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Influence on family psychodynamics on spousal kidney transplantation
Influence on Family Psychodynamics on Spousal Kidney Transplantation T. Watanabe and S. Hiraga
L
IVING donor kidney transplantations are common in Japan, because there are few cadaveric donors.1 Married couples occasionally hope for a spousal kidney transplantation when the patient’s kin cannot be donors. This interest has led to discussions regarding the grounds for approving spousal kidney donors.2– 6 In the past, there have been social problems when patients contracted with paid money to donors. Spousal kidney transplants are currently performed about 20 times per year. The psychological changes are considered here from the viewpoint of family psychodynamics in two cases of spousal kidney transplantation. The influence of family relations on the selection of spousal donors is described. METHOD After the kidney transplant was performed and one year had passed, a psychiatrist evaluated the family psychodynamics of two couples who had undergone spousal donation.7,8 Individual interviews were performed for one hour with the donor or the recipient, and a two-hour joint interview with donor and recipient. Five kinds of psychological tests (SCT, CAS, 16PF, PF-study, Rorsch) were conducted. The family diagnosis scheme of N.W.Ackerman9 was applied to evaluate psychodynamics.
CASE 1 (1) Mr A: Recipient, Mrs A: Donor
Mr A is the eldest of two brothers. After he had graduated from university, he became an employee in a first class bank. He did not take care of his health. He worked hard and kept late hours. He enjoyed companionship with a wide range of people. He went to karaoke and the pub till a late hour every day after work. On the other hand, his wife was born the eldest of two daughters. She concentrated on being a full-time housewife, and raised three children. The wife believed that her concentration on bringing up children and doing housework made the family happy. Her ideal was to be a good wife and a wise mother. Mr A was diagnosed as a diabetic at age 45 years. He continued overworking, and kept an optimistic attitude. However, he received urgent dialysis due to acute renal failure at age 50. He thought, “It is no use remaining alive” and entered a depressed state, taking a pessimistic view of the future. However, after learning about the possibility of
obtaining a kidney transplant, he came to think that transplantation would make him return to the first tier of business. He idealized the possible benefits of kidney transplantation. His son was still a freshman at university when the patient began to receive dialysis. His wife had considered economic reasons to support the idea of kidney transplantation and stated, “My husband wants to keep working until our son graduates from the university.” The wife took the husband to the dialysis room, and waited for him. She considered this to be her natural role as his wife. She became sad as she thought of the changes that had come over her formerly energetic husband. Mr A consulted with his younger sister about organ donation. The transplant was refused because of opposition from her husband and child. Next, he consulted with his wife, who had the same blood type as his own. The married couple was told to visit the transplant medical doctor, and to keep up their hope. The examination was performed, and their ABO and HLA types were compatible. At that time, the wife held a fatalistic feeling regarding her husband. The children supported their parents’ determination. The married couple thought that they would be able to escape the psychological pain of dialysis by undergoing the transplant, and return to life as it was before. Later, the transplant was approved by the ethics committee at the facility, and the operation was performed successfully. The wife expressed her gratitude to us for being able to return to her life as it had been before, thereby increasing her happiness. The husband now goes to the company twice a week. CASE 2 (2) Mr B: Donor, Mrs B: Recipient
Mr B is 48 years old, he is the fourth born among eight siblings, the second son. He succeeded in the family business and was managing manufacturing and sales of a From the All Japan Federation of Social Insurance, Mishima Hospital, Mishima, Japan. Address reprint requests to S. Hiraga, All Japan Federation of Social Insurance, Mishima Hospital, 2276 Azafujikubo Yata, Mishima Shinzuoka 411-0801, Japan. E-mail: mishib29@pmet. or.jp
© 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0041-1345/02/$–see front matter PII S0041-1345(02)02811-7
Transplantation Proceedings, 34, 1145–1147 (2002)
1145
1146
