ARELLANO UNIVERSITY

Florentino Cayco Memorial School of Graduate Studies-Nursing

2600 Legarda St. Sampaloc, Manila

PHILOSOPHY OF MEDICAL-SURGERY NURSES REGARDING ORGAN

TRANSPLANTATION

A Graduate Term Paper

In partial fulfillment of the requirement for the Degree Master of Arts in Nursing
Major in Medical - Surgical Nursing
 By:

RAFFY V. TABALBAG, RN

Submitted To:
BGEN. MARLENE R. PADUA, AFP (Ret)

October 2019

ACKNOWLEDGEMENTS

I would like to thank Ma'am Marlene Padua my professor I can't thank her
enough for her time and expertise. I also want to thank to my classmate who
also part of my study

To the nurses medical surgery ward for there time to answering the
questionnaires despite of their busy schedule

Lastly, I must thank my family for their support and undying love and prayers
as I work on during this semester. Without my family, this process would have
been much more difficult.
 The Researcher

Introduction

"More than 30,000 people are on a national waiting list for an organ transplant.
Seven of those people will die today. Another person joins the waiting list every
twenty minutes" (Partnership, 1993, p. i.). "The actual number of donors is only
about 4,000 per year or about one third the donation potential" (United, 1990, p.
2). These statistics are staggering. Nurses today are caring for a wide array of
patients that may include potential organ donors or organ transplant recipients.
The nurse's knowledge and attitude regarding organ donation may influence
the organ donation process.

A study by Stark, Reiley, Osiecki, and Cook (1984) suggested that positive
attitudes of health professionals influenced the families toward organ donation.
Bidigare and Oermann (1991) suggested that the nurse possessing positive
attitudes and greater knowledge will be better able to provide comfort and
support the donor's family in the decision-making process.

The purpose of this descriptive correlational study was to explore the

knowledge nurses possess and the attitudes they hold regarding organ
donation. The study also described relationships between the nurse's
education and the knowledge possessed regarding organ donation and the
nurse's experience caring for organ donors/recipients and attitudes held
regarding organ donation

1. Ethical Issues Regarding the Donor

a) From the Deceased

In general it is seen as praiseworthy to will one's body or parts of one's body for
the benefit of others after one's death. In 1956 Pope Pius XII summed up the
Catholic view on this:

A person may will to dispose of his [or her] body and to destine it to ends that
are useful, morally irreproachable and even noble, among them the desire to
aid the sick and suffering. One may make a decision of this nature with respect
to his own body with full realization of the reverence which is due it....this
decision should not be condemned but positively justified.(quoted from Ashley
and O'Rourke 1989, 305)

More recently (1985) the Pontifical Academy of Sciences stated:

Taking into consideration the important advances made in surgical techniques

and in the means to increase tolerance to transplants, this group holds that
transplants deserve the support of the medical profession, of the law, and of
people in general. The donation of organs should, in all circumstances, respect
the last will of the donor, or the consent of the family present.(MacNeil)

Such a donation can greatly benefit others and cannot harm the donor who is
dead. Not to offer such a donation can be a sign of indifference to the welfare of
others. To donate, however, is not considered obligatory. Transplantation is
against some people's consciences for religious or other reasons.(cf. LRCC,
140-2) Consideration for the sensibilities of the survivors may also make some
people hesitate to sign over their bodies.

In any case proper respect should always be shown human cadavers. Although
they are by no means on par with a living human body/person, they once bore
the presence of a living person. The probably dying potential donor should be
provided the usual care that should be given to any critically ill or dying person.
Because of a potential conflict of interest, it is widely agreed that the transplant
team should be different from the team providing care for the potential donor,
who is not to be "deprived of life or of the essential integrity of their bodily
functions.... No organs may be removed until the donor's death has been
authenticated by a competent authority other than the recipient's physician or
the transplant team."(CHAC, 44 and 46) Various parts of the human body can
often be kept in good condition for transplant purposes after the death,
irreversible cessation of all brain functions, of the donor.(Jonsen, 235-7)

The Catholic Health Association of Canada (CHAC) considers transplantations

of brain cells (presuming irreversible cessation of all brain functions of the
donor) in order to restore functions lost through disease as permissible "as long
as the unique personal identity and abilities of the recipient are not
compromised in any way."(45)

The German Bishops' Conference and the Council of the German Evangelical
Church consider the transplant of "reproductive glands" as unethical, "since it
intervenes in the genetic individuality of the human being."(374) This does not
seem to exclude transplanting all sexual body parts, but the gonads. Any child
that resulted following an ovary or testicle transplant would have the dead
donor and not the living recipient as its biological mother or father. This would
violate the rights of the child (see SCDF 1987, 23-26).

The case of the body of a pregnant woman in Germany, who had been
declared brain dead, being kept alive with the hopes of the child coming to term
was recently given some media attention. Some criticized this as not giving
proper respect to the woman. Can not this effort, however, be seen as similar in
some ways to organ donation and, therefore, as commendable? The woman
had at least implicitly offered her body for the child's sake before her fatal
accident. Her family also requested this.(Associated Press) Cases such as this
also raise the question of "ordinary" and "extraordinary" means of saving life
(see below under 1.b).

The use and possible use of cadavers and "neomorts" (brain-dead individuals
maintained on life support) for a variety of purposes (transplants, research,
training medical students), perhaps even a considerable time after the person's
death, has provoked ethical and legal debate. Various concerns include
respect for the dead and their wishes, respecting the family's wishes,
benefitting others and the common good. In light of this, anyone considering
donating their organs and/or body after their death, highly commendable in
itself, may wish to specify certain limits.(cf. LRCC, 113-17; Gaylin; and CHAC,
43 and 46)

b) From Living Persons (Adults, Mentally Disabled, Minors)

Transplants between living persons raise the question whether it can ever be
ethical to mutilate one living person to benefit another. Concerning this many
distinguish between parts of the body that can regenerate (e.g. blood and bone
marrow) and parts that do not regenerate. Regarding the latter some are paired
(e.g. kidneys, corneas and lungs), whereas others are not (e.g. heart). Before
transplants of organs such as kidneys were performed, many Catholic
theologians considered this unethical between living persons. They thought it
violated the Principle of Totality which allowed the sacrifice of one part or
function of the body to preserve the person's own health or life (i.e. a part could
be sacrificed for the sake of the whole body), but did not allow one person to be
related to another as a means to an end. When such transplants began in the
early 1950's ethicists gave the problem closer study.

Gerald Kelly (1956) argued that such donations which have as their purpose
helping others could be justified by the Principle of Fraternal Love or Charity
provided there was only limited harm to the donor. Some ethicists argued this
did not violate the Principle of Totality provided that functional integrity of the
body was not destroyed, even though there is some loss to anatomical
(physical) integrity. Donating one of one's kidneys could be justified for
proportionate reasons, since one can function with one healthy kidney. ("Living
kidney donors constituted some 15% of the donor pool in Canada in
1989."[LRCC, 20]) Donating one of one's functioning eyes, however, can not be
justified, since one's ability to see (functional integrity) would be seriously
impaired.

Basic to medical ethics is the Principle of Free and Informed Consent. To be

properly informed the potential living donor should be given the best available
knowledge regarding risks to him/herself, the likelihood of success/failure of the
transplant and of any alternatives. In some cases there is much pressure to
donate (e.g. from family members if one is a good match). The courts have
rightly refused to compel such donations. Motivated by charity, which includes
a properly ordered love for others and oneself, one could decide not to offer an
organ.(Ashley and O'Rourke 1989, 305-8; CHAC, 31 and 34)
The distinction of ordinary and extraordinary means is also applicable to
transplants. The Catholic Church teaches that one is obliged to use ordinary
means to preserve life, but not extraordinary means, that is, means that are
very burdensome (very painful, expensive, inconvenient, risky, or even very
psychologically burdensome) or do not offer reasonable hope of benefit, or are
disproportionate (cf. SCDF 1980, section IV; Ashley and O'Rourke 1986, Ch.
11.5; and CHAC, 52-4). Some forms of organ and tissue transplant from a living
donor, especially those involving invasive surgery, involve considerable burden
to the donor. If means are available that do not involve such burdens, such as a
matching organ from a deceased donor, these are certainly to be preferred.

