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Bangladesh Journal of Bioethics 2010;1(3) :35-42

ORGAN TRANSPLANTATION AND VULNERABLE DONORS: DONATION 
UNDER EMOTIONAL COMPULSION 

Inayat Ullah Memon
 
Chief Pathologist, Peoples Medical College Hospital, Nawabshah, Sindh, Pakistan.
 Email: memon.inayat@gmail.com

Abstract:  During  last  few  decades  advancements  in  medical  knowledge  and 
technologies have increased the practice of organ donation. Organ transplantation, on 
one hand gifts renewed life to the donors, while on the other hand unwanted ethical 
practices  in  the  field  exploit  vulnerable  donors,  such  as  trend  of  ‘transplantation 
tourism’ involving non-related live donors.  Beyond this, some delicate and intriguing 
situations  bring  the  physicians  at  cross-roads  in  cases  of  live  related  donors’ 
transplantation.  In this paper, I would like to discuss and analyze a case of live donor 
(un-married girl), where overtly consents to donate kidney to her brother who is bread-
earner  of  their  joint  family.  By  consenting  to  donate,  the  girl  jeopardizes  her 
matrimonial proposal as her fiancé is uncertain about her post-donation health status. 
The transplant clinician, aware of this fact faces ethical dilemma, whether to perform 
transplantation surgery so as save the life of ailing patient or to abandon it in order to 
save the future marriage of the girl from being broken. The case highlights multiple 
ethical  issues  in  Asian  socio-cultural  context.  I  have  attempted  to  disentangle  the 
dilemma by applying Mc Donald and Rodney’s framework of ethical decision making. 

Introduction: Since the first kidney transplantation in early fifties of twentieth century, 
that  was associated  with some complications,  the  practice  of kidney transplantation 
have  progressively  increased  due  to  development  of  interventions  that  increased 
acceptability of foreign organ, introduction of leading-edge surgical procedures that are 
more  comfortable  as  well  as  safer  for  both  donor  and  recipient,  with  subsequent 
improvement in quality and increased volume of transplantation procedures in coming 
years.1,2  From ethical perspective, though cadaveric organ donation is less problematic 
than acquisition of organs from live donors, but this category of donation alone can’t 
meet  the growing demands for the end-stage renal failure patients.3 Much has been 
debated about ethics of non-related organ donation. In developing and poor countries, 
extreme poverty, non-existence or ineffective legislation governing this procedure and 
presence  of  influential  organ-trade  brokers  in  collaboration  with  some  medical 
professionals  have opened the avenues leading to ‘transplantation tourism’, which is 
coupled with overt  and undesirable unethical  practices.4,5 Alternatively,  the ethically 
preferable and medically favorable mode of transplantation i.e. live-related donation is 
not  absolutely  free  from  ethical  downsides.  On  one  hand  the  related  donors  have 
technically more chances of compatibility than non-related donors, while on the other 
hand some subtle ethical intrigues are frequently encountered in this type of donation 
than more obvious moral  problems associated with non-related type.  Acquisition of 
genuine,  valid,  truly  voluntary  and  coercion-free  informed  consent  from  donor  is 
ethical pre-requisite.6 Role of compelling emotions by the donor towards related organ 
recipient is not only natural, provides psychological satisfaction to the donor as sharing 
the illness of the patient and is commendable act as well. Living organ donation has 

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Bangladesh Journal of Bioethics 2010;1(3) :35-42

