A model of donors' decision-making in adult-to-adult living donor liver transplantation in Japan: Having no choice


  • Misao Fujita,

    1. Department of Biomedical Ethics, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
    2. Department of Biomedical Ethics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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  • Akira Akabayashi,

    Corresponding author
    1. Department of Biomedical Ethics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
    • Professor, Department of Biomedical Ethics, School of Health Science and Nursing, The University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
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    • Telephone: 81-35841-3509; FAX: 81-35841-3319

  • Brian Taylor Slingsby,

    1. Department of Biomedical Ethics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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  • Shinji Kosugi,

    1. Department of Biomedical Ethics, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
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  • Yasuhiro Fujimoto,

    1. Department of Transplantation Surgery, Nagoya University Hospital, Nagoya, Japan
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  • Koichi Tanaka

    1. Department of Transplantation and Immunology, Kyoto University Hospital, Kyoto, Japan
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This study examined the decision-making processes of donors in adult-to-adult living donor liver transplantation. Twenty-two donors were interviewed using a semi-structured format. Interview contents were transcribed verbatim and analyzed qualitatively using grounded theory. A decision-making model was developed consisting of 5 stages: (1) recognition, (2) digestion, (3) decision-making, (4) reinforcement, and (5) resolution. The second and the third stages described donors' experiences of “reaching a decision”; the fourth and fifth stages described those of “facing transplantation.” The central theme of this model was “having no choice,” which consisted of 4 codes: (1) priority of life, (2) only LDLT, (3) for family, and (4) only me. In conclusion, this model can help health care professionals to understand the donor experience and, based on that understanding, to provide sufficient support to the donor. Liver Transpl 12:768–774, 2006. © 2006 AASLD.

Adult-to-adult living donor liver transplantations (LDLT) have increased remarkably worldwide since 1994,1, 2 when a technique to transplant the right hepatic lobe was reported.3 In Japan, over 2,600 procedures had been carried out as of 2004, more than half being adult-to-adult transplantation and a third being performed using the right hepatic lobe.4 Adult-to-adult right lobe transplantation has gained attention internationally as a possible solution for the severe shortage of organs from cadaveric donors.1, 2 This procedure remains controversial, however, because of donor mortality and morbidity being higher than that in pediatric patients with the use of the left hepatic lobe.5 The decision-making processes of adult-to-adult LDLT also involve several psychosocial factors. Compared to child LDLT, in which patients' parents often make an immediate decision to save their children,6, 7 decision-making in adult-to-adult transplantation, which occurs between siblings or from child to parent, often involves familial conflict and struggle.8–13

Understanding the decision-making process from the donors' perspective is imperative for health care professionals to be able to develop a better-guaranteed process of informed consent and a more efficient psychosocial support system. Conceptual models can serve as a tool for health care professionals to understand a donor's preoperational experience as seen with living donor kidney transplantation.10, 12, 14, 15 However, these models cannot be applied directly to LDLT as the 2 procedures differ. Living donor kidney transplantation is an attempt to improve patient quality of life16 while LDLT serves as a “desperate remedy”:17 The patient will die if a donor is not found within a short period of time.18, 19 This study aims to construct a decision-making model of the psychological process leading up to donation in adult LDLT for a donor. As suggested by Crowley-Matoka7 and Walter et al.,20 we designed a qualitative study to investigate the process.


LDLT, living donor liver transplantation.



Participants consisted of donors who underwent a right lobe hepatectomy for LDLT at Kyoto University Hospital. As of 2004, approximately 35% of the <1000 LDLTs performed at this center were between adults.21 At the study site, donors were limited to either a spouse or a relative within the third degree, and over 20 years of age. Between April and December of 2003, a physician of the transplantation ward initially asked donors who met the following criteria to participate in the present study: (1) having recovered enough to tolerate an interview, (2) having no record of psychiatric disease, and (3) being a native Japanese speaker. Of the 25 donors who were asked to participate, 1 donor initially declined and 2 were unable to interview due to scheduling difficulties. Based on theoretical sampling,22 we selected a heterogeneous sample according to donor background (relationship with recipient, employment, length of time between knowing of LDLT and donation, recipient's disease). This study was approved by the Ethics Committee of the Kyoto University Graduate School of Medicine.