Japanese-style confectionery. He graduated from a toprated college and was hoping to find employment in a trading firm. His elder brother did not succeed in the family business, and Mr. B looked after his parents. His elder brother and an elder sister had forced their opinions on him since he was young. He had grown up thinking that it is his role in the family to listen to what his elder brothers say. On the other hand, Mrs B is four years older than her husband, the third of six siblings, the second daughter. Her father was an elderly farmer, and she had a severe upbringing. She helped keep house when she was young and lived at home. She was a sympathetic and bright woman, and had an outlook that she expressed as: “Married couples live by cooperating.” She managed the family business with her husband and took care of her mother-in-law. Five years after Mrs B married, her mother-in-law died. Afterwards, she lived with her three children and her husband. Mrs B underwent an operation for breast cancer at age 30 years and suffered from chronic renal failure at age 40 years. She was introduced to dialysis at age 43 years. Mr and Mrs B concentrated on the family business in the daytime and went out for the dialysis at night time. Such a life style caused the married couple emotional distress. Mrs B cried in front of her husband every evening. Mr B expressed the wish: “I want to help my wife” whenever he saw Mrs B. Mrs B consulted with her sisters about the possibility of a kidney transplant. Their husbands opposed this idea, and the organ donations were refused. It was unpleasant for Mr B to be indebted to others, so he thought to offer his kidney to his wife. They hoped to obtain a transplant between married couples and inquired at several different hospitals. Our hospital was consulted by their physician. The proposal for a transplant between married couples was examined by the ethics committee, and it was approved. Mr B thought of the donated kidney as a “compensation to my wife for her hardship.” Mrs B felt that the kidney was “an important present” from her husband. After the transplantation, they have lived with the purpose of maintaining the transplanted kidney for as long as they can. After one year, they say that the kidney transplantation has led to a strengthening of their marriage bonds. IMPLICATIONS OF THIS STUDY
Approximately 700 kidney transplants per year are carried out in Japan4 and available donors cannot meet the transplant needs of the 15,000 dialysis candidates. Very few cadaveric organs are offered, and this number is overwhelmingly small, compared with Europe and America.5,6 Therefore most Japanese patients must rely on living donors for kidney transplantation. However, organ donation becomes difficult when there is opposition among the donor family, even if a donor exists who is appropriately HLA matched with recipient. There are about 20 examples per year of transplants between married couples in Japan.4,7 The kidney transplant rate between non-kin in the United States is tending to increase, because of prolonged waiting
WATANABE AND HIRAGA
periods to obtain cadaveric organs. Reports of kidney transplants among non-kin are seen occasionally in the United States.13–16 However, the present report is the first treatment of this subject that covers family psychodynamics and the viewpoints of both donors and recipients. Family psychodynamics
In the value system of the married couple in case 1, the husband’s role was to work, and his wife’s role was to do housework and provide childcare. This married couple has had a stable life in which the wife has supported the social activities of the husband. Their views on their respective roles in the marriage were held in common, and they had significant complementarities and identified strongly as a married couple. This couple dealt appropriately with changes and challenges, and this stability meant that large issues were not raised even as they went through a variety of life events such as the kidney removal, the husband’s job change, and the introduction of dialysis. The organ was offered by a devoted wife to regain the social relations of the husband. The kidney transplant was performed, and the life changes due to the transplantation were accommodated well because of the couple’s complementarities. The married couple in case 2 had a common sense of values and identified with common targets: “success in the family business” and “patience is important.” This married couple supplemented each other’s roles at business and at home. Their complementarity is high, as indicated by their mutual respect. Moreover, their stability is high, as reflected by their appropriate actions at life events such as the mother-in-law’s death, the children’s births, the wife’s breast cancer, and introduction to dialysis. The spousal kidney transplantation was performed for similar reasons as in the previous case, ie, with a goal of discontinuing dialysis and regaining a more stable life. The complementarity of the husband and wife contributed to the success of the operation. The organ donation was experienced by the husband as “the wife’s compensation for her hardship,” and the wife considered the donation of an organ from her husband to be an “important present.” The married couple in each case made the maintenance of the kidney function a family purpose. This common purpose seems to contribute favorably to the survival of the patient. Family psychodynamics of spousal kidney transplantation
The kidney transplantation became a common purpose to the married couples. Spousal kidney transplantation was recommended in these two cases so that the patients and their families could acquire greater happiness. The patients and their spouses had both economic and psychological burdens related to the introduction of dialysis. Therefore, achieving independence from dialysis was a common purpose of these married couples. Carrying out a spousal kidney transplantation meant that the married couples solved their problem without borrowing from other families’ resources. It led to stability of the nuclear family and to support among relatives of the married couple.