unique characteristic i.e. for the well being and life of the ailing person, a healthy donor 
is put at potential  risks.1,2 Witnessing by the transplantation team the impulsive and 
hurried decision of relatives to donate organs generates concerns about the validity of 
consent. Some authors argue that participation in clinical trials have similarities with 
donating  organs  for  nears  and  dears  but  there  are  unjustifiable  differences  while 
obtaining  informed  consent  from  these  two  groups  of  altruistic  people.  In  organ 
donation the members of transplantation team have conflict of interest in the form of 
inherent sympathies for the organ recipient that makes the consent taking procedure 
questionable.  1,6 The  most  worrisome  factor  in  the  process  of  donor’s  consent  in 
transplantation procedure is whether it is free from impulsive and compelling emotional 
forces generated due to the close relationship with prospective recipients and sympathy 
toward them. Does the donor ignore associated risks because of these forces? Does the 
donor’s decision–making ability is adversely affected because of financial dependence 
(as in the following case) on the recipient? Does the donor, being close relative of the 
recipient have no alternative but to submit herself to the wishes of the family (which is 
not uncommon phenomenon in Eastern context) so as ‘save the face’? 6,7 Moreover is 
the donor fully aware of all  the possible  outcomes  of the proposed transplantation, 
including failure of the procedure or possible death of the recipient and potential risks 
and  hazards  resulting  from  his/her  nephrectomy?  1,2  Uncertainty  in  the  medical 
fraternity about the risks associated with kidney donation, particularly the long-term 
long  term  such  as  hypertension,  diabetes  and  chronic  kidney  disease,  with  ethnic 
variations, further compounds the issue. 2,8,9 To address these questions, an environment 
is required to exclude the potential weaknesses associated with procedure of obtaining 
informed consent by the transplantation team and offered by the donor in these special 
circumstances. In Eastern socio-cultural  context,  where transplantation team is more 
trusted by the donors as well as recipients who customarily exercise lesser autonomy in 
contrast  to  rights-based  Western  society,  the  responsibilities  of  the  transplantation 
clinician are enhanced in order to resolve ethical issues and help both partners of the 
transplantation procedure and their families to arrive at morally acceptable outcomes. 
Following case explains a situation, similar to which are not infrequently encountered 
in developing countries where the transplantation teams face a dilemma.  Cases like 
these need to be assessed by some recognized frameworks of ethical decision-making. I 
have  made an attempt  to  disentangle  the  issue by using Mc Donald  and Rodney’s 
framework.10                           

Case study: Mr. “P”  (patient) suffering from renal failure is admitted to specialized 
Transplantation Hospital, KTC (Karachi Transplantation Centre, not the real name) in 
Karachi,  Pakistan,  where he is  undergoing hemodialysis.  He is  42 years  aged man, 
belongs to poor socio-economic group. His father Mr. “F” (father) is 65 years old and 
alive, while had mother has passed way a few years ago. Mr. “P” is married, his wife 
Mrs. “W” (wife) is happy and healthy, has two children, one boy and one girl. Mr. “P” 
has one sister Miss “S” (sister), who is unmarried (her marriage is planned after about 
six months), aged 25 years and has one brother “B” (brother) 35 years old. Miss “S” is 
illiterate house woman, not engaged in any job. Being a joint family, all live together 
and are financially dependent on “P” who has/had been the bread-winner. Doctors have 
advised  “P”  for  renal  transplantation.  As  an  initial  step  “S”,  “B”  and  “W”  were 
investigated for compatibility to donate kidney to “P”. The workup reveals that only his 
sister “S” is compatible, the results were communicated to the family. After a few days, 

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Bangladesh Journal of Bioethics 2010;1(3) :35-42

the  Dr.  “U” (urologist,  member  of  transplantation  team)  called  a  meeting  with  all 
concerned people in this case i.e. Miss “S”, Mr. “F” and Mrs. “W” and Mr. “B”. “S” 
was informed that  she has been found the appropriate  person amongst  the three to 
donate kidney to her brother. She does not show any sign of apparent displeasure or 
disagreement  for the procedure,  her father “F” also agrees for her kidney donation. 
After three days, a person Mr.  “FI” (fiancé) came in the office of Dr “U”, introduced 
himself as fiancé of Miss “S”, informed Dr “U” about his concerns regarding kidney 
donation of “S” for “P”. He raised objection on the willingness of the family of “P” for 
the transplantation.  He politely informed Dr.  “U” that  if  her kidney is  removed for 
donation,  he will  not marry with “S” because her  health  would deteriorate.  Doctor 
listened to him carefully and told that his views will be given due consideration, doctor 
“U” also discussed with him about his (“FI”) fears of health deterioration after kidney 
donation and explained that so far no major adverse health consequences have been 
reported by kidney donation, if the donor is carefully looked after. Mr “FI” did not 
make any comment after Dr “U” ‘s explanation, but Dr “U” guessed from his non-
verbal behavior that “FI” has not changed his views even after the explanation.       
Dr. “U” faces ethical dilemma in this case. He wonders what he should do. Should he 
accept the kidney of “S” for “P” (to save the life of patient) despite objection of her 
fiancé? Or advise the relatives of “P” to seek and arrange some other compatible donor. 
The  family  is  not  financially  sound  to  compensate  un-related  donor  for  kidney 
donation.  The  family  is  unable  to  bear  the  expenses  of  long-term  haemodialysis. 
Neither, “P” is insured for his health, nor there is state social welfare system to bear the 
financial cost of dialysis. At the same time, he is aware of the fact that if kidney of “S” 
is removed “FI” would not marry with her. Moreover he is familiar with local customs 
and traditions that once her engagement is broken with bearing this stigma the chances 
for her matrimony are very bleak and he is aware of the fact the prospective donor 
(“S”) is financially dependent on recipient (“P”) that further deepens ethical issue. Dr 
“U” is under pressure from the family of “P” to perform transplantation surgery early 
so as “P” returns to routine life and provide earnings for the family.  
To resolve this issue and in the best interest of “P” and prospective donor “S”, Dr “U” 
thought it better to arrange a meeting with “S” and her father “F” so as to disclose and 
discuss with them views expressed by “FI”. Meeting was held and Dr “U” came to 
know that  “F”  and “S” were  already aware  of  “FI”’s  disagreement  and both  were 
overtly happy if “S” s kidney is transplanted to “P”. Dr “U” attempted to have meeting 
with Miss “S” in privacy, so as to assess her free will of donating kidney and exclude 
the  factor  of  coercion  by her  relatives,  if  any,  but  he  couldn’t  succeed  because  of 
cultural inhibitions.     