Data Collection

One of the authors (MF), a clinical psychologist who was not a member of the transplantation team, met with all donors (n = 22) who had given their verbal informed consent. A written explanation of the current study's objectives and procedures were provided to each donor, and written informed consent was obtained. Participant psychosocial attributes are shown in Table 1. The15 male and 7 female donors had an average age of 37.9 ± 10.1 years. The 11 male and 11 female recipients had an average age of 44.7 ± 14.3 years. Interviews were conducted after the operation (mean, 12.6 ± 5.2 days). Semi-structured interviews were carried out in a private room located within the hospital. Interviews lasted 48 minutes on average and ranged in duration from 20 to 77 minutes.

Table 1. Psychosocial Background of Donors and Recipients
CaseDonor's Relationship With RecipientEmploymentDuration Between Knowing of LDLT and SurgeryRecipientRecipient's Disease
  1. Abbreviations: HCC, hepatocellular carcinoma; HCV, hepatitis C virus; LC, Liver cirrhosis; HBV, hepatitis B virus.

1WifeUnemployed6 monthsHusbandAlcoholic cirrhosis
2FatherEmployed8 monthsSonBiliary atresia
3Brother (unmarried)Employed3 yearsBrotherHCC/HCV-LC
4Brother (married, with children)Employed8 monthsSisterPrimary biliary cirrhosis
5Son (unmarried)Employed3 monthsMotherHCC/HCV-LC
6HusbandEmployed1 yearsWifePolycystic liver and kidney
7Sister (married, with children)Self-supporting3 yearsSisterPrimary sclerosing cholangitis
8Son (unmarried)Unemployed4 monthsFatherHCC/HBV-LC
9Son (unmarried)Employed3 monthsMotherCholestatic LC
10Son (unmarried)Employed6 daysMotherFulminant hepatitis
11Brother (unmarried)Employed6 monthsBrotherHCC/HCV-LC
12MotherEmployed (part-time)10 yearsDaughterBiliary atresia
13Wife (not legally married)Self-supporting3 monthsHusbandHCC/HCV-LC
14Mother (divorced)Self-supporting4 yearsSonBiliary atresia
15Son (married, with children)Employed3 monthsMotherHCV-LC
16HusbandEmployed6 monthsWifePrimary biliary cirrhosis
17WifeUnemployed1 yearHusbandHCC/HBV-LC
18Son (unmarried)Employed7 monthsFatherAlcoholic cirrhosis
19Nephew (married, without child)Employed3 monthsUncleHCC/HBV-LC
20Brother (married, with children)Employed2.5 yearsBrotherHCV-LC
21FatherEmployed6 daysDaughterHepatic failure of unknown origin
22Daughter (unmarried)Employed9 monthsMotherHCC/HCV-LC

The interview guide was based on the results of a literature review and a study that the authors had previously conducted.23 Questions included how participants felt when they first learned of the need for transplantation, circumstances of conversation with family and recipient about who should be the donor, any doubt or anxiety leading up to the actual donation, and so forth (Table 2).

Table 2. Initial Set of Interview Questions
How did you learn of the LDLT procedure?
How did you feel when you first heard that your family member needed a transplantation?
How did the recipient react when you first decided to donate?
How did your other family members feel about your decision to donate?
Before making your decision, did you discuss your decision with the recipient and/or with other family members?
Were there any other candidates? How did you decide among yourselves?
How did you feel when you learned that you could actually become a donor after getting the test results?
Did you experience any anxiety, doubt, or concern?
How did you interpret the explanation given to you about the procedure?
How did you feel while waiting for the actual day of surgery?
How did you take care of your health once having decided to become a donor?
How did you feel right before surgery?
How did you spend your time right before surgery?

Data Analysis

Interview contents were transcribed verbatim and analyzed based on grounded theory.22 This method relies heavily on data and is recognized to be superlative for revealing the social interactive process. Analysis using open coding (identifying concepts in data), axial coding (relating categories to their subcategories), and selective coding (integrating and refining the theory) began after the first interview. Concepts explaining donors' decision-making processes were developed, and further data was collected for the verification and development of those concepts. Analysis continued interchangeably with interviews (constant comparative analysis) until theoretical saturation was reached.