SPOUSAL KIDNEY TRANSPLANTATION
It can be considered that kidney transplant is a complementary act undertaken in order to improve a married couple’s happiness from the viewpoint of family psychodynamics. Two spousal kidney transplantations were approved based on the married couple’s complementarity. Big changes were not seen in the family psychodynamics after the transplants, and the family relations were even steadier after the transplant than they were before. Thus, complementarity is an important element in maintaining a married couple’s functionality. An organ donation from an individual to a complementary spouse will contribute to the stability of the marriage. A second point is that spousal kidney transplantation does not require involvement of the extended family. In transplantations between kin, for instance when an organ is donated by an adult brother, this is usually contrary to the wishes of the spouse and family of the donor. The spouse of the donor becomes passive to the organ donation and experiences a new burden of uneasiness, related to the operation, and the realization that the donor now has only one kidney. When the organ is offered by the extended family, the spouse of the recipient can easily hold various feelings related to a sense of “indebtedness” to the donor.11 Spousal kidney transplantation has the advantage of initiating little psychological conflict between extended families. A third point is that spousal kidney transplantation leads to a strengthening of the marital bond. The recipients are counseled during the admission process for the operation, and they learn details of what their life will be like after the transplantation. When the spouses are hospitalized together for the transplantation, they gain self-knowledge and must consider the life they will continue to share as a married couple. To maintain optimal kidney function, the married couple straightens out their living conditions, and this makes their marital bond strong. Problems Associated With Spousal Kidney Transplantation
There were no problems with motivation, mutual agreement to the transplant, or changes in family psychodynamics after kidney transplantation in these two cases. However, there is a general preconceived notion that various psychological problems will accompany transplantation be-
1147
tween married couples. First, “pathological family psychodynamics” might be suspected when the spouse becomes a donor. For instance, a weak wife might become a donor as a “sacrifice for the family,” and may be compulsorily chosen. The wife may then deprive her husband’s mother of her husband. Second, the spouse who hopes to become a donor might have a “neurotic motivation.” For instance, the spouse may experience guilt that comes from fickleness, etc., and may be motivated by masochistic feelings and a desire for punishment. After transplantation, various psychological conflicts can be activated, if these feelings motivate married couples. Moreover, if the transplant fails, the recipient may experience strong guilt. There is a possibility that the organ donation is related to the “guarantee” problem and the married couple can fall into the crisis of divorce. It is important to have a psychiatrist participate with the transplant team to deal with any psychological problems related to spousal kidney transplantation. The psychiatrist evaluates potential or actual psychiatric problems of both donor and recipient, as well as family psychodynamics and the psychological backgrounds that are behind the motivations for donation. The psychiatrist can then make an informed prediction as to the changes in family psychodynamics that may follow the transplantation.10,11,12 REFERENCES 1. Ota K, Hinotsu S, Kawado M, et al: Clin Transp 1:375, 2000 2. Levy AS, Hou S, Bush HL Jr: N Engl J Med 31:914, 1986 3. Suzuki MM, Cecka JM, Terasaki PI: Br Med Bull 53:854, 1997 4. Terasaki PI, Cecka JM, Gjertson DW, Cho YW: Clin Transpl: 269, 1997 5. Gjertson DW, Cecka JM: Kidney Int 58:491, 2000 6. Cecka JM: Annu Rev Med 51:393, 2000 7. Hiraga S, Watanabe J, Kitamura M, et al: Transplant Proc 24:1320, 1992 8. Hiraga S, Kakuta T: Transplant Proc 24:2059, 1992 9. Ackerman NW: Psychodynamics of Family Life. Jason Aronson paperback 1995 10. Surmon MD: Am J Psychiatry 146:972, 1989 11. Abram HS: Renal transplantation in Masschusetts General: In: Hackett TP, Cassem NH (eds): Hospital Handbook of General Hospital Psychiatry, 2nd ed. Littleton, Mass: PSG; 1986, p 12. Owen SS: Am J Psychiatry 146:972, 1989
L
IVING donor kidney transplantations are common in Japan, because there are few cadaveric donors.1 Married couples occasionally hope for a spousal kidney transplantation when the patient’s kin cannot be donors. This interest has led to discussions regarding the grounds for approving spousal kidney donors.2– 6 In the past, there have been social problems when patients contracted with paid money to donors. Spousal kidney transplants are currently performed about 20 times per year. The psychological changes are considered here from the viewpoint of family psychodynamics in two cases of spousal kidney transplantation. The influence of family relations on the selection of spousal donors is described. METHOD After the kidney transplant was performed and one year had passed, a psychiatrist evaluated the family psychodynamics of two couples who had undergone spousal donation.7,8 Individual interviews were performed for one hour with the donor or the recipient, and a two-hour joint interview with donor and recipient. Five kinds of psychological tests (SCT, CAS, 16PF, PF-study, Rorsch) were conducted. The family diagnosis scheme of N.W.Ackerman9 was applied to evaluate psychodynamics.