The above principles would allow in some cases such procedures as

"transplanting part of the liver from a living adult donor into a child recipient,
whereafter the adult donor's liver regenerates within a month and the child's
new partial liver develops as the child grows"(LRCC, 15), or donating one's
heart if one were to simultaneously receive a heart and lung transplant (Garrett
et al., 200).

A competent adult can give free and informed consent to be or not to be a living
donor, but an incompetent person cannot. Can a guardian ethically consent for
a legally incompetent person, such as a severely mentally disabled adult or a
minor, to be a living donor? Concerning this issue some distinguish, for
example, between a young child and a mature minor's ability to comprehend
the implications of donating. Regarding medical decisions an incompetent
person's guardian is to act for their benefit or best interests, and, as far as
possible, their wishes, if known and reasonable. Some think children and the
mentally disabled should never be living donors. They are simply being used
with a violation of their bodily integrity, risks to their health and life, and no
benefit to themselves. An argument against their being a living donor of an
organ such as a kidney, is that an alternative such as renal dialysis is often
available until a suitable deceased donor can be found. Others argue that in
some cases the psychological benefit to the donor (e.g. a child's sibling lives)
could outweigh the risks (e.g. of donating bone marrow).(LRCC, 48-50) The
Catholic Health Association of Canada (CHAC) says that, "Organ or tissue
donation by minors may be permitted in certain rare situations."(44)

Can it be ethical to have another child for transplant purposes (e.g. for a bone
marrow transplant)? Conceiving and having a child for this motive alone would
involve treating him/her as a mere means to another's benefit. This would
violate the great dignity of a person, created in God's image, who should be
loved for his/her own sake.(cf. CHAC, 45; Garrett et al., 200)

Concerning the whole issue of living donors, the German Bishops' Conference
and the Council of the German Evangelical Church say:

...No one is obliged to donate tissue or an organ; therefore no one can be

forced to do so. The decision to donate one's organs while still alive can only be
made by the individual concerned personally. Not even parents are allowed to
decide on an organ donation by their child; they are allowed to give their
consent only for a donation of tissue (e.g., donation of bone-marrow). The
doctor in this case has a special responsibility because no one can control
whether a donation is truly voluntary.

When a living person donates an organ as a result of a personal decision, then

the organ's transplant is to be carried out with due attention, and post-operative
medical care of the donors as well as the recipients must be provided. Further,
consideration must be given so that no problems develop in the relationship
between the donor and the recipients (dependence, excessive gratitude, guilt
feeling).(375)

c) From Anencephalic Infants

Anencephalic infants are born with a major portion of the brain absent. If born
alive they die within a few days, although in rare cases some survive for weeks
or months. They can suck and cry and some argue that their degrees of
consciousness or unconsciousness may vary. According to the widely
accepted criteria of death as irreversible cessation of all brain functions, they
are living human beings/persons. To increase the likelihood of procuring viable
organs from them, some would like to redefine death in terms of partial brain
death so that they could be considered dead (although still breathing
spontaneously...), or for them to be exempt from the total brain death criteria, or
to consider them non-persons. Many others, however, argue that partial brain
death criteria are invalid in light of our present knowledge and/or such an
arbitrary move would endanger other classes of living human beings and lead
many more people to refuse to sign organ donor cards. Although extraordinary
means of prolonging the life of anencephalic infants do not need to be used,
they should be given the normal care of dying persons.(cf. CHAC, 45-6; LRCC,
95-106; Garrett et al., 202; Ashley and O'Rourke 1986, Ch. 11.2, and 1989,
311-12)

d) From Human Fetuses

Is it ethical to transplant brain or other tissues from human fetuses to benefit

others (e.g. those suffering from Parkinson's Disease)? If the fetus has died of
natural causes, the ethical issues would be similar to other transplants from the
deceased. When the fetus has died or will die as a result of procured abortion,
however, other ethical issues arise. The Catholic Church considers direct
abortion (the intentional killing of an innocent human being) to be gravely
immoral. Some argue that to use tissues from a fetus killed by abortion could be
done without approving direct abortion (cf. using tissues or organs from a
murder victim). Such use, however, could "justify" abortion (i.e. to benefit others)
for many women who otherwise are unsure about having an abortion. A good
end though does not justify an evil means (see Rm 3:8). The timing of the
abortion may be influenced as well. The widespread usage of electively aborted
fetuses would establish an "institutional and economic bond between abortion
centers and biomedical science..."(Post, 14; cf. CHAC, 15, re unethical
cooperation)

Some argue that transplanting fetal brain tissue would require the fetus to be
still alive, that is, the tissue would not be good for transplant purposes after the
fetus has experienced total brain death.(cf. Duncan, 16-22) Some say that
other means of treating such diseases as Parkinson's can and should be
developed.(cf. Dailey)

Another issue involves consent. Anyone involved in procured abortion would

not qualify as the fetus' guardian since they hardly have his/her best interests at
heart. The Catholic Health Association of Canada (CHAC) concludes that,
"Transplantations using organs and tissues from deliberately aborted fetuses
are ethically objectionable." (45; cf. SCDF 1987, 16-18)

2. Ethical Issues Regarding the Recipient

...nobody [i.e. no potential recipient] has a claim on organs or tissue of any

person, living or dead. The sick should thus accept the tissue and organs freely
offered by others as a gift.(German Bishops..., 373)

This position is widely accepted.

Another moral issue involving the recipient is free and informed consent. A
competent person who could possibly benefit from receiving a transplant
should be adequately informed regarding the expected benefits, risks, burdens
and costs of the transplant and aftercare, and of other possible alternatives. So
should the guardian(s) of an incompetent person. A legally incompetent person
who can understand some things that are relevant to their condition, a
proposed transplant, and decisions that they are capable of making, should be
informed of these in an appropriate way. Guardians should respect the wishes,
if known and reasonable, of incompetent persons in their care. No unfair
influence should be put on someone to be a transplant recipient. Potential
recipients and their families can be tempted to pressure, blackmail or bribe a
potential living donor to donate or a health care professional to give them a
privileged position on the waiting list. Such practices are unethical because
they fail to properly respect the freedom of the donor or they violate other
potential recipients' rights regarding access (cf. Garrett et al., 206-7) Recipients
should also avoid any unethical cooperation in any abuses (e.g. the organs or
tissues have been procured immorally/illegally) that are sometimes associated
with transplantation.(cf. CHAC, 15 and 31; Ashley and O'Rourke 1986, 88 and
90-1; and 4.a below)

A potential transplant recipient and/or their guardian(s) could also consider

their decision in light of ordinary and extraordinary means of preserving life (see
above, under 1.b). The competent adult Jehovah Witness who refuses a
life-saving blood transfusion, for example, because this is against a tenet of
their religion, can be understood to be refusing means that would be "very
burdensome" for them. Courts, however, sometimes override the decision of
natural guardians including parents when this is judged clearly against the best
interests of incompetent persons including a child (e.g. to allow a life-saving
blood transfusion to the child of Jehovah Witness parents). This issue is more
difficult when the child begins to develop his/her own value system, but is still
considered legally incompetent.(see n. 3 below under "Some Cases...")
Proper safety measures should be followed to protect transplant recipients from
receiving AIDS and hepatitis viruses, etc.(cf. LRCC, 161; and Garrett et al.,
200)

3. Ethical Issues Regarding Allocation of Limited Resources

a) Criteria for Selection

Requests or the demand for human organs and tissues usually exceed what is
available or the supply. Significant practical and ethical questions regarding
efficiency and fairness arise as to how best to distribute these limited resources.
On what basis should this person rather than that person be chosen to receive
a given organ? Who should choose? These decisions are serious as they can
involve who will live and who will die. In section 4 below we will consider some
ways of addressing this problem by attempting to increase the supply of human
organs and tissues. In sections 3.b and c we will consider some alternative
methods of attempting to meet some of the needs in this area. In this section,
however, we will consider some criteria for selecting which potential transplant
recipient will receive a given human organ or tissue.