Based on constant comparative analysis, we developed a model of donors' decision-making processes consisting of 5 stages: (1) recognition, (2) digestion, (3) decision-making, (4) reinforcement, and (5) resolution. The second and third stages differed from the fourth and fifth in a participant's psychological state. In the former stages, donors reached a decision having experienced anxiety and conflict; in the latter stages, they prepared for transplantation having experienced impatience and nervousness (Fig. 1). Underlying the entire decision-making process was a central theme: a perceived reality of “having no choice.”

Figure 1.

Features of the decision-making model of “having no choice.”

Central Theme: “Having No Choice”

Participants described a reality of having no choice. Becoming a donor was not a decision but rather the “only decision.” This theme informed the entire decision-making process and was further delineated into 4 codes: (1) priority of life, (2) only LDLT, (3) for family, and (4) only me.

“Priority of life” described a candidate's perception that he or she should prioritize the recipient's life over all else and, therefore, should be willing to pay a sacrifice.

“Only LDLT” depicted a donor's understanding that there exists no other means of saving a recipient's life besides LDLT. In Japan, there have been only 37 cases of organ transplantation from brain-dead donors since 1997, when the Organ Transplant Law was passed.24 As one participant stated, “it is like winning the lottery.” Drug therapy merely sustains a recipient's life and is not regarded as an alternative therapy.

“For family” described the thought that one would give all that is in his or her power for his or her family. For adult donors, one's “family” often meant one's immediate family. Subsequently, the experience of a donor whose recipient is a parent, sibling, or distant relative is likely to be more complicated than that of a donor whose recipient is his or her immediate family member.

“Only me” depicted an awareness that one was the only candidate eligible to donate and save the recipient. This awareness was based not only on medical reasons, but also on a participant's subjective understanding that he or she was the only one: “It is best for a parent to help their child.”

Although the reality of having no choice existed as a psychological burden, it concurrently motivated each participant to donate. For instance, one male participant said, “If another option were available, of course, I would have chosen it” (“only LDLT”). Others indicated that they would have not donated if the circumstances were not so emergent (“priority of life”), if it were not for family (“for family”), and/or if somebody else could have become a donor (“only me”). The four codes were applied to each step of the decision-making process for those who felt they had no choice.

Stage 1: Recognition

The decision-making process began soon after a participant recognized that they had no choice. Often participants determined that they had no choice without ever having visited the transplantation center. Several participants first learned of LDLT from the recipient, family, or physician who initially saw the recipient. Others learned of LDLT through the media (e.g., books, internet) when they tried to find a way to save a loved one.

It was at this point when participants first realized that they were to become the designated donor. The following candidates were usually omitted when more than 1 existed within the family: those with an unfit blood type, those with presence of disease or who carried a high risk of disease, the mother of an infant, the breadwinner of the household, the elderly, and the young. Young single women were often excluded not only because of their possibility of pregnancy but also because being physically unscarred is traditionally symbolic of maidenhood. When several candidates existed, “only me” seemed to no longer apply. However, participants usually foresaw that they would become the donor if test results show their compatibility.

A participant's recognition of having no choice did not necessarily mean that one understood or realized the consequences of his or her decision. Participants sometime saw LDLT as “something you see on television” and had no real knowledge of the actual procedure: “At first, I thought it would be like taking an appendix off.” Many passed through this stage and only later gained an accurate understanding of the risks and expenses of LDLT.

Stage 2: Digestion

Having had no choice, participants began to consider all possible outcomes that their decision could yield. Some of them realized the seriousness of LDLT, became anxious and/or concerned, and tried to convince themselves that LDLT was the only option. Others attempted to collect additional information prior to making a decision. These were all attempts to gain control over the situation and to digest the reality of having no choice.

During this stage, donor candidates considered the benefits of donation, including saving a recipient's life, relieving a recipient's suffering, and contributing to the welfare of the family. A fraction of participants were motivated to donate by a desire to avoid the guilt and criticism of others: “Most likely, people would see that person [who did not donate] as the one who killed the patient.”

At the same time, participants considered the costs of donation, including the risk of death, complications and/or hospitalization, the need to take a temporary leave from one's job, economic struggle, and an imposed burden on one's immediate family. The possibility that LDLT could be unsuccessful also caused several participants to feel doubtful.

