Public Solicitation and The Canadian Media: Two Cases of Living Liver Donation, Two Different Stories.

BACKGROUND: . Two stories of public solicitation for living liver donors received substantial Canadian media attention in 2015: The Wagner family, with twin toddlers, each needing transplants, and Eugene Melnyk, wealthy owner of a professional hockey team. This study compared the print media coverage of these 2 stories to understand how public solicitation was portrayed and whether coverage differed depending on the individual making the plea.
METHODS: We conducted a content analysis on 155 relevant Canadian newspaper articles published between January 1, 2015 and December 31, 2016. Articles were analyzed for their description of public solicitation, benefits and issues associated with public solicitation, and overall tone with respect to public solicitation.
RESULTS: The foregrounding of public solicitation and associated ethical issues featured heavily in articles focused on Melnyk but were largely absent when discussing the Wagner family. The fairness of Melnyk's solicitation was the most prominent ethical issue raised. Laws and policies surrounding public solicitation also featured in the Melnyk story but not in articles focused on the Wagners. Public solicitation was portrayed more negatively in the Melnyk articles, but overall, was portrayed positively in relation to both Melnyk and the Wagner family.
CONCLUSIONS: Public solicitation was generally portrayed as a positive phenomenon in Canadian print media, yet there were stark differences in how these cases were presented. The Wagner story was largely portrayed as a human-interest piece about a family in dire circumstances, whereas Melnyk's wealth, status, and influence raised questions of the fairness of his transplant.

In 2015, 2 high-profile media stories emerged in Canada detailing individuals in need of liver transplants: the first was of Binh and Phuoc Wagner, 3-year-old adopted twins from Vietnam, and the second was of Eugene Melnyk, owner of the National Hockey League's Ottawa Senators. Both stories generated significant media attention and advanced their respective searches for donors among the public (see Supplemental Materials [SDC, http://links.lww.com/TXD/A228] for complete context). These stories are part of the growing trend of public solicitation, whereby patients in need of a transplant (or their representatives) request members of the public to donate. These requests are on the rise and can now be made through a variety of mediums, including billboards,[1] vehicles,[1] newspaper advertisements,[2] t-shirts,[3] YouTube,[4] Facebook,[5] and other social media platforms.[6] Patients can also purchase memberships on MatchingDonors.com, where people interested in donating can peruse the profiles of those in need of an organ and contact potential recipients.[7]

Public solicitation is controversial.[8] Concerns include potential compromises to donor/recipient anonymity and privacy, commercial exchange and exploitation, strain on the healthcare system, and questions of fairness.[9,10] There is a perception that public solicitation allows recipients to “jump the queue” and a concern that it privileges those with a large public profile, access to the media, or those with the most heart-wrenching story.[11,12] There are also concerns that minority or underprivileged groups may be discriminated against either in terms of lacking access to media platforms or in being chosen as potential recipients on websites such as MatchingDonors.com.[5,7,10,12]

Given the considerable media attention to the Wagner and Melnyk stories, the Canadian donation and transplantation communities convened to provide some policy direction. The Canadian Society of Transplantation (CST) developed a position paper as a result, acknowledging some ethical issues but overall viewing the phenomenon as acceptable with some social benefits.[13] The position paper explains that public solicitation generates new donors, and in turn, helps alleviate the pressure on waitlisted patients. Other claimed benefits include an increased public awareness around donation and leveling the playing field for those with limited familial and social network options for finding potential donors.[9,14]

Although public solicitation is not a new phenomenon, the Wagner twins and Melnyk stories received unprecedented media coverage in Canada. Media representations can influence people's attitudes and beliefs about organ donation and transplantation, particularly when the messaging about donation is negative.[15,16] There are concerns that negative publicity associated with public solicitation could lead to a public backlash toward the donation system more broadly and that public solicitations, particularly on websites such as MatchinDonors.com,[17] could erode public trust.[8,18] The Wagner and Melnyk stories, therefore, provide an important opportunity to examine the information the public is receiving on these issues.

Print media is a prominent source of information through which the public receives information about donation.[19,20] Research on organ donation stories in US newspapers has shown that stories that are deviant (unusual or sensational), significant (relevant to the current social, economic, or political climate), and negative stories were more likely to receive prominence in news coverage.[21] However, this particular study focused on all donation-related stories and did so specifically through the analytic lens of newsworthiness.[21] In contrast, our study on the Canadian media coverage of the Wagner and Melnyk stories is specific to public solicitation and, placing both cases on a relatively equal level of significance, hypothesized that the media portrayal of each public solicitation would be significantly different. If there was a significant difference observed in the coverage, the task was then to elucidate the specific discursive differences at play, including the focus given to public solicitation, which issues, if any, were being reported on, and whether public solicitation was being portrayed positively or negatively.

