Due to the development of medicine in general and surgery in particular, the vast majority of diseases can be cured completely or be in long-term remission. However, it is impossible to restore the normal functions of the body organs using therapeutic or conventional surgical methods at a certain stage of some pathological processes. In this context, the question about the organ replacement and transplantation from one organism to another arises.
Organ transplants are quite complex since they require special equipment. However, the issues of technical nature as well as anesthesiology and intensive care provision are fundamentally resolved. Continuous improvement of medical technologies connected with transplantation significantly expanded the practice of transplantation and increased the need for donor organs. The questions of moral, ethical and psychological nature are particularly acute in this area of medicine. This paper will discuss different aspects of organ donation and transplantation from psychological point of view.
Transplantation is a surgery, where tissue, organ, or part of the body of one person (the donor) is transplanted to the same or another person (the recipient) in order to preserve the life of the recipient or to recover his/her health. At the same time, dead and alive people can be donors (including people with a diagnosis of brain death). In some cases, living beings of other biological species can be donors.
Such type of transplantation as kidney transplantation improves the physiological and metabolic balance of a patient and returns the necessary level of confidence. The functioning of the transplanted kidney leads to a global improvement of physical and mental health. The symptoms of uremia, which could not be completely eliminated during dialysis therapy, reduce, sleep restores and appetite disorders disappear. Restoring the level of hematocrit and hemoglobin is accompanied by improvement of cognitive functions. After kidney transplantation, the life of a patient is not dependent on the dialysis machine. It means that he/she can organize the life in a way he/she likes, having more freedom and autonomy. For women, the possibility of pregnancy becomes a reality. In addition, patients can spend their vacation wherever they want (Morris & Knechtle, 2013).
The recipient may perceive a new kidney as something alien, which creates certain contradictions in his/her structure of personal integrity. This new and unusual sense is projected onto the partner and may cause significant difficulties in their intimate relationships. Sexual dysfunction in patients with transplanted kidney is expressed in varying degrees, depending on the individual physical and psychological factors. In this case, dominant physical factors of sexual dysfunction are partial return uremic syndrome, the development of surgical complications and infections as well as the risk of impotence and infertility as a result of long-term use of immunosuppressive drugs (Morris & Knechtle, 2013).
From psychological point of view, sexual dysfunction is formed as a result of recurrent episodes of depression, emotional crises and psychological consequences of steroid therapy, which has the side effect of decreased libido and interest in sex. A fear of damaging the transplanted organ and imaginary rejection symptoms, which are manifested in the immediate physical activity, have a significant negative impact on the motivation of the patient in his/her attempts to have sexual intercourse.
Mental complications which occur due to the use of steroids at different stages of the procedure of organ transplant are common. Thus, their potential impact on the body and psyche has to be reported. Mood swings caused by medications should be taken into account when it comes to the emotional well-being of the patient. The side effects of immunosuppressive drugs are most evident when looking at a pale face of the patient. The patient’s hair becomes thin and sparse. As a result, the patient experiences stress and starts to perceive his/her own body negatively (Morris & Knechtle, 2013). The intensity of these effects depends on the age of the patient and manifests itself to the greatest extent in adolescence.
Mental changes associated with taking steroid medications can manifest themselves as symptoms of depression and episodes of the so-called “steroid psychosis.” They include anxiety, euphoria, confusion, hallucinations, and paranoid reactions. In addition, the symptoms of confusion can often occur in the explicit or implicit form; depression can often occur as well. Also, there are cases of psychopathological phenomenon of hysterical type.
The disease can damage self-esteem of some patients because transplantation is regarded as the restoration of the overall health and can lead to the permanent loss of status. It results in promiscuity, substance abuse, and evasion of the concomitant therapy.
Kidney rejection evokes the painful feeling of “returning to the very beginning” in patients and puts them back in the position of powerlessness. This feeling is more pronounced than it was prior to transplantation. General psychological fatigue occurs due to the loss of huge amounts of psychic energy during the process of transplantation (Rodrigue, Mandelbrot, & Pavlakis, 2010). The fatigue causes the collapse of mature psychological defenses, which manifests itself in a regressive position, passive attitude or irritation, and bad mood or intolerance.
Kidney transplantation as a therapeutic method entails a range of psychological, social, legal, and philosophical problems. Psychological problems, emotions, motivations and other issues can be divided into two groups – donor’s psychological experience and recipient’s psychological experience.
Sometimes psychological adaptation of the donor to transplantation leads to intrapsychic conflicts that need the therapeutic intervention before and after the organ transplant. A doctor must inform the potential donor about any facts related to transplantation, including those that could lead to possible problems and complications. Direct persuasion to donate organ or tissue is not permitted.
