Ralph Angelique F, Butow Phyllis, Craig Jonathan C, Chapman Jeremy R, Gill John S, Kanellis John, Tong Allison
Sydney School of Public Health, The Children's Hospital at Westmead, Sydney, Australia.
Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia.
Nephrology (Carlton). 2019 Feb;24(2):252-262. doi: 10.1111/nep.13238.
Careful assessment of the potential donor-recipient relationship is recommended by guidelines to prevent undue coercion, and to ensure realistic expectations and genuine motivations. However, relationships are complex, nuanced and value-laden, and can be challenging to evaluate in living kidney donation. We aimed to describe the attitudes and approaches of transplant clinicians towards assessing the relationship between potential living kidney donors and their recipients.
Semi-structured interviews were conducted with 54 transplant clinicians (nephrologists, surgeons, coordinators, social workers, psychiatrists and psychologists) from 32 transplant centres across nine countries including Australia, United States, Canada and New Zealand. Transcripts were analyzed thematically.
Four themes were identified: protecting against vulnerability and premature decisions (ensuring genuine motivation, uncovering precarious dynamics and pre-empting conflict, shared accountability, relying on specialty psychosocial expertise, trusting intimate bonds, tempering emotional impulsivity); safeguarding against coercion (discerning power imbalance, justified inquiry, awareness of impression management); minimizing potential threat to relationships (preserving the bond, giving equitable attention to donors and recipients, ensuring realistic expectations); and ambiguities in making judgments (adjudicating appropriateness and authenticity of relationships, questioning professional intervening, uncertainties in subjective and emotional assessments).
Clinicians felt ethically compelled to minimize the risk of undue coercion and to protect donors and recipients when evaluating the donor-recipient relationship. However, disentangling voluntariness and altruism from potential undisclosed pressures to enact societal and family duty, making decisions within this complex, multi-stakeholder context, and avoiding the imposition of undue paternalism and donor autonomy, were challenging. Multidisciplinary expertise and practical strategies for managing uncertainties are required.
指南建议对潜在供受者关系进行仔细评估，以防止不当胁迫，并确保现实的期望和真实的动机。然而，关系是复杂、微妙且充满价值观念的，在活体肾移植中对其进行评估可能具有挑战性。我们旨在描述移植临床医生在评估潜在活体肾供者与其受者之间关系时的态度和方法。
对来自澳大利亚、美国、加拿大和新西兰等9个国家32个移植中心的54名移植临床医生（肾病学家、外科医生、协调员、社会工作者、精神科医生和心理学家）进行了半结构化访谈。对访谈记录进行了主题分析。
确定了四个主题：防范脆弱性和过早决策（确保真实动机、发现不稳定动态并预防冲突、共同承担责任、依靠专业心理社会专业知识、信任亲密关系、抑制情感冲动）；防范胁迫（识别权力不平衡、合理询问、意识到印象管理）；尽量减少对关系的潜在威胁（维护关系纽带、公平关注供者和受者、确保现实期望）；以及判断中的模糊性（裁定关系的适当性和真实性、质疑专业干预、主观和情感评估中的不确定性）。
临床医生在伦理上感到有必要在评估供受者关系时尽量减少不当胁迫的风险，并保护供者和受者。然而，将自愿性和利他主义与履行社会和家庭义务的潜在未公开压力区分开来，在这个复杂的多利益相关方背景下做出决策，以及避免施加不当的家长式作风和供者自主权，都具有挑战性。需要多学科专业知识和管理不确定性的实用策略。