CASE 1 (1) Mr A: Recipient, Mrs A: Donor
Mr A is the eldest of two brothers. After he had graduated from university, he became an employee in a first class bank. He did not take care of his health. He worked hard and kept late hours. He enjoyed companionship with a wide range of people. He went to karaoke and the pub till a late hour every day after work. On the other hand, his wife was born the eldest of two daughters. She concentrated on being a full-time housewife, and raised three children. The wife believed that her concentration on bringing up children and doing housework made the family happy. Her ideal was to be a good wife and a wise mother. Mr A was diagnosed as a diabetic at age 45 years. He continued overworking, and kept an optimistic attitude. However, he received urgent dialysis due to acute renal failure at age 50. He thought, “It is no use remaining alive” and entered a depressed state, taking a pessimistic view of the future. However, after learning about the possibility of
obtaining a kidney transplant, he came to think that transplantation would make him return to the first tier of business. He idealized the possible benefits of kidney transplantation. His son was still a freshman at university when the patient began to receive dialysis. His wife had considered economic reasons to support the idea of kidney transplantation and stated, “My husband wants to keep working until our son graduates from the university.” The wife took the husband to the dialysis room, and waited for him. She considered this to be her natural role as his wife. She became sad as she thought of the changes that had come over her formerly energetic husband. Mr A consulted with his younger sister about organ donation. The transplant was refused because of opposition from her husband and child. Next, he consulted with his wife, who had the same blood type as his own. The married couple was told to visit the transplant medical doctor, and to keep up their hope. The examination was performed, and their ABO and HLA types were compatible. At that time, the wife held a fatalistic feeling regarding her husband. The children supported their parents’ determination. The married couple thought that they would be able to escape the psychological pain of dialysis by undergoing the transplant, and return to life as it was before. Later, the transplant was approved by the ethics committee at the facility, and the operation was performed successfully. The wife expressed her gratitude to us for being able to return to her life as it had been before, thereby increasing her happiness. The husband now goes to the company twice a week. CASE 2 (2) Mr B: Donor, Mrs B: Recipient
Mr B is 48 years old, he is the fourth born among eight siblings, the second son. He succeeded in the family business and was managing manufacturing and sales of a From the All Japan Federation of Social Insurance, Mishima Hospital, Mishima, Japan. Address reprint requests to S. Hiraga, All Japan Federation of Social Insurance, Mishima Hospital, 2276 Azafujikubo Yata, Mishima Shinzuoka 411-0801, Japan. E-mail: mishib29@pmet. or.jp
© 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0041-1345/02/$–see front matter PII S0041-1345(02)02811-7
Transplantation Proceedings, 34, 1145–1147 (2002)
1145
1146
Japanese-style confectionery. He graduated from a toprated college and was hoping to find employment in a trading firm. His elder brother did not succeed in the family business, and Mr. B looked after his parents. His elder brother and an elder sister had forced their opinions on him since he was young. He had grown up thinking that it is his role in the family to listen to what his elder brothers say. On the other hand, Mrs B is four years older than her husband, the third of six siblings, the second daughter. Her father was an elderly farmer, and she had a severe upbringing. She helped keep house when she was young and lived at home. She was a sympathetic and bright woman, and had an outlook that she expressed as: “Married couples live by cooperating.” She managed the family business with her husband and took care of her mother-in-law. Five years after Mrs B married, her mother-in-law died. Afterwards, she lived with her three children and her husband. Mrs B underwent an operation for breast cancer at age 30 years and suffered from chronic renal failure at age 40 years. She was introduced to dialysis at age 43 years. Mr and Mrs B concentrated on the family business in the daytime and went out for the dialysis at night time. Such a life style caused the married couple emotional distress. Mrs B cried in front of her husband every evening. Mr B expressed the wish: “I want to help my wife” whenever he saw Mrs B. Mrs B consulted