It should be noted that understanding of the motivation of organ donation requires a complex approach. In this regard, it is necessary to study closely the psychological characteristics of a donor, relations in the extended family (grandparents) as well as his/her emotional or family relationship with a recipient. The important part here is the understanding of family relationships established prior to transplantation, ethno-cultural and social characteristics, their dependence on the culture and traditions with regard to the living donor, especially in the case of cadaveric donation.
Altruism of a potential donor is often taken for granted without a deep analysis of internal and unconscious motives. The latter appear because of fear of rejection in case of possible refusal, an exaggeration of minor health problems, and expression of pessimism regarding the procedure. One can talk about the so-called “pure motivation” only in rare cases, but in most cases, it is a combination of motives and impulsive decisions (Rodrigue, Schutzer, Paek, & Morrissey, 2011).
As a rule, most donors decide to donate an organ or tissue impulsively, without thinking rationally and possessing no information about the details of the procedure. Sometimes they are under the influence of a strong passion. Moralistic and altruistic relations in the framework of the impulsive type of donation are often used as a mask for the actual unconscious needs and desires.
Different reasons motivate a person to become a donor, and they can be manifested in many ways in practice. In some cases, the decision to donate a kidney is an expression of genuine and deep emotional bonds between the donor and the recipient, and therefore the donor believes that any questions about his/her motivations are redundant (Dew & Jacobs, 2012).
Such intense motivation, forcing the recipient to accept the forthcoming organ transplant, can make the donor become “emotionally naked” and exhaust his/her emotional reserves. In the case of unfavorable outcome of transplantation, such an adjustment can lead to the emotional antithesis, which may appear as a violation of personal functioning and paranoid and depressive reactions. For example, mothers who become donors are often motivated by a desire to experience a symbolic rebirth of a child, getting rid of the subconscious sense of guilt for the birth of the “defective child” in the case of successful transplantation (Prihodova et al., 2010).
People, who have low self-esteem or feel alienated from society, are often willing to be donors in order to seek psychological security. It is known that the primary motivation of kidney donors is the increase of self-esteem and improvement of self-relationship and psychological health. They often tend to attract attention of relatives in order to get the required position in the family and, in a broader context, to give meaning and value to their own life (Weng, Dai, Huang, & Chiang, 2010).
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As a rule, such people are middle-aged, usually divorced, and so on. They live alone; thus, their deed cannot be ignored by their family. Donation as the act of self-sacrifice allows them to get the desired respect. However, after some time, the importance of their act dilutes, the attention to them reduces, and admiration fades (Weng et al., 2010). This fact may subsequently lead to a deep disappointment and bitterness, underlying the feeling of inadequate recognition of the “greatness of their sacrifice” (Rodrigue et al., 2011).
Some family members may be motivated to donate a kidney because they have a feeling of guilt about being healthy. There are cases when family members are fighting for the right to become a kidney donor, thereby seeking to compensate for the earlier negligence and mistakes disapproved by their family. Also, there are cases when the recipient takes an active part in the restoration of the family through selection of a member that will donate a kidney, thus skillfully manipulating family members (Dew & Jacobs, 2012). For this purpose, he/she chooses the people that are easy to manipulate, dependent and influenced by others.
Organ rejection in the post-transplant period may make a donor disappointed because it can be interpreted as a recipient’s refusal to accept the donor’s identity, a kind of betrayal and “lack of respect for his/her sacrifice” (Dew & Jacobs, 2012). Because of angry reaction of the donor, the recipient can feel guilt and become depressed. However, the recipient’s sense of guilt is not the only psychological experience he/she has, so the latter requires further consideration.
The recipient of the organ may feel obliged. Sometimes, it is very difficult for him/her to take kidney given by a donor (family member) because the recipient realizes that he/she will have an alien organ in own body. Evolution of relations between the donor and the recipient determines the fate of the donated organ and psychological potential of the two participants in this process. It allows them to ensure realistic dynamics of their relationship, recognize their expectations and disappointments and express everything during the tolerant discussion (Prihodova et al., 2010). In this context, one should note the presence of obvious thesis about the direct connection between emotions of donor and recipient and somatic manifestations of the engraftment or transplant rejection.
Preparation and implementation of transplantation are usually accompanied by the manifestations of emotional stress felt by all parties involved. It occurs in different ways, depending on its nature at various stages of transplant procedure. The transformation of the emotional relationships supports the dynamics of existing relations between recipient and donor and their surroundings (Rodrigue et al., 2011). In view of this, it is evident that, for example, family relations of a recipient must have their own characteristics. Thus, family members of the recipient may experience anxiety manifested through guilt, intrafamily conflict, or imbalance between the principles of voluntariness and reasonableness in transplantation.