A widely used and approved criterion of selection is to give priority to those who
have great need and who are expected to benefit greatly. For example, it does
not make sense to give a limited number of available organs to those who will
not benefit or who are expected to only live marginally longer but suffer much
with the transplants, when others would benefit greatly. While this criterion is
widely accepted as fair, there is much discussion about how to define and
assess "benefit". Many argue that both expected length of survival and the
possibilities regarding rehabilitation should be considered.

In spite of the success of transplants, care must be taken not only that they
extend life biologically, but that they also offer the patient a real chance for a
healthy life. The new organs should add new years to life, and help to provide a
new and better life.

....as a last resort a choice sometimes has to be made between a transplant

immediately available but with a very small chance of survival, and a long term
transplant offering a greater possibility of healing.(German Bishops..., 374-5)

With regard to who will likely benefit more from receiving a transplant, medical
criteria such as blood and tissue typing (i.e. who is less likely to reject the
transplant), and the absence of other life-threatening diseases, are used. Other
factors such as the potential recipient's will to live, motivation and ability to
follow post-operative directions (e.g. taking immunosuppressants), his or her
family support, and the skill of the transplant team can also be relevant to the
success of a transplant.(Garrett et al., 213-216)

Potential recipients (i.e. those likely to benefit from a transplant) are registered
on a "first come, first serve" basis. This, or random methods of selection (e.g. a
lottery) where there is equal chance, is fair provided that the need and benefit
are approximately the same among potential recipients.(cf. Varga, 226; and
Ashley and O'Rourke 1986, 112, and 1989, 308)

Some argue in favor of using criteria such as social worth, and merit or demerit,
to select or prioritize potential recipients. Concerning "social worth", for
example, is it fair to give priority to a mother of young children over a single
person, or to a successful doctor over someone who is at present unemployed?
Concerning merit should a retired person who contributed a lot to the
community be given priority over a young person who has not yet proven him or
herself? Regarding demerit, for example, should someone who previously
abused alcohol, smoked heavily or ate unhealthily be denied a liver, lung or
heart transplant?(cf. Altman; Moss and Siegler) Many, however, criticize these
and other criteria such as ability to pay, race, religion, gender, and age, as
involving unfair discrimination. They are said to violate the equal dignity of all
human beings. Criteria such as "social worth" are also seen by some to be too
difficult and subjective to apply efficiently and reasonably.(cf. CHAC, 30 and 45;
Appleton International Conference, 6-7; Varga, 226; Garrett et al., 216;
Childress) Childress argues as well that the criteria for selecting recipients
should be open and subject to public scrutiny.

b) Using Animals

The shortage of various human parts for transplant purposes has in part
motivated research in animal to human transplants. The use of some animal
parts such as insulin extracted from animal pancreases, catgut as absorbable
sutures, and pig heart valves, are already "accepted" medical treatments.
Attempts, however, to transplant a baboon's heart to a human infant (Baby Fae)
or a pig liver to a dying woman, for example, have aroused considerable
controversy.(see LRCC, 18-19; n. 4 below under "Some Cases..."; and Siegel)
Some argue that the present state of transplants between species does not
justify such experiments which so far do not offer hope of therapeutic benefit to
the human recipients. Defenders of such experiments argue that they can be
justified if no other alternatives are available and for the knowledge gained.
Some have questioned whether such transplants involve irresponsible
meddling with nature. Various animal rights groups have protested the sacrifice
of animals involved in this and other research, which uses them as "mere
means" to human welfare. Concerning organ transplants from animals to
human beings research is being done with various immunosuppressive agents
with the hope of finding a combination to overcome the rejection
problem.(Johnston) Attempts are also being made to genetically engineer and
breed new strains of some animals such as pigs so that their organs can be
transplanted into humans with less risk of rejection. If successful, the scientists
involved hope that this will overcome the large shortage of human donor
organs.(Reuter; Hanson)

Widely accepted directives for human experimentation call for both adequate
preliminary animal experimentation to minimize the risks to human subjects
and that the welfare of animals used in research be respected.(e.g. Helsinki
Declaration of 1975, p. 1771) Pope John Paul II in an address to a Congress of
the Pontifical Academy of Sciences said, "...animals are at the service of man
and can hence be the object of experimentation. Nevertheless, they must be
treated as creatures of God which are destined to serve man's good, but not to
be abused by him...."(p. 5) The Catholic Health Association of Canada (CHAC)
stipulates that animals involved in research are to be properly respected and
such research "is to be allowed only when other methods involving non-living
subjects are no longer helpful. When use of such subjects is justified, pain relief
must be used or suffering reduced to a minimum."(60)

With respect to tissue transplants between individuals of different species,

Pope Pius XII on May 14, 1956, spoke of the transplant of a cornea, for
example, as moral, if possible and warranted. He, however, considered the
transplant of the sexual glands of an animal to a human being as immoral.
Thomas O'Donnell interprets the condemnation of the latter as aimed at
transplants that would "envision an act of attempted generation."(104-7)

The Sacred Congregation for the Doctrine of the Faith excludes, among other
things, attempts of fertilization between human and animal gametes and to
gestate human embryos in the uteruses of animals as contrary to human dignity.
It considers genetic interventions that are therapeutic, for proportionate
reasons, however, as licit.(SCDF 1987, 15-20; cf. CHAC, 60)

The Catholic Health Association of Canada (CHAC) considers transplants from

living animals to humans as

...permissible as long as these can fulfill an essentially beneficial human

function in the recipient. The human dignity of the recipient is not to be
compromised in any way and due respect is to be paid to the non-human donor
in the whole transplant procedure.(46)

c) Artificial Substitutes for Tissues and Organs

The shortage of various human parts for transplant purposes has also in part
motivated research in the development of artificial and synthetic substitutes for
tissues and organs. There are a number of substances that the human body
does not reject. A number of artificial replacement technologies including false
teeth, artificial limbs and joints, hearing aids, synthetic lenses, pacemakers,
mechanical and synthetic heart valves, genetically engineered insulin and
growth hormone, and renal dialysis, are already routinely used in treatment.
Other technologies such as the implantable artificial heart are still experimental
or are used temporarily with the hope of keeping the person alive until a
suitable human donor organ is found.

Artificial replacement technologies are generally very costly to develop. If they

prove to be successful and are mass produced, their long-term costs can be
significantly reduced. A number of routinely used replacement technologies
such as long-term renal dialysis, however, remain expensive. Some ethical
questions concerning such costs will be considered in section 3.d below.

Another issue is that the recipient of some artificial parts may need to make
certain psychological adjustments. Consider, for example, the implantable
artificial heart (also a heart transplant from another animal species) in light of
the "popular belief that the heart is the center of human emotions, the organ of
love."(Varga, 239. Cf. ibid, 238-41; LRCC, 20-22; and Thomas and Waluchow,
Case 7:3.)