with her sisters about the possibility of a kidney transplant. Their husbands opposed this idea, and the organ donations were refused. It was unpleasant for Mr B to be indebted to others, so he thought to offer his kidney to his wife. They hoped to obtain a transplant between married couples and inquired at several different hospitals. Our hospital was consulted by their physician. The proposal for a transplant between married couples was examined by the ethics committee, and it was approved. Mr B thought of the donated kidney as a “compensation to my wife for her hardship.” Mrs B felt that the kidney was “an important present” from her husband. After the transplantation, they have lived with the purpose of maintaining the transplanted kidney for as long as they can. After one year, they say that the kidney transplantation has led to a strengthening of their marriage bonds. IMPLICATIONS OF THIS STUDY
Approximately 700 kidney transplants per year are carried out in Japan4 and available donors cannot meet the transplant needs of the 15,000 dialysis candidates. Very few cadaveric organs are offered, and this number is overwhelmingly small, compared with Europe and America.5,6 Therefore most Japanese patients must rely on living donors for kidney transplantation. However, organ donation becomes difficult when there is opposition among the donor family, even if a donor exists who is appropriately HLA matched with recipient. There are about 20 examples per year of transplants between married couples in Japan.4,7 The kidney transplant rate between non-kin in the United States is tending to increase, because of prolonged waiting
WATANABE AND HIRAGA
periods to obtain cadaveric organs. Reports of kidney transplants among non-kin are seen occasionally in the United States.13–16 However, the present report is the first treatment of this subject that covers family psychodynamics and the viewpoints of both donors and recipients. Family psychodynamics
In the value system of the married couple in case 1, the husband’s role was to work, and his wife’s role was to do housework and provide childcare. This married couple has had a stable life in which the wife has supported the social activities of the husband. Their views on their respective roles in the marriage were held in common, and they had significant complementarities and identified strongly as a married couple. This couple dealt appropriately with changes and challenges, and this stability meant that large issues were not raised even as they went through a variety of life events such as the kidney removal, the husband’s job change, and the introduction of dialysis. The organ was offered by a devoted wife to regain the social relations of the husband. The kidney transplant was performed, and the life changes due to the transplantation were accommodated well because of the couple’s complementarities. The married couple in case 2 had a common sense of values and identified with common targets: “success in the family business” and “patience is important.” This married couple supplemented each other’s roles at business and at home. Their complementarity is high, as indicated by their mutual respect. Moreover, their stability is high, as reflected by their appropriate actions at life events such as the mother-in-law’s death, the children’s births, the wife’s breast cancer, and introduction to dialysis. The spousal kidney transplantation was performed for similar reasons as in the previous case, ie, with a goal of discontinuing dialysis and regaining a more stable life. The complementarity of the husband and wife contributed to the success of the operation. The organ donation was experienced by the husband as “the wife’s compensation for her hardship,” and the wife considered the donation of an organ from her husband to be an “important present.” The married couple in each case made the maintenance of the kidney function a family purpose. This common purpose seems to contribute favorably to the survival of the patient. Family psychodynamics of spousal kidney transplantation
The kidney transplantation became a common purpose to the married couples. Spousal kidney transplantation was recommended in these two cases so that the patients and their families could acquire greater happiness. The patients and their spouses had both economic and psychological burdens related to the introduction of dialysis. Therefore, achieving independence from dialysis was a common purpose of these married couples. Carrying out a spousal kidney transplantation meant that the married couples solved their problem without borrowing from other families’ resources. It led to stability of the nuclear family and to support among relatives of the married couple.