Ethical analysis of the case: 
First, I would like to identify the ethical issues in the case followed by their analysis 
using  the  framework  of  McDonald  and  Rodney,  which  includes  within  its  larger 
framework the ‘four boxes’ clinical ethical analysis of Jensen et al. This framework has 
four components i.e. 
A. Collection  of  information  and identification  of  the problem.  This  includes  four 

factors  of  Jonsen,  Siegler  and  Winsdale  11 (Medical  indications,  Patient’s 
preferences, quality of life and contextual factors)   

B. Specification of feasible alternatives
C. Use of ethical resources to identify morally significant factors in each alternative

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Bangladesh Journal of Bioethics 2010;1(3) :35-42

D. Making the choice 

Ethical issues: 1. Is the donor (being a lady/a vulnerable member of the community 
and financially dependent on prospective recipient) truly autonomous, genuinely free 
and emotionally neutral to give voluntary informed consent? 2. Is she able to make her 
own decisions  in  the  background  of  the  fact  that  her  father  and  brother  would  be 
unhappy, if she declines to donate kidney? 3. If she donates the kidney, what would be 
the fate of her prospective marriage? 4. Is she well informed about the possible adverse 
consequences of the kidney donation? 
Let us discuss each issue separately: 
1: Given the fact that “S” is financially dependent on his brother “P” and is part of an 
intricately woven joint family, it appears very impracticable for her to decline to donate 
kidney (to genuinely exercise her autonomy), even if she decides to do so. Now let us 
further explore this issue in context of developing countries. Presuming that donor is 
male,  bread-winner of the family and financially supporting joint  family,  then what 
would hypothetically be the voluntary decision of a brother for his sister who needs 
kidney  for  transplantation.  In  general  no  brother  or  sister  having  equal  social  or 
financial  standing will  disagree  for  organ donation  for  his/her  brother/sister,  if  this 
process has no bad health consequences for donor. That is demand of the doctrine of 
“Ethics of Care”2.  It  is the brother-sister  relationship (like any other close bondage) 
which attracts more care for each other out of love. These situations do not involve any 
apparent  influencing  /  coercing  factors  on close relatives  to  donate  the organs.  But 
when viewed in context of poor developing countries, the read-winning brother would 
hardly sacrifice his precious organ to save the life of his sister having low financial 
value.   

2: Is she emotionally neutral  to make decision about kidney donation (neuroethics). 
This  aspect  of  the  case  needs  further  exploration.  It  can  be  appreciated  that  one’s 
emotional situation,  previous experiences and context do affect  the decision-making 
ability.  As  described  by  Moll  and  Crafman12 in  their  “Event-Feature-Emotion” 
complex, interplay of different parts of brain (i.e. pre-frontal lobe, temporal lobe and 
limbic  system)  results  in  ethical  decisions  making.  Limbic  system being concerned 
with emotions does affect  the ultimate decision.  Moreover, they assert  that person’s 
background (exemplified by orphan child) will affect the decision as well. Likewise in 
this case, she can’t be considered emotionally neutral. Prospective kidney recipient is 
the bread-earner of the family and his sister is the only compatible match amongst three 
available donors. Will not this situation compel her to donate? Moreover process of 
decision making varies with social and cultural context.13 I mean to say that Western 
individual-based  autonomy  can  neither  be  expected  from  Eastern  society  nor  it  is 
practiced to that extent as in the West. In Eastern culture a man is considered superior 
while  women  is  given  secondary  status,  this  fact  becomes  even  harder  where  the 
literacy rate and socio-economic condition go down. In this background and the fact 
that she is not earning member of the family, if she declines to donate kidney, there are 
strong fears that her father and brother would not only be unhappy but angry. She being 
a part of this culture would be aware of this fact. Will this affect her ability of decision 
making? 

