CHAPTER 79: Bioethical and Risk Management Issues in Kidney Transplantation

INTRODUCTION

Prinmum non nocere, first do no harm, the fundamental precept in medicine described by Hippocrates, must be applied to transplantation medicine. As the volume of kidney, heart, liver, and other organ transplantation has increased in the United States, so have complications and adverse outcomes. Similar to the other disciplines of medicine, the basic principles of risk management, quality, and patient safety must be followed to ensure patient outcomes are of the highest order, while managing the risks and uncertainties in the practice of medicine, surgery, and the subject of this chapter, solid organ kidney transplantation.

This chapter will review the principles of risk management and patient safety as they apply to kidney transplantation, specifically:

• Biomedical ethical issues in transplantation

• Medical errors and their prevention

• Risk and enterprise risk management techniques

• Informed consent for donor and recipient

• Diagnostic and medical errors

• Transparency when errors occur

How does the kidney transplant surgeon, the team, and program in which they function deal with or manage the risks inherent in kidney transplantation? The answer is risk management and patient safety techniques along with the strict application of biomedical ethics.

BIOMEDICAL ETHICAL ISSUES IN TRANSPLANTATION

The six bioethical values are:

1. Nonmaleficence

2. Distributive justice

3. Autonomy

4. Beneficence

5. Dignity

6. Truthfulness/honesty or transparency

1. Nonmaleficence or first do no harm, is one of the six medical ethical values that governs the medical profession in general, and certainly kidney transplantation, in the ethical treatment of recipients and donors alike. The ethical value of nonmaleficence is particularly important for the kidney transplant surgeon when conflicting interests arise.

2. Justice in its most basic form is fairness to vulnerable patients. By definition, all patients should be considered vulnerable because they totally rely on the transplant team and enterprise “to do the right thing”; even as lay persons they do not know what the right thing is. Patients and family must rely on the learned medical and health care professionals, which creates the physician–patient or health care professional/enterprise relationship. Distributive justice is key when it comes to the organ donor waiting lists, or as the United Network for Organ Sharing (UNOS), website states, “A national computer system and strict standards are in place to ensure ethical and fair distribution of organs.” Distributive justice also concerns itself with the distribution of scarce health resources such as kidneys and the decision of who gets what treatment or transplantation within the bounds of fairness and equality.

3. Autonomy is permission from the patient and donor (live or deceased) to go forward with procuring the kidney and transplanting it. Medically and legally, it is known as the doctrine of informed consent. The patient has the right to refuse or choose treatment, accepting your recommendation to transplant a kidney or donor’s right to donate a kidney. However, patient autonomy or informed consent/refusal is only within the bounds of the ...