The Catholic Health Association of Canada (CHAC) states that artificial

substitutes for tissues and organs are permissible provided they "can fulfill an
essentially beneficial human function in the recipient" and the "human dignity of
the recipient" is not compromised in any way.(46)

d) High Costs, Universality and Justice

The development and use of technology related to organ and tissue transplants
or artificial substitutes is expensive. For example, estimates of the costs of
transplant procedures, without complications, "range from $20,000-$30,000 for
a kidney, $60,000-$80,000 for a heart, and $120,000-$150,000 for a
liver."(Goddard) With complications the costs can be much higher. Such costs
are beyond the means of many people, if they are not covered by public funds,
medical insurance or charity. The demand for transplants has also increased
because they have become quite effective. For example, the one-year survival
rate for all transplants is at least 70-80%; and the five-year survival rate for
heart and liver transplants is 70% and 70-80% respectively.(Goddard)

Today the issue of whether transplants and other expensive medical

technologies are cost-effective and whether public funds should cover the costs
of all such procedures for everyone who could benefit from them is being
discussed a lot. It should be noted, however, that the average cost per life year
gained from a transplant (e.g. kidney) can be significantly lower than alternative
treatments (e.g. hemodialysis). In addition, the recipient of a successful
transplant often contributes much more to the economy through work, spending
and paying taxes, than if they would have died or remained ill.(Goddard)

Other questions include: Could the large sums of money (or some of it) that is
spent on developing and using transplant technology and artificial substitutes
be better used to improve the health and quality of life of more people if spent in
other ways (e.g. providing better access to primary health care, improving
education and preventative health programs, improving the environment by
further reducing pollutants, etc.)? What percent of health care dollars should be
allotted to transplant programs and related research? Broader questions
include: What per cent of public funds should be spent on the good of health as
compared to other goods? Should government spending and public health
services be limited or reduced, or should taxes be increased to provide for more
people's needs and/or wants? To what extent should transplant services and
organs be supplied to people of other countries? There are no easy answers to
such questions of distributive justice which, among other things, can affect who
lives and who dies. One can also ask how it affects us as moral agents if we do
not help or save all those we can?(cf. Ashley and O'Rourke 1989, 308-10;
Engelhardt; Garrett et al., 216-19; and Thomas and Waluchow, 132-4)
Parliament through the Canada Health Act (1985) has committed Canada to
providing "reasonable access" to "medically necessary" hospital and health
services on a uniform basis. Reasonable access, however, does not mean
absolute access. The term "medically necessary" is also open to
interpretation.(LRCC, 124-5)

The position of the Catholic Health Association of Canada (CHAC) is: "Basic
health care needs are to be considered in the allocation of resources for
transplantations, especially when it is a question of novel procedures involving
scarce organs and expensive, limited medical facilities."(45) With respect to
allocating resources in general it calls for solidarity with sick persons, careful
stewardship of God's gifts and "active participation in the formulation of policy
for the equitable distribution of health care funds in society as a whole", among
other things.(22-24)

4. Ethical Issues Regarding Procurement of Organs and Tissues

a) Buying and Selling Human Organs and Tissues

Some argue in favor of allowing human organs and tissues to be bought and
sold to increase the supply and to respect people's autonomy. Others argue
against such saying that to treat the human body and its parts as commodities
violates human dignity.(cf. LRCC, 56-62; and May, 165-7) Human tissues and
organs are in fact being sold in some places. For example, a French
pharmaceutical firm buys placentas from 110 Canadian hospitals to
manufacture vaccines and other blood products (Aikenhead), and
some living poor people in countries such as India sell one of their kidneys for
$700 or so. In Bombay, for example, there have also been some cases of
kidnapping where victims regain consciousness to find that one of their kidneys
was removed while they were drugged.(Wallace; cf. Rinehart)

Concerning this whole issue some distinguish between human waste products
such as placentas, body parts that regenerate such as blood, and
nonregenerative human organs such as kidneys. Many distinguish profit
making from covering the donor's expenses. Paying for organs can constitute
unjust moral pressure on the donor. It could invalidate any free consent or a
contract. Some also fear that the buying and selling of organs and tissues, if it
became widespread, would undermine the altruism (giving motivated by love)
and social bonding now associated with transplants. It could also lead to organs
going to the highest bidder. Equity would be violated with ability to pay rather
than medical need determining the distribution of organs. Some others,
however, argue that this could be controlled by regulating sales, and that totally
forbidding the buying and selling of human tissues and organs would drive the
market underground. Because of the controversy and ethical problems
surrounding the buying and selling of human body parts, some say that other
alternatives should be pursued to increase the supply.(cf. LRCC, 78-86; and
Garrett et al., 203-4)

A World Health Organization resolution in 1989 that was eventually supported

by more than 151 nations in part, "Calls Upon Member States to take
appropriate measures to prevent the purchase and sale of human organs for
transplantation..."(LRCC, 162-3 and 202-3) With respect to blood transfusions,
Pope Pius XII said, "It is commendable for the donor to refuse recompense: it is
not necessarily a fault to accept it."(LRCC, 58) Concerning the Christian vision
which sees human life and the body as "a gift of the Creator, which persons
cannot dispose of as they please", the German Bishops' Conference and the
Council of the German Evangelical Church say, "This does not exclude
compensation for the expenses incurred by the donation of tissue and organs,
but it does forbid deriving profit from it."(375; cf. Chilean Bishops' Permanent
Commission, 374). The Catholic Health Association of Canada (CHAC) holds
that the buying and selling of human organs, tissues and blood "contradicts the
principle of charity which is part of the necessary justification for such
transplantations."(46)

b) Media Publicity

Sometimes an organ or tissue is procured for a person by publicizing their need

through the media. This could bypass the regular transplant channels and their
selecting recipients for an available organ on the basis of greatest need and
greatest likelihood of benefit, and first come first serve (see 3.a above). On the
other hand, media pleas frequently bring in more volunteers than those
required for the case being publicized. Media publicity also increases public
awareness of the need for transplants and so in the long run should increase
the supply of donated tissues and organs. Garrett et al. argue that at this stage
of medical history media publicity for a particular case should be tolerated, but
in time it should be eliminated as much as possible.(212)

c) Types of Consent (Voluntary or Expressed, Family,

Presumed, Required Request, Routine Inquiry)

Voluntary or expressed consent involves a person making known their free

offer to donate one or more of their organs and/or bodily tissue, after they have
died or while alive.(cf. 1.a and b above) Concerning cadaver donation, a person
can express their wishes by some form of advanced directives, such as by
filling out the Universal Donor Card attached to their driver's license. Free and
informed consent is required when the transplant is from a living donor.
Previously expressed voluntary consent regarding a deceased donor is the
ideal because it involves an act of love and responsible stewardship over one's
body. It also communicates to others, including one's family and health care
professionals, one's wishes. In the absence of clearly expressed voluntary
consent, the family or person lawfully responsible for the body of the deceased
may be approached regarding donation. Proper respect involves due
consideration of the wishes of the deceased and their loved ones.

Many potential organs and tissues for transplantation (e.g. of brain-dead

accident victims) are lost because the person did not previously express
voluntary consent and their families were not approached about donating.
Because of this and the shortage of organs and tissues for transplantation,
some have proposed other models of consent including presumed, required
request and routine inquiry, to hopefully increase the supply. Although only a
minority of deceased potential donors have signed donor cards, surveys show
that most people favor organ donation. Some argue that it is ethical to presume
consent on their behalf, unless the person while alive gave clear indications to
the contrary, since a transplant does not harm the donor after death and it can
benefit others. France, Belgium and some other countries have various forms
of presumed consent legislation in place. People can opt out by registering their
intention not to be a donor. Questions concerning this approach include:
Should minors and the mentally disabled be included? To what extent should
health care professionals check to see if the person has expressed a wish not
to donate? Can not this be a form of exploiting human ignorance and weakness
(cf. people ignorant that they can opt out or too lackadaisical to do so)?

Required request requires hospitals to develop protocols to ensure that families

of potential donors are actually asked to donate. Routine inquiry requires
hospitals to develop protocols to ensure that families of undeclared potential
donors have the opportunity to donate - people tend to react more positively
when offered a choice. Some have criticized these approaches as not allowing
professional discretion. Many health professionals are reluctant to approach
families who have just lost a loved one about transplantation. This is
considered a major barrier to increasing the supply of organs and tissues. Most
families though do not object to being approached. Required request or routine
inquiry has been widely endorsed in the United States as a preferred public
policy option when compared to a free or regulated market of organ and tissue
sales or a presumed consent approach. It is seen as more respectful of altruism,
familial sentiments and religious interests. It can also help the bereavement
process by making something positive come out of the death. Some significant
increases in organ and tissue donation have been recorded where this policy is
in place. A few jurisdictions also allow presumed consent following required
inquiry if the family did not object.

