A perspective and review on nondirected liver donation

INTRODUCTION

Since the introduction of the first living donor liver transplant (LDLT) case in 1988,¹ most of the living donation practices have been biologically or emotionally related. Nondirected anonymous donations started gaining some momentum after 2000.² It is important to emphasize that all living donors should be considered “altruistic” and that terminology should not be used.³ Altruism applies to all donors; therefore, terminology for living liver donors should be focused on the presence or absence of anonymity and whether the donation is directed or nondirected as stated in the recent consensus statement.³ For the rest of the manuscript, recommended terminology will be used as follows: Directed, nondirected, anonymous directed, or anonymous nondirected living donors. The current paper will focus on the features, acceptances, and criteria of anonymous nondirected (NDD) liver donation.

Early LDLT reports had as high as 30% for any complications, up to 8% for major complication rate requiring procedure or operation, and 0.8% for mortality.⁴ Larger and more recent series reported a 6.2% major complication rate without mortality.⁵ In a study from 2012, authors followed more than 4000 living donors in the United States for a mean of 7.6 years.⁶ They concluded that the risk of early death among living liver donors in the United States is 1.7 per 1000 donors. More importantly, they concluded that the mortality of living liver donors does not differ from that of healthy, matched individuals over a mean of 7.6 years.⁶ Despite these improved statistics, there is no question that liver donation is a major operation with a significant complication profile, bringing more questions toward nondirected anonymous donation. In this review, we will address the following items: Features of nondirected anonymous donation, ethical questions, framework for NDD, and strategies to prevent coercion.

FEATURES OF NONDIRECTED ANONYMOUS DONORS

There is some literature indicating that the desire to donate to a stranger is not necessarily indicative of psychopathology.^7–10 In 2023, there were 91 unrelated anonymous liver donations in the United States, the highest number per year since 2009, although this is not specified as directed or nondirected.² Wright et al⁷ described their first NDD in 2007. This initial case was a left lateral donation to a child and took 9 months from evaluation to surgery. In their subsequent reports, initially 29 then 35 NDD cases, 70% of the NDD had altruistic activities before liver donation such as volunteered work or bone marrow donation.^8,9 In another study, NDDs were found to be highly cooperative and self-directed. They did not exhibit attention-seeking or religious motivations for their actions.¹⁰ The rationale for remaining anonymous may include avoiding recipient indebtedness, seeking internal satisfaction, limiting emotional attachment to the recipient, forestalling negative perceptions among family and friends, and ambivalence to meeting the recipient.³ Donors universally report significant positive psychological impact, including newer scales such as high posttraumatic personal growth scales in NDDs.^7–10 In addition, evidence suggests that anonymous NDDs have physical and psychosocial outcomes on par with directed donors.^3,6 Below is the Toronto Criteria for nondirected donors:

1. high level of motivation;

2. logical rationale for donation;

3. no expectation of secondary benefit;

4. voluntary informed consent;

5. no evidence of increased risk of negative psychosocial or psychiatric outcomes;

6. willingness to maintain confidentiality;

7. family support of donors’ decisions; and

8. understanding and acceptance of organ allocation criteria.

LIVER DONOR EVALUATION

There are well-defined mandatory and almost universal pieces to living liver donation workup, independent from the presence or absence of a biological or emotional connection.^11–13 However, the acceptance of NDD varies around the world.^13,14 In a recent global report, NDD is legal in the United States, India, Pakistan, and Saudi Arabia; illegal in South Korea, Turkey, and China; and requires specific committee permissions in Japan.¹³ Among countries that accept NDD, there may also be institutional restrictions to the graft type (left lateral vs. no restriction).¹⁴ There are many variations in the psychosocial evaluation of a living donor, such as the involvement of formal psychologists and psychiatrists or the utilization of validated tools; however, psychological domains assessed and absolute contraindications were almost universal.¹⁵ Overall, we can conclude that NDD candidates would not have a different workup, other than the transplant team ensuring an independent decision-making process, and these are variable based on country regulations and institutional policies.

ETHICAL CONCERNS

LDLT is a complex procedure that poses serious health risks and provides no direct health benefit for the donor. Because of this uneven risk-benefit ratio, ensuring donor autonomy through informed consent is critical.¹⁶ According to the literature, donors’ decisions to donate often occur before evaluation; therefore, they often make uninformed decisions.¹⁶ Therefore, it is critical to engage in living liver donor conversation early on with patients and provide existing literature about donor outcomes, specifically to donor candidates as transparent as possible.³

Public solicitation

Professional transplant societies and expert recommendations are clear that NDD is ethically and legally acceptable for transplant programs to consider including public solicitation.^17–19 Soliciting is considered organ trafficking when carried out for financial gain or comparable advantage.²⁰ These concepts are valid and binding internationally, independent from directed versus NDD. It is also important to remember, when used properly, that social media can be the main information source for donors^8,9 for their selfless generous act that results in excellent psychosocial donor outcomes, not to mention the benefits for recipients to gain a new life with a new organ. Lastly, while the prevention of monetary benefit is critical, it is important to keep in mind that donations should be financially neutral.^3,20 Transparency, regulations, and additional support systems may be necessary to accomplish financial neutrality based on the health care systems of the country.

SUMMARY

Nondirected altruistic liver donation is uncommon, and acceptance of this practice varies globally. It is legal and gaining more momentum in North America. Although there is limited data, expert consensus reports state that the most impactful and feasible strategy for addressing ethical concerns about anonymous living donation is to disseminate the existing research and published outcomes for anonymous LDLT donors.³ The development of program-specific multidisciplinary, transparent, and scientific protocols is crucial. Ongoing research regarding the long-term physical and mental outcomes of nondirected living liver donors is necessary to assure protection while respecting donor autonomy and benevolence.