Organ donation by an individual with a psychiatric diagnosis presents a number of ethical issues. This paper notes that particular attention must be paid to mental competence, consent, and guardianship, when making any decision about organ donation in such individuals.
Legislation in all provinces in Canada outlines conditions for organ transplantation and provides a definition of mental competency. Under the Human Tissue Gift Act of Alberta, mental competency is defined as the ability to comprehend the subject matter pertaining to the decision of organ transplantation and the ability to understand the consequences of such a decision. (1) Little has been written concerning persons with a psychiatric illness, who want to donate an organ for transplantation, although there has been some discussion concerning potential donors and organ procurement and such important factors as consent, abuse (moral), and coercion. (2) (3) (4) (5) (6) When a third party asks a psychiatric patient under their care to donate an organ, a treatment team faces a number of difficult decisions.
In the case that follows, a man diagnosed with schizophrenia was asked by his family to donate a kidney to another family member. As a consequence, the treatment team had to deal with legal issues, face time constraints, and address family and guardian concerns.
A 50-year-old man ("Mr. X") with a long history of chronic undifferentiated schizophrenia and dull normal intelligence was admitted to Alberta Hospital Ponoka, a facility that provides specialized psychiatric and brain-injury rehabilitation services. Earlier, under the Dependent Adults Act of Alberta, (7) Mr. X had been placed on a Public Guardianship Order because the authorities deemed him to be too incompetent to make decisions about his own well being. In addition, Mr. X was illiterate. Because of his numerous admissions to psychiatric facilities and many failed community placements, Mr. X had lost contact with his family over the previous few years. Mr. X's brother had endstage renal disease that required dialysis, and he had been placed on a transplant list at a local general hospital. Shortly thereafter, after returning from a visit with his family, Mr. X began to ask the staff questions about the process of donating a kidney. He asked what would happen to someone who could not get a kidney donation. We explained to him the physical consequences of donating a kidney and the implications for him of subsequent kidney disease. Because of his low intellectual level and his psychiatric illness, we doubted that he grasped the complexity of the situation.
Subsequently the family asked Mr. X if he would act as a donor for his brother and the treatment team asked the public guardian (who had not been notified) for advice concerning their response to this request. After discussing the experience of donation with Mr. X, the treatment team concluded that Mr. X could not comprehend fully what he was being asked to do. Eventually, Mr. X said he did not want to donate a kidney, and thereupon the public guardian notified his relatives.
The staff person representing the public guardian reported that her supervisor had instructed her that she could not make a decision on Mr. X's behalf (whether he could donate a kidney). The supervisor said that the courts would have to decide if Mr. X wanted to pursue the option of organ donation.
Until his illness, our patient's brother (the intended recipient) had managed the family farm and was the only one capable of doing so. On the other hand, the family had little contact with Mr. X until recently when they had met more frequently. While our patient was visiting his family, they had raised the issue of the transplantation without notifying the treatment team or the guardian responsible for Mr. X's care. When Mr. X told the treatment team about his family's request, he displayed considerable anxiety about the decision. …