This document discusses several issues related to kidney donation and transplantation around the world. It notes that organ donation rates among black populations are much lower than whites in some countries, due to lack of knowledge and religious/cultural beliefs. Cadaveric donation is limited by various religious traditions that prohibit altering the body after death. Living donation is increasingly common but raises ethical issues like financial exploitation of vulnerable groups and transplant tourism. Overall, there are conflicts between principles of autonomy, justice and beneficence in providing access to kidney treatments globally given economic and resource differences between countries.

1. Racial differences in kidney donation and
transplantation
• Organ donor referrals among Africans in 1995 and 2000 were 28% and
17%, respectively while it was 60% and 72% among whites in South Africa.
• African Americans are reportedly accounting for 13% of organ donors and
18% of organ recipients and they have a high incidence of kidney problems,
hence the need for transplantation.
• This racial and cultural discrepancy in organ donation was found to be
caused by lack of knowledge, religious fears, fear of surgical complications
and lack of communication between lay families and healthcare personnel
among black Americans

2. Cadaveric kidney transplantation
• Cadaveric transplantation is hampered by religious beliefs, cultural
traditions, social norms and ethical principles.
• In Japan, death is not considered to occur at an exact instant but is a
continuum that requires several days and the body must remain
whole.
• A dead person with an incomplete body before burial or cremation is
associated with misfortune and this also applies to African cultures.

3. • In South Africa, Zulu speaking people believe in the creator and that they
have no authority to donate their bodies or organs
• Moreover, cadaveric transplantation is problematic because the availability
of the organs means that someone has died.
• The donor should be a young healthy person who has been injured or killed
violently.
• This alone creates several ethical and religious issues, including the
acquisition of the appropriate consent and the various interpretations of
brain death in different cultures.

4. • Due to the limited number of cadaveric organs, the ethical principle of equity
looms large in the allocation of this scarce resource.
• Currently, Spain, USA, France, Germany and Italy have relatively high donation
rates for cadaver transplants due to legal and ethical frameworks that have been
put in place to address the inequalities.
• These frameworks include the Spanish Model for Organ Donation, World Health
Organization Guiding Principles on Human Cell, Tissue and Organ Donation (2010)
and the Madrid Resolution on Organ Donation and Transplantation (2011).
• However, cadaveric donors are failing to meet demands for kidney
transplantation in all countries, despite the frameworks that have been put in
place.
• This alone is causing a significant number of candidates with end-stage renal
disease to die while waiting or become too sick for transplantation

5. Living kidney donation
• There is ever increasing use of living donors as sources of kidneys since cadaveric donors are
failing to meet the demands of kidney transplantion in all countries.
• This is causing the development of unregulated markets for donation and consequently increased
organ trafficking and transplant tourism
• As a result, there are controversies and ethical issues of living donation It is estimated that organ
trafficking accounts for 5% to 10% of the kidney transplants performed annually throughout the
world
• Kidney markets have been documented in Pakistan, Philippines, South Africa, Egypt, India, South
America and Eastern Europe
• According to Verger (2012), Israel has struggled to curb kidney markets for many years but since
the introduction of its law in 2008, there has been redued organ trafficking and transplant.

6. • Commercialising human organs is criticised because it puts those who
can afford transplant at an advantage and leads to financial
exploitation of the vulnerable .
• Despite the declaration of Instabul on Organ Trafficking, Transplant
Tourism and Commercialism (2008), the Amsterdam Forum on the
care of the Live Kidney Donor (Delmonico, 2005) and World Health
Assembly Resolution adopted in 2004 (WHA57.18), transplant
tourism continues to expose vulnerables like minors, illiterate
individuals, impoverished, undocumented immigrants, prisoners,
economic and political refugees.

7. • The use of children as kidney donors is still questionable and it is
really an ethical problem when they are the only possible donors for
their parents or siblings.
• The children may not be old enough to understand the informed
consent process and the complications of donating an organ as they
may feel pressurised by their parents.
• Nonetheless, a young girl might feel that she should be given the
opportunity to save her mother through donation
• In this view, the use of children in kidney donation should regarded as
a special circumstance and needs guidance, counselling and ethics.

8. • Again, use of kidneys from executed prisoners remains an ethical
issue as this is considered repulsive and morally repugnant (Tilney,
2003).
• This is violation of autonomy, informed consent and justice.
• Since November 2013, China is in the process of stepping towards an
ethical organ donor system as it is one of the countries who have
been using organs from executed prisoners (Alcorn, 2013).

9. • There are ethical principles to consider when dealing with living kidney
donor transplantation and these principles are respect for autonomy, no
maleficence, beneficence and justice
• Respect for autonomy means that an unrelated kidney donor is acting
freely, rationally and able to understand and decide on the information
presented.
• Nonmaleficence emphasises that nobody should be injured intentionally
• In kidney living donation, physical harmis unavoidable and there is
violation of this ethical principle as living kidney donation is associated
with a mortality rate of 0.03% in donors and some surgical complications.
Nevertheless, it provides enormous benefit to the recipient

10. • The ethical principle, beneficence, instructs to do good for others.
• It is clear that living kidney donation provides huge benefit to patients with CKD.
• However, the enormous benefit to the recipient does not provide enough
justification for accepting all kidney donors.
• The donor may receive benefits from the restored health of the recipients as in
spousal transplantation.
• In addition, many donors benefit psychologically by making a major sacrifice and
saving a life.
• Some donors benefit physically when their treatable health problems are
detected during the donor evaluation

11. Use of kidneys from brain dead patients
• With regards to brain death, a kidney is harvested from a donor whose brain is dead but
with a heartbeat.
• The concept of brain death has been accepted by the majority of people and strict
medical criteria must be fulfilled before undergoing a transplant from a brain dead donor
• However, the acceptance of the concept of brain death is essential for retrieving healthy
viable organs and this view is not universally accepted.
• For example, Orthodox Jewish Beliefs identify death as the termination of heart function,
not the brain.
• Brain death is not recognised in some parts of Asia

12. CONCLUSION
• The economic differences and competing public health problems in
different countries have made it far more difficult to formulate a
series of rights that could be applicable to all individuals with CKD.
• The conflict between justice and autonomy is important to analyse
when looking at the existence of RRT for CKD around the world.
• Health professionals want to provide their patients with the greatest
autonomy but this can be limited by one’s ability to access RRT in
different countries.

13. • The principle of justice would support a mechanism that could meet the
needs of all people suffering from chronic kidney failure regardless of their
ability to pay or access such care.
• However, there are insufficient amounts of dialysis units and kidney
transplantation in nations with emerging economies.
• This contributes to a lack of distributive justice as well as facilitating a
healthcare patient relationship that is non-maleficence.
• Inadequate dialysis and kidney transplant, high risk of infection and
inconsistenties in treatment could be considered to cause more harm to
patients than benefits (maleficence versus beneficence).
• Consequently, there is limited patient engagement in RRT resulting in non-
adherence thus ineffective management among CKD patients.

14. THANK YOU