The Law Reform Commission of Canada recommends maintaining and

strengthening the present express consent model in Canada with hospitals
implementing routine-inquiry protocols. These, however, are to recognize
professional discretion not to ask in cases where this would clearly be
inappropriate.(LRCC, 39-46, 145-39, and 176-82; cf. Varga, 221-2; Garrett et
al., 210-11; Ashley and O'Rourke 1989, 310; and May, 167-8)

d) Fears, Confusion and the Need for Education

There is a need for education of the general public and many health care
professionals concerning the whole area of organ and tissue transplants. Many
people are not well informed of the needs, the shortage of organs and tissues,
and the great potential benefit of many people for transplants. Many have
unfounded fears or reservations or are confused about some of the issues of
being a donor. In a recent United States survey, "the two most common
reasons given for not permitting organ donation were (1) they might do
something to me before I am really dead; (2) doctors might hasten my
death."(LRCC, note 226) This shows ignorance of standard policy and
procedure concerning transplants. These include strict criteria for determining
total brain death and the separation of the ill or dying patient's health care team
and the transplant team.

Although surveys show that most people think transplantation is a good thing,
only a minority sign an organ donor card. Why? First of all, many are not fully
aware of the advantages of this type of voluntary expressed consent.(see
section 4.c above) Some people may be unwilling to think about their own
mortality, an inevitable fact, or be superstitious. For example, they may
mistakenly think that signing a donor card will increase their chance of a fatal
accident. Some may have concerns about the mutilation of their body. Organs
and tissues, however, are carefully removed and incisions are closed, so that it
will not be apparent to anyone viewing the body that organs or tissues have
been donated.(HOPE, 3) Also,

Some people wonder what will happen to their bodies if at death they donate an
organ. The truth is that every earthly body decays. Therefore, the alternative is
between an organ decomposing or serving to keep an other human being alive.
We Christians believe, as St Paul tells us, that our corruptible body will be
transformed into a spiritual body for the glory of God (cf. 1 Cor
15:35-53)(Chilean Bishops' Permanent Conference, 375)

Some people may also not realize that they can specify limits on an organ
donor form regarding the use of their body (e.g. which organs they may or may
not wish to donate). People should be encouraged to consider organ and tissue
donation as a "legacy of love", as an incarnate form of "CHARITY AFTER
DEATH."(Wolak, 18)

Health care professionals also need to be educated about the meaning of

organ and tissue donation.(CHAC, 43) Some have unfounded reservations
about approaching individuals or families to consider organ and tissue donation.
It is important that some members of the health care team be trained in
approaching potential donors and their families in a sensitive way. They need to
be able to provide the necessary personal and social support regarding the
grieving process.(cf. Batten) Some health care professionals also need to learn
that properly respecting the dead human body is a requirement of our
humanness. Along these lines some medical schools offer services of
remembrance and gratitude before and after dissecting human
cadavers.(Lynch, 1018) Care needs to be taken, too, regarding the language
one uses about the dead. For example, "harvesting the dead" connotes "taking"
and is repugnant, whereas "donation" connotes "giving" and is dignified.(cf.
Belk) In order to increase the potential for transplants, some health care
professionals have a special responsibility with regard to raising the general
level of consciousness of the needs. This should be done in a way that always
properly respects patients' rights of confidentiality and that does not detract
from communicating other pressing health care issues. "The public is entitled to
be accurately informed about the medical progress and implications of
transplantation."(CHAC, 47; cf. German Bishops..., 376)
CONCEPTUAL FRAMEWORK
Jean Watson's theory of human caring provided the theoretical framework for
this study. According to Watson, each nurse has a causal past and
phenomenal field. The nurse's causal past and phenomenal field would include
his or her knowledge and attitude regarding organ donation and experience in
the care of the organ donor and recipient. The nurse's causal past and
phenomenal field might affect his or her ability to realize and accurately detect
feelings and the inner condition of the patient. The nurse's knowledge and
attitudes will determine if the nurse will be able to support the patient's and the
family's choices. Effective caring, on the part of the nurse, promotes individual
and family growth as well as allowing patients and/or families to choose the
best action for themselves at a given point in time. The choice being whether
or not to donate organs. Watson's theory of human caring is an evolving
nursing theory. She has described the nursing metaparadigm concepts in her
work, which will be included in the following section of this paper. The variables
of interest in this study will also be described, as well as reconceptualization of
the metaparadigm concepts and the concepts of interest from Watson's theory
to fit the variables of interest in this

Watson's (1988) views person as "a being-in-the-world" that possesses three

spheres of being— mind, body, and soul— that are influenced by the concept
of self. The notion of self is the subjective center that experiences and lives
within the sum total of body parts, thoughts, sensations, desires, memories, life
history, and so forth. One's self is a process; an unending process wherein
new experience is turned into knowledge, each psychological moment shapes
the next psychological moment (pp. 54-55) .

Watson's (1988) view of environment encompasses the belief that

the human care transactions provided a coming together and establishment of

contact between persons ; one's mind-body-soul engages with another's
mind-body-soul in a lived moment. The shared moment of the present has the
potential to transcend time and space and the physical, concrete world as v/e
generally view it in the traditional nurse-patient relationship (p. 47).

"The world refers to all those forces in the universe, as well as a person's
immediate environment and situation that affect the person, be they internal,
external, human, humanmade, artificial, natural, cosmic, psychic, past, present
or future" (Watson, 1988, p. 56).

Health, as defined by Watson (1988), "refers to unity and harmony within the
mind, body, and soul. Health is also associated with the degree of congruence
between the self as perceived and the self as experienced" (p. 48). "If there is
harmony within a person's mind, body, and soul then a sense of congruence
will exist between the I and me; between the self as perceived and the self as
experienced by the person" (p. 56).

Watson (1988) defines nursing as

a human science of persons and human health-illness experiences that are

mediated by professional, personal, scientific, esthetic, and ethical human care
transactions, wherein the nurse as a person is engaged as an active
coparticipant in the human care transactions (p. 54).

"The goal of nursing proposed is to help persons gain a higher degree of

harmony within the mind, body, and soul which generates self-knowledge,
self-reverence, selfhealing, and self-care processes while allowing increasing
diversity" (p. 49). This allows for a higher degree of h armony.

Causal past is an important concept in Watson's theory and this study. Causal
past "involves collective but unique past experiences and events that each
person brings to the present moment" (Watson, 1988, p. 47).

The last concept in Watson's theory that is important in this study is the
phenomenal field.

The totality of the experience at any given moment constitutes a phenomenal

field. The phenomenal field is the individual's frame of reference and
comprises the subjective internal relations and the meanings of objects,
subjects, past, present, and future as perceived and experienced (Watson,
1988. p. 51).

The two variables of interest in this study are knowledge and attitude of the
nurse regarding organ donation. The theoretical definitions of these two
variables are as follows: Morris (1973) states knowledge "is the familiarity,
awareness, or understanding gained through experience or study" (p. 725) and
attitude "is a state of mind or feeling with regard to some matter" (p. 85) .
Purpose of this study

Watson's concept of person was conceptualized as the registered nurse.

Causal past was conceptualized as the knowledge the nurse possesses
regarding organ donation. The background variables of interest (eg. age,
religious affiliation, education) were conceptualized as part of the nurse's
causal past. The phenomenal field was conceptualized as the attitude the
nurse holds regarding organ donation. The situational variables of interest (eg.
number of organ donors/recipients cared for, personal/family experience with
organ donation) was conceptualized as part of the nurse's phenomenal field.
The environment was conceptualized as the time and place the nurse starts
caring for the patient. The goal of nursing, is achieved when the nurse
supports any decision the patient and/or family makes regarding organ
donation. At this point, the nurse can gain a higher degree of harmony, which
is conceptualized as health.