SPOUSAL KIDNEY TRANSPLANTATION
It can be considered that kidney transplant is a complementary act undertaken in order to improve a married couple’s happiness from the viewpoint of family psychodynamics. Two spousal kidney transplantations were approved based on the married couple’s complementarity. Big changes were not seen in the family psychodynamics after the transplants, and the family relations were even steadier after the transplant than they were before. Thus, complementarity is an important element in maintaining a married couple’s functionality. An organ donation from an individual to a complementary spouse will contribute to the stability of the marriage. A second point is that spousal kidney transplantation does not require involvement of the extended family. In transplantations between kin, for instance when an organ is donated by an adult brother, this is usually contrary to the wishes of the spouse and family of the donor. The spouse of the donor becomes passive to the organ donation and experiences a new burden of uneasiness, related to the operation, and the realization that the donor now has only one kidney. When the organ is offered by the extended family, the spouse of the recipient can easily hold various feelings related to a sense of “indebtedness” to the donor.11 Spousal kidney transplantation has the advantage of initiating little psychological conflict between extended families. A third point is that spousal kidney transplantation leads to a strengthening of the marital bond. The recipients are counseled during the admission process for the operation, and they learn details of what their life will be like after the transplantation. When the spouses are hospitalized together for the transplantation, they gain self-knowledge and must consider the life they will continue to share as a married couple. To maintain optimal kidney function, the married couple straightens out their living conditions, and this makes their marital bond strong. Problems Associated With Spousal Kidney Transplantation
There were no problems with motivation, mutual agreement to the transplant, or changes in family psychodynamics after kidney transplantation in these two cases. However, there is a general preconceived notion that various psychological problems will accompany transplantation be-
1147
tween married couples. First, “pathological family psychodynamics” might be suspected when the spouse becomes a donor. For instance, a weak wife might become a donor as a “sacrifice for the family,” and may be compulsorily chosen. The wife may then deprive her husband’s mother of her husband. Second, the spouse who hopes to become a donor might have a “neurotic motivation.” For instance, the spouse may experience guilt that comes from fickleness, etc., and may be motivated by masochistic feelings and a desire for punishment. After transplantation, various psychological conflicts can be activated, if these feelings motivate married couples. Moreover, if the transplant fails, the recipient may experience strong guilt. There is a possibility that the organ donation is related to the “guarantee” problem and the married couple can fall into the crisis of divorce. It is important to have a psychiatrist participate with the transplant team to deal with any psychological problems related to spousal kidney transplantation. The psychiatrist evaluates potential or actual psychiatric problems of both donor and recipient, as well as family psychodynamics and the psychological backgrounds that are behind the motivations for donation. The psychiatrist can then make an informed prediction as to the changes in family psychodynamics that may follow the transplantation.10,11,12 REFERENCES 1. Ota K, Hinotsu S, Kawado M, et al: Clin Transp 1:375, 2000 2. Levy AS, Hou S, Bush HL Jr: N Engl J Med 31:914, 1986 3. Suzuki MM, Cecka JM, Terasaki PI: Br Med Bull 53:854, 1997 4. Terasaki PI, Cecka JM, Gjertson DW, Cho YW: Clin Transpl: 269, 1997 5. Gjertson DW, Cecka JM: Kidney Int 58:491, 2000 6. Cecka JM: Annu Rev Med 51:393, 2000 7. Hiraga S, Watanabe J, Kitamura M, et al: Transplant Proc 24:1320, 1992 8. Hiraga S, Kakuta T: Transplant Proc 24:2059, 1992 9. Ackerman NW: Psychodynamics of Family Life. Jason Aronson paperback 1995 10. Surmon MD: Am J Psychiatry 146:972, 1989 11. Abram HS: Renal transplantation in Masschusetts General: In: Hackett TP, Cassem NH (eds): Hospital Handbook of General Hospital Psychiatry, 2nd ed. Littleton, Mass: PSG; 1986, p 12. Owen SS: Am J Psychiatry 146:972, 1989