To the best of our knowledge, there has yet to be published academic work on the print media's portrayal of public solicitation. Although the Wagner and Melnyk stories broke in 2015, public solicitations have continued, and this study provides novel analysis on how print media reported this issue to the public, with findings that remain relevant today.

MATERIALS AND METHODS

To examine the 2 stories, we conducted a content analysis of all relevant Canadian newspaper articles published over a 2-year period from January 1, 2015 to December 31, 2016. We searched for articles using the DowJones Factiva database[22] using search terms designed to capture all potentially relevant articles (Supplementary Materials [SDC, http://links.lww.com/TXD/A228]).

The search yielded a total of 223 articles, of which 68 were excluded for irrelevancy. Articles were deemed irrelevant if they were duplicates, transcripts of television or radio broadcasts, or not focused on the topic of organ donation. Transcripts of television or radio broadcasts were excluded because they are a different type of discourse from print media and can therefore not be conflated as discursively equivalent for content analysis. The finalized dataset comprised 155 articles.

To conduct the content analysis, we developed an inductive and deductive coding frame using methods developed from our team's previously published work (see Supplementary Materials [SDC, http://links.lww.com/TXD/A228] for the coding frame).[23,24] The Factiva database provided metadata concerning publication source, author, date, and word count, whereas the coding frame captured information on the articles' focus, description of public solicitation efforts, benefits or issues associated with public solicitation, statistics, laws or policies raised in relation to organ donation and public solicitation, and overall tone with respect to public solicitation. The main focus versus secondary focus of an article was determined based on the focus of the article's headline, lead paragraph(s), and word allocation with respect to a topic.

One researcher coded all 155 articles. Upon completion, a secondary coder external to the project coded a random sample of 32 articles (28% of the total) to ascertain a measure of coding reliability. We used the methods of Miles and Huberman[25] to calculate agreement. Average agreement was 93% and was between 81% and 100% for all coding categories after consensus reaching sessions on 3 categories which had <70% agreement. These were question number 3, descriptions of pain and suffering of individuals (50%), question number 7, descriptions of public reactions to the public solicitation (69%), and question number 16, mentions of issues or difficult realities raised with regards to the donation process (69%) (see Supplementary materials http://links.lww.com/TXD/A228 for a complete coding frame).

RESULTS

Focus of Articles

As presented in Figures 1A–C, Melnyk's story generated more articles than the Wagners'. Melnyk was present in 111 articles (72%), of which he was the main focus in 83 and a secondary focus in 28. The Wagners were present in 59 articles (51%), of which they were the main focus in 44 and a secondary focus in 15. Stories of other patients needing transplants (“others”) were the main focus of 27 articles (17%) and a secondary focus in 34 (22%). Figure 1B shows how the stories of “others” continued to generate media attention into 2016. One article's main focus was public solicitation as a phenomenon.

FIGURE 1.

Focus of Articles and Time-line of Events. A, Total number of articles by focus. B, Main focus of articles over 2 y, 2015–2016 (n = 155). C, Secondary presence in main focus articles (n = 154). D, Major events timeline containing number of articles per mo by main focus.

Melnyk was mentioned in all stories focused on “others” (27, 100%), whereas the Wagners were present in only 5 (18%) (Figure 1C). When Melnyk was the main focus, the Wagners were present in 10 articles (12%), whereas Melnyk was not present in the stories primarily focused on the Wagners (Figure 1C). This was largely because 37 of these 44 articles (84%) were published before the Melnyk story broke (Figure 1D).

Focus on Public Solicitation

Articles focused on Melnyk mention public solicitation much more often than articles focused on the Wagners (94% versus 48%). Further, the reasons why public solicitation is being undertaken are provided in 44 (53%) of the Melnyk-focused articles and in only 10 (23%) of the Wagner-focused ones. For Melnyk, the reasons included his rare blood-type, exhausting his family-member options, and medical urgency. In the case of the Wagners, the sole reason given was that public solicitation was a potentially effective tool to find a donor. In the articles focused on “others,” public solicitation was mentioned in nearly every article (26 [93%]), and reasons were given in 13 (46%). In 7 of these articles, Melnyk was described as a source of inspiration for public solicitation. Other reasons included running out of options and time, exhausting potential family members, and in one case, following a doctor's advice.

Presence of Ethical Concerns

Many more Melnyk-focused articles raised ethical concerns (33 [40%]) than those primarily focused on the Wagner twins (0 [0%]). Indeed, in all articles in which the Wagner twins were mentioned (n = 59), there were just 10 instances in which ethical concerns were raised around public solicitation. In 6 of these cases, however, the Wagners' public solicitation was mentioned in a broader discussion of ethical issues. Just 4 articles raised ethical concerns specifically with regards to the Wagner family: the “beauty contest” concern (ie, more compelling stories generate more attention) (3), and jumping the queue (1).