The three research questions are: What knowledge do nurses possess and
what attitudes do they hold regarding organ donation? What is the relationship
between the nurse's education and the knowledge possessed regarding organ
donation? What are the philosophy of medical surgery nurse regarding organ
donation?

This study is important to nursing because one must be able to describe the
knowledge possessed and the attitude held by nurses regarding organ
donation before one can begin to correlate these variables with other variables
of interest: for example, the relationship between nurses' knowledge and
attitude regarding organ donation and how they affect the organ donation
process. Once the registered nurses' knowledge related to organ donation is
determined, then appropriate education can be offered to improve or enhance.
Knowledge enhancement may improve the nurse's ability to communicate with
potential organ donors and/or their families and also improve the nurse's ability
to identify potential donors. Attitudes are sometimes very difficult, if not
impossible, to change; but with knowing the attitudes a nurse holds one may
then correlate them with other variables.
 CHAPTER II

Review Related Literature

The majority of the research done in the area of nurses' attitudes and
knowledge regarding organ donation has focused on nurses working in the
intensive care/critical care setting. Only one study looked at the broad range of
nurses working in areas other than intensive care.

A two phase qualitative, quantitative study conducted by Sophie, Salloway,

Sorock, Volek, and Merkel (1983) looked at intensive care nurses' perceptions
of cadaver organ procurement. In phase I, a staff of three social scientists
observed 10 donor calls from first telephone contact with the organ
procurement coordinator by a donor hospital until final distribution of organs.
Operating procedures and coordinator perceptions regarding intensive care
nurses' roles were compared across geographical regions and organizational
structures for organ recovery. Phase II consisted of the distribution of
questionnaires to 560 intensive care nurses employed in 27 hospitals. Three
hundred and twelve nurses responded to the mailed questionnaires (55.7%).
Ninety-six percent of respondents were female; 72% were associate degree
graduates while the remaining 28% were graduates of colleges or universities.
They had a mean of 8.4 years of nursing experience and a mean of 5 years
intensive care experience. Forty-four percent had actual nursing experience in
the care of a potential cadaver organ donor.

The results of the study showed that in clear-cut cases 65.8% of the nurses
were able to identify instances in which donors were suitable, but only 20.7%
could do so in cases that were less clear-cut. Also, 86% of the nurses
approved of organ donation, and 80% stated they wanted to be donors
themselves. Only 28%, though, actually carried donor cards. Twenty-five
percent of the nurses did not know the 8 hospital's policy regarding cadaver
organ donation. Lastly, 48.8% of the intensive care nurses were unaware of
the attitudes of the neurologists and the neurosurgeons with whom they
worked. These findings suggested that there may be inadequate knowledge
regarding donor eligibility criteria.

The study had a good sample size that was randomly obtained (N=312) and
was conducted in several hospitals of varying sizes, which facilitates
generalization of findings. One limitation was the use of only intensive care
nurses. The other limitation was the lack of information in the article on the
reliability and validity of the instrument
A descriptive study conducted by Stark, Reiley, Osiecki, and Cook (1983)
examined attitudes affecting organ donation in the intensive care unit. Eight
hospitals participated from the Boston area, of which 2 were metropolitan
teaching institutions, 3 were community based with medical school affiliations,
and 3 were community based with no medical school affiliations. Only one
nurse from each intensive care unit collected data on a seven-item
questionnaire each time a potential donor presented in the intensive care unit.
The questionnaire looked at when a individual was recognized as a donor and
by whom, the general attitude of family, nurses, physicians, and, if applicable,
reasons why donations did not occur.

Twenty-six questionnaires were returned over 1 year. Seventy-seven percent

of the patients were recognized as potential kidney donors within 24 hours of
admission to the intensive care unit, the physician was the first to recognize
the patient as a potential donor in 35% of the cases, the nurse in 42% of the
cases, and the nurse and physician concomitantly in 23% of the cases. Only
eight donations actually took place, in which 88% of physicians, 100% nurses
and 66% family members favored donation. Of the 18 donations that did not
take place, 7 were for physiologic reasons, fear of physician litigation in 6,
physician assessment of family inability to cope or agree in 2, and family
reluctance in 3.

The fact that the nurse was the first person to recognize the patient donor in
42% of the cases could be explained by the nurse spending more time with the
patient and the nurse researchers having had preliminary education about
transplant opportunities. The study suggested that the attitudes of physicians
and nurses dealing with the families whose attitudes were initially assessed as
unsure but eventually became favorable were also described as favorable.
The findings suggested a need for education of healthcare personnel and the
public on organ donation.

Two limitations of this study were the small sample size (N=26) and a singular
focus on kidney donors thus limiting the ability to generalize findings. Also, the
preliminary training received by the nurse researchers at 10 the eight facilities
may have biased the results of the nurse recognizing potential donors first.
Lastly, estimates of reliability and validity of the instrument were not presented
in the article.

Another study conducted by Frottas and Batten (1988) described a random

sample of neurosurgeons (n=246), hospital administrators (n=222), directors
of nursing (n=227), and ICU nurses (n=878). The neurosurgeons were mailed
a 50-item questionnaire on organ donation and separate surveys (90- item
questionnaire) were mailed to the other three groups from 344 hospitals. The
hospitals were acute care of more than 100 beds and without their own
transplant program. All four surveys were different but designed to measure
attitudes and opinions about organ donation for each group. Subjects were
randomly selected from each of the four groups. A representative sample of
the public (n=750) also was surveyed by telephone about their attitudes
towards organ donation.

The study found that more than 90% of all the professionals who supported
organ donation, would donate their own organs and would consider giving
permission for procurement of a relative's organs. Ninety percent of the public
approved of organ donation, 72% would donate their own organs, and 53%
would consider giving permission for procurement of a relative's organs.
Seventy-one percent of the neurosurgeons saw themselves as supportive of
organ 11 donation, whereas 26% of the nurses saw physicians as opposing
organ donation. Lastly, 50% of the nurses thought brain death criteria were not
well established.

The limits to the study included age variations within the groups surveyed, as
well as education levels and gender differences between groups. Also, smaller
hospitals (less than 100 beds) were excluded which may have influenced in
the results. The study used only ICU nurses in the survey, which prohibits
generalization to nurses working in other areas in acute care hospitals. Lastly,
reliability and validity of the instruments were not discussed in this article.

A cross-sectional survey descriptive research design was utilized by Matten,

Sliepceivich, Sarvela, Lacey, Woehlke, Richardson, and Wright (1988) to study
nurses' knowledge, attitudes, and beliefs regarding organ and tissue donation
and transplantation. A 70-item questionnaire based on two primary sources,
the Donation of Human Organs for Transplantation Survey, and two public
survey instruments with established content validity and reliability was used.
Data were collected from 1,683 nurses employed in 62 hospitals in rural and
urban centers in three states in the Midwest. Hospital size ranged from 29 -
1,054 beds. Eighty-eight percent of the sample were registered nurses with
27.8% holding an associate certificate, 28.2% a diploma certificate, 22.8% a
bachelor's degree in nursing, 4.2% a 12 bachelor's degree in another discipline,
and another 5.2% holding a degree beyond the bachelor's level. Twelve
percent were licensed practical nurses. Medical/surgical (26.1%) and intensive
care (16.1%) were the two most frequently identified units of assignment.
The authors found the nurses' knowledge of the criteria for organ donation had
a mean score of 7.5 (with 10 as the possible high). A mean score of 62.29
(total possible score of 80) was found for nurses' personal beliefs toward organ
and tissue donation and transplantation.

Strengths of the Matten et al., (1988) study were large sample size (N=l,683),
nurse representation from differing educational programs, hospitals of varying
sizes from multiple sites, and complete survey information. The authors did not
discuss the strategies that contributed to the high response rate in a 3 week
period.