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Bangladesh Journal of Bioethics 2010;1(3) :35-42

3:  Another  factor  is  fate  of  her  matrimony.  If  she donates  kidney there  are  strong 
chances  that  her  fiancé  would  refuse  to  marry  with  her  as  her  fiancé  has  already 
expressed his views about the proposed transplantation. This is generating producing 
conflict in her mind (a conflict of interest), either to save the life of her ailing brother 
and ‘save her face’ in family and society or for the sake of her matrimony refuse to 
donate.    

4: The root problem that created the dilemma is the issue of adverse consequences on 
donor’s  health  after  nephrectomy,  because  this  is  the  issue  that  prompted  “FI”  to 
contact Dr “U”. According to Canadian scientist, issue of knowledge and assessment of 
medical consequences of organ donation is important one, as he said: “A more precise  
understanding  of  the  long-term  medical  outcomes  is  critical  for  improving  donor  
selection, informed consent and follow-up”14. Though there are few post-donation risks 
of lesser gravity, but still there is no complete and high-volume studies available on 
record for the ethnic minorities in USA and for the people of developing countries; that 
hinders the ethically compete disclosure of information to the donors so as to  allay 
their fears if any. 

While analyzing the issue of girl’s consent for donation, it is important to assess the 
validity of her informed consent, to inform her about health related consequences of 
kidney  donation,  available  alternatives  and  possible  chances  success/failure  of 
transplantation surgery.  I  am afraid this  issue is not faithfully dealt  with at  least  in 
developing countries. The legal formalities are fulfilled, donors’ willingness is taken 
just in the form of signature (or thumb impression) but requirements of understood and 
informed  consent  are  not  met.  I  would like to  refer  here two episodes  of  program 
televised about kidney selling/donation, shown on local TV network in Pakistan on 14th 

and 21st April 2007 (08-05 PM), wherein surgeon said that he used to tell to the donors 
all the things about removing kidney and further explained that he had documentary 
proof of that. He stressed on documents but gave very little importance to the ongoing 
process of informed consent.15     

Analysis in Mc Donald and Rodney’s Framework:  
A.  Collection  of  information  and  identification  of  the  problem:  It  will  be 
appropriate  to  apply  the  ‘four  boxes’  of  Jensen  et  al on  both  the  patient  (organ 
recipient) and donor. Regarding  medical indications, from the patient’s perspective, 
the process of kidney transplantation fulfils the goals of medical treatment i.e. there are 
bright chances of recovery of the patient  from renal failure while  from the donor’s 
perspective in general there are only few (if any) chances of damage to her health and 
these are same to as to any other donor in case of kidney transplantation. But lack of 
data and absence of studies regarding long-term post-nephrectomy consequences for 
donors of developing countries makes  the issue more problematic.  As far patient’s 
preferences  are  concerned,  the  he  wishes  with  his  full  senses,  to  have  the  kidney 
transplanted to him and it is informed, understood and voluntary. While it is uncertain 
if  the donor’s consent  is  genuine  and informed or  given under  emotional  coercion, 
duress or family compulsion.  Regarding patient’s quality of life,  it  would improve 
both in the view of patient and the caregiver (transplantation clinician), moreover it is 
worthwhile to perform this process as it is internationally recognized mode of treatment 
for the end-stage renal failure. But from the donor’s perspective it is doubtful, being a 

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Bangladesh Journal of Bioethics 2010;1(3) :35-42

