organs received markedly different public responses: one faced criticism⁹ and the other garnered sympathy. The difference in public perceptions was likely due to the different recipient profiles. In both cases, anonymous donors came forward, were screened and donated a part of their livers.

There are no guidelines for public solicitation of organs in Canada. Canadian transplant programs have had to address this issue on a case-by-case basis, often without consensus. Within Canada, different responses to organ solicitation by potential donors may be producing inequity of access to organs. Transplant programs and their patients could benefit from guidance on how to address the challenges raised by public solicitations. Many transplant doctors would be comfortable with public solicitation only if the donor became a nondirected altruistic donor, by which the organ is allocated to the next suitable recipient on the waiting list rather than to the actual solicitor (unpublished survey data, July 2015). Transplant doctors consider the next best thing to be to ensure that a relationship existed between the recipient and the solicited donor before donation occurs.

Donors who respond to public solicitations should be considered for transplantation. However, transplant programs must ensure that the motivation for donation is based on altruism rather than secondary intention, and that donors meet medical and psychosocial criteria for living donors, provide informed consent and agree to meet the requirements of the program regarding contact with the recipient. Although they should not be dissuaded from donating to the intended recipient, solicited donors should be made aware of alternatives such as donating to the recipient with the greatest need. A model is Canada’s National Kidney Paired Donation program. This program is the best option for candidates who have living kidney donors who are willing to donate and medically able, but who are incompatible with their intended recipient. The program coordinates a chain of multiple transplants so that a willing donor’s organ can find its way to a compatible recipient while the intended recipient also receives an organ.¹⁰ This system allows the most people in need of an organ to get one. Even if the solicited donor and recipient are compatible, they can still choose to enter the National Kidney Paired Donation program as a pair, to benefit the greater transplant community, because a critical number of pairs are required for the overall success of the program.¹⁰ Whether donors from a public solicitation should remain anonymous to their recipients is a decision best left to the transplant program.

Donations of living organs are valued. Solicited organ donation helps to identify willing donors. It is an important facet of living donation and should be promoted. However, solicited organ donors should be encouraged to consider anonymous nondirected organ donation within systems, such as the National Kidney Paired Donation program, to maximize the number of patients in need who receive a transplant from a willing altruistic donor.

Key points

• Some Canadian transplant programs evaluate potential organ donors who respond to a public solicitation for an organ; however, the practice remains unregulated.

• Public misunderstanding surrounding recent well-publicized cases involving public solicitation has the potential to undermine trust in the organ donation system.

• Well-managed public solicitation for organ donors can improve donation rates of living organs, can reduce the waiting list of those waiting for an organ from a deceased donor and can help to raise awareness about organ donation and transplantation.