Participants who considered the benefits larger than the costs passed through this stage without hesitance: “If I donated, I would save my brother, so I guess there was no room at that point to think about something like work.” On the other hand, candidates who elicited ambivalence took time to pass through this stage. Some struggled with having to weigh the benefits and costs; others felt pressure to avoid guilt and criticism: “Everyone is human; no one thinks only of other people. I thought of the pain and scars, or even worse.” Once a participant accepted their reality of having no choice, they were ready to make a decision.

Stage 3: Decision-making

Participants decided in a variety of ways. The majority of participants took a chance on the hope of saving a loved one: “It would just have been a matter of time before [my husband] died without the transplant. With this understanding, I decided to take the gamble.” Others were driven by a sense of mission that often led to an underestimation of risks, either conscious or unconscious.

Many participants decided once family, friends, and/or health care professionals relieved their anxiety and conflict. For example, when anxiety was a result of insufficient medical knowledge, a thorough explanation by the attending physician combined with a positive test result often provided comfort, confidence, and the capability to decide. What seemed like coercion from a third person's perspective was sometimes considered encouragement from a participant's perspective. We named this perception “quasi-coercion”:“Anxiety certainly existed, and just when I was considering the fear in it all, [the recipient] said, ‘So are you just going to let me die?’ When I heard this, I realized it was only a parent who could save their child.”

Some participants felt obliged to donate when test results showed that they were the most suitable candidate. Participants who were passive toward donation decided at the last minute, when the recipient's condition began to deteriorate. The psychological pressure that the recipient would die if one did not become a donor stimulated a decision as well: “It was not like I could say no.… I was unable to say not even as a joke.” In all, participants often decided with a myriad of emotions, when “both a sense of mission and pressure existed.”

Stage 2 to 3: Reaching a Decision; Anxiety and Conflict

Stages 2 to 3 can be summarized as a psychological state of “reaching a decision.” Participants did not go directly from Stage 2 to Stage 3, but rather vacillated between these 2 stages, experienced a variety of anxiety and conflict and eventually made a decision.

Anxiety and conflict were prevalent throughout Stages 2 and 3; the degree ranged from fleeting anxiety related to the procedure to internal and/or familial conflicts. Participants rarely had an opportunity to express their anxiety and conflict since they assumed it would hurt the patient, cause family concern, and possibly result in the medical staff's canceling the procedure. Proper support by family, friends, and medical staff eased donors' feelings; otherwise, unexpressed fear and concern became a constant weight on donors' minds, and some of them took it out on their families and/or spouses. In all, the greater the anxiety and conflict, the longer a donor candidate fluctuated between Stage 2 and Stage 3.

Stage 4: Reinforcement

Participants who arrived at a decision would then subsequently reinforce it psychologically. Once they confirmed that there was no choice, donors would want to go ahead with surgery: “I believe the turning point was when the test confirmed my eligibility. After that, I had my mind set on donating.”

Participants also tried to take responsibility in their decisions. Reversing their decision meant going back on their word and disappointing the recipient and family. When the candidates who had reached this stage learned of their eligibility to be donors, they usually expressed feelings of relief and joy.

This shift in a participant's psychology catalyzed several other behavioral changes. Most donors began to change their lifestyle habits for the better (e.g., quitting smoking, no alcohol, proper diet, increased exercise). They believed that an improvement in their state of health would not only lead to a better prognosis for the recipient, but also would help them to recover. Participants began to make preparations for their hospitalization both at work and home (e.g., handing over duties to colleagues, arranging for insurance).

Some participants at this stage tried to convince recipients, whom showed reluctance in hurting a loved one, that LDLT was the right choice and that they should accept the offer. Also, they would deny any opposition to their decisions and would disregard any feelings of uncertainty or anxiety: “I didn't really think that I would become sick as a result of complications.” One month after we began this study, the first LDLT donor death in Japan was reported.25, 26 Despite this news, 1 donor expressed the following: “[Physicians] are probably being even more precautious now than before in order to prevent another misfortune like this one from happening. So, that was probably the best time [to become a donor].”