Stoeckle (1990) used a convenience sample of critical care nurses (N=44)

from a level one trauma center (n=17) and a private hospital (n=27) to examine
the attitude of critical care nurses toward organ donation. The study correlated
knov/ledge, selected situational and background variables to nurses' attitudes.
The study used a descriptive correlational design. The Organ Donor Attitude
Questionnaire, that was used, had established content validity and reliability

Ninety-five percent of the critical care nurses surveyed reported a positive to

strongly positive attitude toward organ donation. The belief in donating one's
own organs was 86.4% but only 65.9% for donating the organs of a family
member. No difference was seen between the attitudes of the critical care
nurses from the trauma center and from the private hospital. Four of the six
major areas demonstrating knowledge level of the organ donor identification
and management criteria were poorly understood. Those four were:
Electroencephalogram requirements (63.9%), initial injury under the influence
of barbiturates (56.8%), less than 10 minutes needed to resume a heartbeat
following cardiac arrest (47.7%), and age requirements (36.4%). Two major
factors influenced the critical care nurses' attitude toward organ donation:
increased knowledge about organ donation (75%) and previous experience
caring for either organ donors or recipients (88.4%).

A limitation of the study was the sample (N=44) that included only critical care
nurses, which impeded generalization. The questionnaire's reliability and
content validity were discussed in the article.

The last relevant study used a descriptive correlational design (Bidigare and
Oermann, 1991) . The purpose of the study was to examine critical care nurs e
s ' attitudes and knowledge regarding organ donation. The 14 sample
consisted of 75 registered nurses employed in critical care areas in a
university-affiliated, 350-bed level 1 trauma center in the Midwest with no
transplant program or institutional protocol for organ donation. Ninety percent
of the nurses were female. Fifty-two percent held bachelor's degrees in
nursing, 25% diplomas, 20% associate degrees, and 3% master's degrees.
The respondents had a mean of 8 years of nursing experience. Seventy-one
percent had previously cared for an organ donor, and 27% had previously
cared for an organ recipient.

The instrument was a self-administered questionnaire, in which part 1

consisted of questions regarding attitudes toward organ donation, and part 2
consisted of questions assessing the nurses' knowledge regarding organ
donor protocol used in their hospital. Reliability was not established by the
authors and validity was not discussed in the article.

The results of the knowledge section of the questionnaire included 30 items

where the scores for the variables were summed and a knowledge score
obtained. The mean score for the entire group was nine (SD=3). Differences in
scores were based on different demographic variables. Surgical intensive care
nurses had the highest scores on knowledge of organ procurement
procedures (F[6, 53]=2.99, p=.01). There was also a difference in the
knowledge levels of nurses who had previous donor experience 15 and those
without (F[l, 58]=5.54, p=.02). Nurses with higher knowledge scores were
found to have more positive attitudes toward donating their own organs (r=.33,
p=.005), the extent to which they would attempt to influence family members in
donation (r=.53, p<.001), and the extent to which they would participate in the
care of a patient for organ donation (r=.44, p<.001).

The limitations of this study included a convenience sample and the use of one
hospital, thereby limiting the ability to generalize results. Reliability and validity
of the instrument were not discussed in the article.

CHAPTER III

METHODOLOGY
Research Design

The purpose of this descriptive study was to explore the knowledge nurses
possess and the attitudes they hold regarding organ donation. The study also
described relationships between the nurse's education and the knowledge
possessed regarding organ donation and the nurse's experience caring for
organ donors/recipients attitudes and philosophy held regarding organ
donation.

Setting and Sample

The setting for this study was a 245-bed capacity in cardinal santos medical
center.that does not have an organ transplant program. This medical center
has a policy and procedure for the organ, tissue, eye and/or other body parts
donation process, as well as a policy and procedure on determination of brain
death. Nurses are required to determine if the patient, upon admission, has an
advance directive for healthcare. It is also part of the nurse's or supervisor's
responsibility in post-mortem care to ask the families about their wishes for
organ donation,

Eligible subjects for this study were registered nurses who practice in medical
surgery ward. A convenience sample of approximately 15 registered nurses
was obtained.

Table 1
Demographic Background Variables of the Subjects
Background Variables Number Percent
Gender (N=15)
MALE 4 26.667
FEMALE 11 73.333
Religious Affiliation
Catholic 15 100
Iglesia ni cristo
Seventh-Day Adventist
No religious affiliation
Other

CHAPTER IV

ANALYSIS AND INTERPRETATION

This chapter deals with the analysis and interpretation of data collected from
the respondents. The study was computed using descriptive and inferential
statistic.
To summarize the characteristics of this study's sample the subjects were
generally female (73.33%), majority of my respondent all are roman catholic
(100%.) Regarding to seminar and workshop concerning organ transplant
indicate (93.3%) attended and (6.67%) not yet attending in any kind of organ
transplant seminar/workshop ,the number of respondent had already attended
in seminar/workshop regarding values ,ethical or moral development (93.3%)
of them attended and (6.67%) not attended. The majority of the subjects had
no experience caring for organ donors (100%), and 100% of the subjects have
had no personal or family experience with organ donation no one have
personally signed the back of their driver's license,

Table 2
Professional Background Variables
Background Variables Number Percent
Have you ever attended a course,
seminar, or workshop concerning organ
donation or transplantation?

Yes
13 93.3
No
1 6.67

Have you ever attended a course,

seminar, or workshop concerning values,
ethical, or moral development?

Yes
13 93.3
No
1 6.67

What is your area of specialty?

Critical Care 15 100

Emergency Room
Medical/Surgical
Oncology
Dialysis
Pediatrics

Have you had any personal or family

experience with organ donation?

Yes
No
15 100

Have you personally signed the back of

your driver's license, consenting to be an
organ donor?

Yes
No 15 100

Instrument

The instrument used to collect data for this study was The Organ Donor
Attitude Questionnaire. This instrument investigates nurses' attitude and
knowledge concerning organ donation. The first section provided data for
correlational analysis. The background variables (eg. age, religious affiliation,
education) were conceptualized as part of the nurse's causal past; and, the
situational variables (eg. donors/recipients cared for, personal/family
experience with organ donation) were conceptualized as part of the nurse's
phenomenal field. These variables were used to describe the subjects
(registered nurses) and to determine knowledge and attitude regarding organ
donation, which dealt with knowledge level. The Organ Donor Attitude
Questionnaire used three different levels of measurement. The levels of
measurement nominal , ordinal, and interval.

Table 3
 Freauencv Distribution of Knowledge Items Correct Answers
Knowledge Items Frequency Percent
A relative of an
individual that has died
can give permission for
that person's organs to
be donated

YES
NO
5 33.33
DON’T KNOW
8 53.33
13.33
A licensed physician can
give permission to
donate organs of an
individual that has died.

YES
NO
DON’T KNOW 15 100

The result shows that the majority of my respondent in favor of giving

permission for that relatives to donate persons organs when it die (53.33%)
And regarding to the licensed physician give permission to donate organs of
an individual has died got (33.33%)

Table 4

Means for Attitude Items

Situational Variables NUMBER PERCENT
Approve of cadaver
organ donation

STRONGLY AGREE 11 73.33

AGREE 2 13.33
UNDECIDED 2 13.33
DISAGREE
STRONGLY DISAGREE
Would donate own
organs

STRONGLY AGREE
AGREE
2 13.33
UNDECIDED
10 66.66
DISAGREE
3 20
STRONGLY DISAGREE
Would donate organs of
child/family

STRONGLY AGREE
1 6.66
AGREE
UNDECIDED
6 40
DISAGREE
8 53.33
STRONGLY DISAGREE

The removal of a
person's organs before
the heart stops is a
violation of a person's
rights

STRONGLY AGREE
AGREE
UNDECIDED
DISAGREE 8 53.33
STRONGLY DISAGREE 4 26.66
3 20

I would be willing to sit

down and discuss organ
donation with my family.