Exaggerated sense of duty of the recipient as well as the dependence on the emotional state of the donor can change the quality of the relationship, leading to an adversarial relationship. After a successful transplant operation, the importance of a donor diminishes because a family shifts its attention to the recipient. This phenomenon intensifies the donor’s sense of rejection and can be an onset of depression or the emergence of feelings of hostility to the recipient. In such a situation, it is important to develop effective interpersonal communication to show feelings toward each other and emphasize altruism.
In case kidney is donated by a person of the opposite gender, male recipients are concerned about the future functioning of the transplant due to the peculiarities of the surgical manipulation in the urinary organs. Persons with gender identity problems, adolescents, and young men whose sexual identity is forming have difficulties during the post-transplant period, especially if the donor is a person of the opposite sex.
When an organ is donated by a deceased person, the recipient develops a sense of guilt. The phenomenon of “psychological incorporation” of a deceased donor can make patients acquire various psychological formations and requires individual psychotherapy (Dew & Jacobs, 2012).
Common psychological changes that patients undergo after organ transplantation are caused by a certain combination of physical and psychological symptoms that develop during post-transplant period. Thus, the patient feels insecure in his/her “new freedom” since there is no necessity for dialysis and constant contact with medical staff (Falvo, 2013). What is more, the patient fears his/her new abilities.
In the early postoperative period, the fear of kidney rejection has a significant influence on some activities of the recipient, determines his/her behavior and puts the recipient in a certain mood (Dew & Jacobs, 2012). Over time, the fear of the patient is gradually reduced.
The role of psychologist working in the field of organ donation and transplantation is difficult to overestimate. His/her help is of paramount importance in the case of a kidney transplant from a living immune-compatible donor, who is willing to sacrifice a healthy organ in order to contribute to the health of the patient. Effective psychological impact during the various stages of transplantation requires profound training of psychologists, who must have a thorough knowledge of all available patient treatment conditions. Modern therapeutic possibilities with their advantages and disadvantages should be provided to the patients and their families when the failure of kidney function is almost inevitable (Falvo, 2013). As a consequence, the optimal treatment plan that has the enormous psychological importance for the patient can be made.
Preventive psychological treatment based on the concept of biological, psychological and sociological factors proceeds from the fact that the patient’s illness creates his/her psychological portrait and its negative defense mechanisms. Thus, the negative effects of the disease can be prevented by forming an adaptive attitude of the patient to the disease. What is more, the same process has to be initiated in others. The patient receives the necessary information about the therapeutic possibilities and limitations (which is an important moment in the psychotherapeutic work) and, therefore, is ready to recognize the early signs of the disease and face the new challenges in a mature way (Rodrigue et al., 2010).
Regressive behavior of the patient has a protective nature. A psychologist provides preventive counseling and psychotherapeutic influence with the aim to help the patient adapt to the disease in the most constructive way and give a new meaning to his/her life despite the significant limitations. For this purpose, the psychologist must limit any intention that involves convincing the patient of unrealistic expectations since the deceived victim of physical illness has no power to reorganize and restore the balance (Falvo, 2013).
When deciding on the organ transplantation, the most important task of the psychologist is to assess the mental state of the donor and the recipient before the operation. In this context, it is necessary to inform and warn them of their upcoming specific emotional relationships, proactively indicate the possible development of adverse psychological and psychopathological manifestations in the case of transplant rejection. In the case of unsuccessful transplantation, a patient must be assured that frustration and depression will gradually pass.
Over time, the potential for organ rejection becomes less realizable. Kidney transplantation makes the sense of life authentic, explicit and tangible. A new quality of life, creating a harmonious balance between the provision of preventive health services and applicability of therapeutic effects, allows the patients to gradually distance themselves from a psychologist.
Transplantation is a medical intervention that involves numerous ethical and deontological problems which, in turn, make both the donor and the recipient face numerous psychological consequences. Transplantation causes problems of moral, ethical and psychological nature. One of the most acute problems of transplantation is the understanding of emotional, motivational and behavioral ways of coping with organ transplantation and organ donation as a traumatic situation. These problems can be generalized in several sections and areas: from the development of programs to work with the families of donor and recipient to the determining of the approaches of counseling and psychotherapy during the process of transplantation. The development of transplant centers as the units involved in this specialized type of medical care is a part of a strategy aimed to improve the quality of life and treatment of the patients.
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