Thus, for participants at this stage, information on risks provided at the transplantation center was no longer a factor in their decision. In all, this stage of reinforcement described a motivation to donate and included a psychological defense mechanism to overcome internal conflict and anxiety.

Stage 5: Resolution

Resolution denoted various meanings such as preparedness, resignation, and/or acceptance of donation. This state of mind was particularly apparent as surgery approached. At the present center, the schedule was confirmed one week before the procedure and candidates were hospitalized for the following day. For instance, 1 participant expressed his full acceptance of having become a donor: “Until actually entering the operation room, I did not think of anything. I didn't have any anxiety; all I thought was that there was no other option.”

Others resigned themselves to the fact that, “once you had come this far, there was nothing you could do about it” or “what will happen will happen.” To explain this state of mind, many participants used the idiom “manaita no koi,” which depicts a koi carp lying on a cutting board just waiting to be cut open, a state of being unable to escape from another's control. Others felt it up to the heavens—“All I could do was pray for success”—while some resigned themselves to fate: “For the time being, I just had to do it and that was it.”

A few expressed their anxiety and inability to sleep the night before surgery. Yet participants expressed that the anxiety and sleeplessness were due not to a lack of acceptance but rather to never having been hospitalized and never having undergone surgery. Overall, it was usually rare for candidates to doubt their decision to donate: “It was inevitable at this point.”

Stage 4 to 5: Facing Transplantation: Impatience and Nervousness

Stages 4 and 5 illustrate the psychological process of “facing transplantation.” Participants did not commit to transplantation by going directly from Stage 4 to Stage 5. Rather, they fluctuated between these 2 stages and, while experiencing impatience and nervousness, finally underwent surgery.

It was rare for participants to turn back from “facing transplantation” to “reaching a decision.” Once they had decided, “there (was) no return.” This did not mean that candidates no longer experienced anxiety, but rather that donors no longer felt, or at least tried not to feel, doubt.

Impatience and nervousness were prevalent in this state of facing transplantation. Participants became irritated with a prolonged waiting period (e.g., the transplantation center was not able to confirm a day for surgery). To maintain commitment to donation and to a healthy lifestyle, fighting against “a sometimes overwhelming” fear was both mentally and physically straining. Recipients' deterioration also became a concern. Several participants were unable to stand this uncertainty and complained that “I had the feeling of ‘let’s hurry up and just cut me open.' Anything was better than just having to wait.” Other participants started drinking and smoking again to ease their strain and failed to maintain their healthy habits. Without a specific date being set for surgery, candidates were left with having to reschedule their work, which also led to additional restlessness. As a result, some expressed anger and complained to transplantation coordinators. Many felt that support from family and friends and understanding from one's boss and colleagues were significant.

Participants often became nervous as surgery approached. The seriousness of LDLT, which may have not been fully recognized up until this point, was now realized, bringing a plethora of other emotions (e.g., fear of surgery). “At first, I didn't think it was such a big deal. But once the day grew closer, I began to realize the weight of the matter. It was overbearing, and there was a lot of fear as well. And it kept increasing. It was quite hard.” This nervousness was often relieved by family, friends, and medical staff. In cases where there was insufficient support, this nervousness persisted and often increased.


The decision-making model of “having no choice” provides a new perspective on understanding adult LDLT donors' experiences leading up to organ transplantation. This model consisted of 2 features. The first feature was a 5-step psychological progression: (1) recognition, (2) digestion, (3) decision-making, (4) reinforcement, and (5) resolution. This model can help to explain previous decision-making models for living donor kidney transplantation.10, 12, 14, 15 For instance, Simmons et al.10 proposed 3 forms of donors' decision-making: (1) moral decision-making model—volunteering immediately after hearing of the need; (2) model of deliberation—deliberating and/or seeking information before commitment; and (3) postponement model—postponing the final step that commits one to donation. However, each model categorizes donors' decision-making patterns and delineates only the psychological process described between Stage 2 and 3 in this study's model.

The second feature of this model was a series of 4 codes that comprised a donor's perception of having no choice: (1) priority of life, (2) only LDLT, (3) for family, and (4) only me. While previous studies on living donor kidney transplantation and adult-to-child LDLT have reported similar results including “the only option”27 and “the total lack of choice,”28 these studies do not describe the conditions for having no choice. It is possible that a candidate may reject donation in the absence of any one of the 4 conditions.

