Читать книгу Transfusion Medicine - Jeffrey McCullough - Страница 76

With increasing use of bone marrow transplantation to treat a wider variety of diseases and with the success of the treatment improving, the lack of a suitable family donor for most patients became a major limitation in the availability of this treatment. The first successful transplant using marrow donated by a volunteer not related to the patient [51] opened the urgent need for large numbers of human leukocyte antigen (HLA)‐typed individuals who would be willing to donate marrow. A remarkable story unfolded, resulting in the establishment of the National Marrow Donor Program [52].

Initially it was believed that it might be improper or even unethical to ask volunteers unrelated to the patient to donate marrow. The risks of donation, the discomfort, the nature of the patient’s preparation for the transplant, and lethal consequences of withdrawal by the donor all contributed to an atmosphere in which this kind of donation seemed unlikely. However, the possibility was pursued in a small number of centers [52]. One of the major first steps was a conference sponsored by the University of Minnesota at which the legal, ethical, social, financial, and practical issues in unrelated volunteer marrow donation were discussed [53]. The involvement of two community blood centers added strength at this early stage because they were separate from the transplant centers and also because of the involvement of representatives of the general community as part of their governing boards. As these organizations began to consider establishing a marrow donor program, the results of the conference strengthened the belief that there were proper ways to inform people of the opportunity and the consequences of donation and to provide the opportunity to become a donor if desired [53]. The initial ethical principles involved respect for life, promotion of good, prevention of harm, justice, fairness, truth‐telling, and individual freedom [53].

Because of the extensive commitment required of donors, it was decided to approach multigallon blood donors and apheresis donors [54, 55]. This had the added benefit that most were already apheresis donors who had been HLA‐typed, and this avoided the cost of additional HLA typing. The “recruitment” involved providing an extensive description of marrow transplantation, the situations in which it was used, the results of transplantation, including actual survival statistics, the marrow donation process, and the steps that would lead up to marrow donation. The recruitment process drew heavily on the considerable experience of sociologic studies of families making the decision to donate an organ either to a relative or for cadaver transplantation [56, 57]. The informed consent process was given very heavy weight in the recruitment process [54]. Remarkably, about three‐fourths of the donors who were provided an extensive description of the marrow donor program elected to participate [54, 55]. Important factors in the donor’s decision whether to participate in the program were religion, experience with the medical system, and the spouse’s attitude regarding marrow donation [55].

Donor recruitment efforts were expanded to the general public. Although there was concern that people who had never donated blood would not be sufficiently well informed or willing to make the necessary commitment, general community appeals for donors resulted in the recruitment of donors who became as committed to the program as the cytapheresis donors [55]. The national marrow donor file has now grown to more than 10 million volunteers in the United States and many more worldwide. The extensive experience with marrow donation establishes the effectiveness of the recruitment process and the lifesaving impact of the therapy on patients.