STRONGLY AGREE
3 20
AGREE
10 66.667
UNDECIDED
2 13.33
DISAGREE
STRONGLY DISAGREE

Organ donation is more

trouble than it's worth.

STRONGLY AGREE
AGREE
1 6.667
UNDECIDED
9 60
DISAGREE
5 33.33
STRONGLY DISAGREE

.
Approve of cadaver Strongly agree 73.33%
organ donation
Would donate own Undecided 66.66%
organs
Would donate organs of Disagree 53.33%
child/family

The removal of a Agree 53.33%

person's organs before
the heart stops is a
violation of a person's
rights

I would be willing to sit Agree 66.667

down and discuss organ
donation with my family.

Organ donation is more Undecided 60%

trouble than it's worth.

Table 5

Attitude concerning organ donation influenced by my:

Family attitudes
Friend's attitudes

STRONGLY AGREE
AGREE
UNDECIDED
DISAGREE 15 100
STRONGLY DISAGREE

Work experience with an

organ donor or recipient
STRONGLY AGREE 10 66.667
AGREE 3 20
UNDECIDED
DISAGREE 2 13.33
STRONGLY DISAGREE

Nursing school
STRONGLY AGREE 10 66.667
AGREE 5 33.33
UNDECIDED
DISAGREE
STRONGLY DISAGREE
education
Increased knowledge of
the subject
STRONGLY AGREE
10 66.667
AGREE
5 33.33
UNDECIDED
DISAGREE
STRONGLY DISAGREE

Religious beliefs
STRONGLY AGREE
AGREE
UNDECIDED
DISAGREE 10 66.667
STRONGLY DISAGREE 5 33.33
Friend's attitudes Disagree 100

Work experience with an Strongly agree 66.667

organ donor or recipient

Nursing school Strongly agree 66.667

Increased knowledge of Strongly agree

the subject
66.667

Religious beliefs Disagree 66.667

 CHAPTER V

CONCLUSIONS

Watson's theory of human caring focuses on two transpersonal dimensions

that include the nurse and the patient. This study focused on the transpersonal
dimension of the registered nurse. The transpersonal dimension includes the
registered nurse's causal past and phenomenal field.

Causal past included the background variables describing the registered

nurses in the study and the knowledge possessed by those registered nurses
regarding organ donation. It does not appear, from this study, that the levels of
nursing education makes any difference in the knowledge and attitudes
regarding organ donation.
The phenomenal field of the registered nurses in this study included the
attitude of the registered nurses regarding organ donation and the situational
variables describing the registered nurses. The phenomenal field is, according
to Watson (1988), "the totality of the experience at any given moment and is
the individual's frame of reference" (p. 51). The registered nurses frame of
reference includes a positive attitude regarding organ donation but no
relationship was found between their experiences in caring for organ
donors/recipients and their attitudes. According to Watson (1988), "how a
person perceives and responds in a given situation depends upon the
phenomenal field (subjective reality) and not just upon the objective conditions
or external reality" (p. 55). Therefore, the registered nurse's phenomenal field
may affect their ability to support decisions of the patient and/or family in
relations to organ donation.

Using Watson's concepts of causal past and phenomenal field, this study
suggests that it might be difficult for the nurse to realize and accurately detect
the feelings and the inner condition of the patient. Because of their lack of
knowledge, the nurse might not be able to communicate with potential organ
donors and/or their families.

Recommendations

The first recommendation, before this study is replicated or as an idea for

future research, all the questionnaire needs to be revised, especially the
knowledge level items, to improve the reliability of the instrument. Future
research needs to randomly select nurses from multiple hospitals of varying
sizes to enhance generalizability.

LIST OF REFERENCES
Bidigare, S. A., & Oermann, M. H. (1991). Attitudes and knowledge of nurses
regarding organ procurement. Heart & L ung, 2 0 , 20-24.

Matten M. R., Sliepcevich, E. M . , Sarvela, P. D . , Lacey, E. P., Woehlke, P.

L . , Richardson, C. E . , & Wright, W. R. (1991). Nurses' knowledge, attitudes,
and beliefs regarding organ and tissue donation and transplantation. Public
Health Reports, 106. 155-166.

Morris, W. (Ed.). (1973). The American heritage dictionary of the English

language. New York: American Heritage Publishing Company.

Prottas, J. , St Batten, H. L. (1988). Health professionals and hospital

administrators in organ procurement: Attitudes, reservations, and their
resolutions. American Journal of Public Health, 7 8 , 642-645.

Sophie, L. R . , Salloway, J. C ., & Sorock, G. (1983). Intensive care nurses'

perceptions of cadaver organ procurement. Heart & L u n g . 13., 261-267 .

Stark, J. L . , Reiley, P., Osiecki, A., & Cook, L. (1984). Attitudes affecting
organ donation in the intensive care unit. Heart & Lung, 13 , 400-404.

Stoeckle, M. L. (1990). Attitudes of critical care nurses toward organ donation.

Dimensions of Critical Care Nursing. 9, 354-361.

The Partnership for Organ Donation, Inc. (1993). The American Public's
Attitude Toward Organ Donation and Transplantation (prepared by The Gallup
Organization, Inc.). Boston, MA.

United Network for Organ Sharing. (1990). Facts about transplantation in the
United States. Richmond, VA: UNOS.

Watson, J. (1988). Nursing: Human science and human care - A theory of

nursing. New York: National League for Nursing.
 ORGAN DONOR ATTITUDE QUESTIONNAIRE
1. What is your age
2. What ia your gender? 1. Female 2. Male
3. What is your religious affiliation?
Catholic
Iglesia ni cristo
Seventh-Day Adventist
No religious affiliation
Other
4. Have you ever attended a course, seminar, or workshop concerning organ
donation or transplantation?
Yes No

5.Have you ever attended a course, seminar, or workshop concerning values,

ethical, or moral development?
Yes No
6 what is your area of specialty?
Critical Care
 Emergency Room
Medical/Surgical
Oncology
Dialysis
Pediatrics
7. Have you had any personal or family experience with organ donation?
Yes No
8. Have you personally signed the back of your driver's license, consenting to
be an organ donor?
Yes No

Please draw a circle around the letter under each statement which best
represents your reaction to that statement. Try to respond to each
statement. The meaning of the letters are:

Y = Yes
N = No
D = Don't know
1. A relative of an individual that has died can give permission for that person's
organs to be donated.
Y N D
2. A licensed physician can give permission to donate organs of an individual
that has died.
Y N D
Please draw a circle around the letter under each statement which best
represents your reaction to the statement, Try to respond to each
statement. The meaning of the letters are:

SA = Strongly agree
A = Agree
U = Undecided
D = Disagree
SO = Strongly disagree
1. approve of cadaver organ donation SA A U D SD.
2. I do not feel it is right to prolong life through the use of human organ
transplants. SA A U D SD
3. I would donate my own organs.SA A U D SD
4. I would donate the organs of my child or family member,
SA A U D SD
5. The removal of a person's organs before the heart stops is a violation of a
person's rights.
SA A U D SD
6. I would be willing to sit down and discuss organ donation with my family.
SA A U D SD
7. Organ donation is more trouble than it's worth.
SA A U D SD

Please fill in the sentence with each of the following statements and
continue to draw a circle around the letter to the right of each statement
which best represents your reaction to that statement, The letters
represent
SA = Strongly agree
A = Agree
U = Undecided
D = Disagree
SO = Strongly disagree
1. My attitude concerning organ donation is influenced by my
A) Family attitudes SA A U D SD
B) Friend's attitudes SA A U D SD
C) Work experience with an organ donor or recipient SA A U D SD
D) Nursing school education SA A U D SD
E) Increased knowledge of the subject SA A U D SD
F) Religious beliefs SA A U D SD

THANK YOU FOR YOUR PARTICIPATION IN THIS SURVEY !