woman she has slightly more chances of developing hypertension related disorders of 
pregnancy moreover belonging to poor socio-economic group makes it uncertain that 
she  would  be  properly  looked  after  in  case  her  health  deteriorates.2 Regarding 
contextual  features,  transplantation  will  improve  the  economic  condition  of  the 
recipient’s family, as he is the bread earning member. But it is doubtful if the family 
would  be  able  to  bear  the  expenses  of  ongoing  treatment  of  the  recipient  after 
transplantation.  From the  donor’s  perspective,  she  will  be  in  a  fragile  situation,  as 
recipient being the bread-winner will be preferentially looked after than the donor in 
case of illness.              
B. Specification of feasible alternatives: For the patient the possible alternatives are 
either  to  have  transplantation  performed  or  to  continue  the  haemodialysis.  But  the 
second option  because  of  economic  constraints  is  not  feasible  for  the  family.  This 
factor also applies to the physician, if he performs the transplantation surgery he will 
knowingly jeopardize the matrimonial proposal of the donor but on the other hand if he 
doesn’t, then he will increase the miseries of the renal failure patient. This situation 
brings the physician at cross-roads.       
C.  Use  of  ethical  resources  to  identify  morally  significant  factors  in  each 
alternative: When physician applies four founding bioethical principles of Beauchamp 
and Childress, he faces a dilemma. Veracity of informed consent of the donor is tinted 
due to many reasons,  including  disclosure of insufficient  and uncertain  information 
about post-donation risks for donor,2,8,9,16-18 She, because of her peculiar position in the 
society and in the family is unable to exercise her innate autonomy. As the donor will 
benefit  from the process of transplantation,  thereby physician  fulfils  requirement  of 
beneficence, but lesser attention is paid to the women folk in our society will make the 
donor medically more vulnerable which will negate non-meleficence, another principle 
of bioethics. Regarding justice, what the society and the medical profession will do in 
case the donor is brother and the recipient is sister who is not in a position to bring 
monetary  benefit  to  the  family.  Will  the  members  of  the  society  permit  this 
transplantation if some important event of life (such as marriage) of the male donor is 
at risk due to this process?              

D. Making the choice: In this case the transplantation clinician has two choices, either 
to perform the surgery for the health of the patient or to refuse the procedure due to 
ethically questionable consent of the donor. To pave the way for decision the surgeon 
utilized his efforts to persuade the fiancé of donor not to object and by explaining that 
there  are  minimal  chances  of  adverse  effects  to  the  donor’s  health  of  donor.  This 
framework, fortunately allows the decision maker (transplantation surgeon) to select a 
better choice amongst the available ones, the chosen one may not necessarily be the 
best,  but  transplant  clinician  still  has  to  decide  which  is  better  choice  in  Eastern 
perspective. Dilemma has still remains un-resolved!      
 
Though Mc Donald and Rodney’s framework has obvious and convincing strengths in 
the process of ethical decision-making but it is not free from weaknesses. Application 
of  the  framework  in  this  particular  case,  though  involves  all  the  stakeholders  in 
decision making which is ethically required19 but the particular situation where parents 
of  donor  and  recipient  are  not  only  willing  but  eager  for  early  procedure  with 
questionable consent of the vulnerable donor brings the onus of ultimate decision on 
the shoulders of transplantation surgeon. This framework does allow the clinician to 

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Bangladesh Journal of Bioethics 2010;1(3) :35-42

make  choices  between  available  options,  as  well  as  taking  the  responsibility  of 
decision.  Therefore by using this  framework,  one can reach at  some conclusion.  In 
cases of live related donor transplantation, the four boxes of Jonsen et al ought to be 
applied in both involved persons i.e. patient and donor. The results of application of 
two boxes amongst  the four i.e.  preferences  and  quality of life,  four boxes, on two 
persons  (donor  and patient)  are  inherently  opposing  and conflicting  (when donor’s 
interests are protected the recipient’s interests are jeopardized) as it involves a process 
of organ transfer from one member of the pair  to  another,  that  makes  the decision 
difficult. This requires more suitable frameworks that can meet the needs of dilemmas 
like one presented in this paper.    

Conclusion: 
This  case  presents  one  of  the  many  unique  issues  characteristic  of  developing, 
particularly poor countries, where specific cultural traditions, tribal customs, societal 
factors,  poverty  and  legislative  weaknesses  facilitate  undesirable  and  unethical 
practices  to  flourish.  The  vulnerable  groups  of  the  population  are  easy  prey  to 
undesirable  organ  transplantation  practices,  a  ethical  problem  shared  by  clinical 
research  mal-practices.  More  obvious,  overt  and  loudly  heard  issues  like 
‘transplantation tourism’ have attracted the attention of clinicians and bioethicists since 
many years but subtle ethical issues attached to live-related organ donations by weak 
and silent family members or relatives such as mentally retarded or unknowledgeable 
females deserve attention of society leaders,  clinicians and other stakeholders. Mere 
obtaining  of  documentary  informed  consent  is  neither  sufficient  nor  the  required 
condition. We need to as sincerely and honestly safeguard the donors’ interests as we 
ethically protect the wellbeing of our organ-recipient patients.          

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