Clinical Implications

This study has several implications for clinical practice in LDLT. Health care professionals can provide donor candidates with effective support by using our model to know which stage the candidate is in. In Stage 1, donors tried to make a decision without any information about surgical risks or costs as soon as they learned of LDLT. As Lennerling et al.27 reported, the decision-making process had started long before the candidate visited the transplantation center and received any information. A lack of information also was found to instill fear in several participants. Information about the surgical procedure and self-help groups should be widely available, for instance, through the home page of a transplantation center. Then the recipient, his or her family (including a donor candidate, and even the primary care physician he or she first visited could easily access the information at the early stage of the decision-making process.

Participants tended to experience the most anxiety and conflict when going through Stages 2 to Stage 3. However, the majority of them were unable to express their anxiety and conflict out of consideration for the recipient and his or her family, or out of concern that the transplantation could be cancelled. Donor candidates at these stages are those who most need psychosocial support to cope with “having no choice” process. Even candidates who had decisively visited a transplantation center sometimes experienced feelings of doubt and conflict after they learned the involved risks from health care professionals. Health care professionals should provide support such as counseling with a psychologist and/or social worker when candidates seem to be in these stages. Although the present study did not conduct interviews on individuals who decided not to donate, it is preferable to provide such support to help deal with candidates' guilt, which is experienced when hurting a family member or when a recipient dies.

In Stages 4 to 5, participants occasionally had bursts of anger at transplantation coordinators. Donors' frustration reached the highest point due to impatience caused by rescheduling tests and increased nervousness as surgery day nears. When dealing with donors at these stages, health care professionals need to understand the feelings of restlessness and nervousness behind their anger and help them to express these emotions.

For donors who participated in this study, donation was the only decision. Previous reports have emphasized the significance of informed consent in adult-to-adult transplantation.7, 23 However, as this study has highlighted, there exist several psychological constraints that make refusal to donate difficult. Discussions on informed consent have derived from the idea of respecting patient autonomy: to decide one's treatment after receiving a sufficient explanation. Can donors properly participate in the process of informed consent having been merely informed? In a decision-making process without any other (perceived) options, can donors truly exercise their autonomy? This study's findings underline the need for a reevaluation of informed consent in the area of transplantation.

Cultural Considerations

This study also resulted in several interesting findings related to culture. Young and single women were omitted from candidacy partly because an uninjured body is symbolic of maidenhood in Japanese culture. Simmons et al.15 reported that a family from India had excluded 1 brother as a potential donor because his arranged marriage agreement with the bride's family assumed the groom to be in perfect health. Further studies from other nations are needed in order to examine whether omitting the young from candidacy for reasons of marriage and/or maidenhood is common in other cultures.

The present study found “for family” to be a strong motive behind participants' decisions to donate. De Villa, Lo, and Chen29 explained that a strong family relationship among Eastern cultures is a factor for the increase in LDLT among Asian nations. Another study reported that Chinese and Indo-Canadians make a straightforward decision without conflict.12 We found that participants would have not committed to such a huge sacrifice if it were not for family. A fraction of participants elicited a slight reluctance to accept an organ from an anonymous brain-dead donor. The Japanese concept of family associated with transplantation may be a factor behind why intra-family LDLT is spreading in Japan while there continues to be a persistent lack of cadaveric donors. However, is familial affection a significant cause for the prolific use of LDLT in Japan? Further research is needed to explore these issues.


Because this study did not interview nondonors who initially were candidates, the psychological process of nondonors remains unclear. An investigation of nondonors could further clarify the familial conflict inherent to donor selection.8, 9 All interviews were conducted an average of 12 days after surgery. Interviews could lead to different results if conducted before surgery or once the recipient's prognosis was clear. However, interviews conducted immediately postsurgery provided data unaffected by a recipient's prognosis or by the donor's presurgery anxiety. Donors' memories were also still fresh.

In conclusion, the model of “having no choice” describes the psychological process of donors' decision-making in LDLT. This study's framework serves as an essential tool for health care professionals to understand a donor's experience and, based on that understanding, to provide sufficient support to the donor. Ultimately, development of a psychological and social support system for transplantation could improve treatment quality in transplantation medicine.