Conversely, in the Melnyk-focused articles, 33 articles raised 11 different ethical concerns (Table 1), the most common being Melnyk's celebrity and financial power to generate a larger media platform than others would be capable of doing. In the articles focused on “others” (n = 28), ethical concerns surrounding Melnyk's public solicitation were raised in 8. In sum, of the 111 articles in which Melnyk was either the main or secondary focus, ethical issues around public solicitation were raised in 41 (37%).

TABLE 1.

Ethical concerns raised around Melnyk's public solicitation

Portrayal of Benefits and Public Reaction

Articles focused on Melnyk and “others” raised more benefits of public solicitation (69% and 73% respectively) than those focused on the Wagner twins (41%) (Table 2). All articles discussed the benefit of campaign success with similar frequency (Wagners, 17 [39%]; Melnyk, 33 [40%], “others,” 14 [50%]). Only 3 (7%) of the Wagner-focused articles mentioned the benefit of generating awareness and potential additional donors, whereas Melnyk-focused articles did so in 36 (43%). Also, 7 (10%) Melnyk-focused articles explicitly mentioned the idea that live donation reduces transplant waitlists.

TABLE 2.

Overall portrayal of each respective story organized by main focus of articles (n = 155)

Discussion of the public's response to the public solicitation was less common in the Wagner-focused articles (14, 32%) and was described positively in every case where this occurred. In contrast, 54 articles (65%) did so in the Melnyk-focused articles, and though most cases were positive (52%), there was 1 negative article and 10 (12%), which included both positive and negative sentiments. In nearly a quarter (20, 24%) of the Melnyk-focused articles, reasons why people responded to the public solicitation were given compared with only 2 (5%) of the Wagner-focused articles. For the Melnyk-focused articles, 12 out of 20 stated that people had come forward to help the hockey team win the Stanley cup. One article in the Wagner-focused articles mentioned that the donor was military and therefore part of the same “community.”

Tone With Regards to Public Solicitation

The tone with regards to public solicitation in the Wagner-focused articles was either positive (57%) or neutral (43%). Only articles focused on Melnyk, and 1 article focused on “others,” had an overall critical tone (Table 2). In the Melnyk-focused articles, 46% were positive, 11% mostly positive, 30% neutral, and 13% negative.

DISCUSSION

This media analysis shows a stark difference in how 2 cases of public solicitation were portrayed in the Canadian popular press. The story of the Wagner twins was essentially a human-interest story: a noble family struggling with a health issue, where the solution was an organ for transplant they could not provide. In contrast, Melnyk's story was one of a wealthy man employing the contentious act of public solicitation to save his life.

There is a concern that public solicitation may lead to a loss of public trust in organ donation systems.[8,17,18,26] The fact that public solicitation was reported primarily in positive terms in relation to both Melnyk and the Wagners is, therefore, significant, and the absence of a widespread media backlash to this practice may provide some evidence to counter this concern. However, coverage was not uniformly positive. Given that media representations can impact public understandings of and attitudes toward donation,[15,27,28] the stories critical of public solicitation warrant further attention.

The only articles with an overall negative tone toward public solicitation were focused on Melnyk or the “others” and not the Wagners. In addition, the fairness of Melnyk's transplant was explicitly questioned, whereas the Wagners generally escaped criticism on these grounds. The fact that Melnyk, a wealthy, powerful, and prominent individual, exclusively attracted concerns about fairness reflects, and may reinforce, myths perpetuated in mass media representations that the rich and famous receive preferential treatment in organ allocation systems.[15,16,27,28] These questions of fairness may also reinforce beliefs that the medical system cannot be trusted, which is among the most prominent concerns expressed in public survey data related to organ donation.[29] Although relatively few articles were critical, this concern about fairness ought to be taken seriously as transplant programs and professionals continue to grapple with this issue and develop much-needed policy.

There is a clear call in academic literature for transplant centers and professional bodies to develop policy on this issue.[6,26,30] A 2018 scoping review of literature on public solicitation found that 35 of the 41 articles studied “made suggestions for policy development to address public solicitation.”[26] While some bodies, like the CST and the European Society for Organ Transplantation,[31] have done so, many other professional societies and transplantation programs have not. It is clear that public solicitations are happening around the world,[5] and particularly with social media, patients have access to increasingly broad platforms. Established policy would be useful in addressing high-profile cases before they arise. The Melnyk and Wagner stories may provide helpful insight for transplant centers and professionals who will continue encountering patients seeking to solicit donors from the public.

News coverage can impact policy debates and development.[32,33] Although it is beyond the parameters of this study to measure what impact the Wagner and Melnyk stories may have had, our results reveal how public solicitation was being discussed and portrayed in the popular press immediately prior to major policy development by the CST. It is notable that the CST's largely positive stance toward public solicitation reflects the largely positive reporting of this issue in the media.

In particular, many ethical issues featuring prominently in academic discourse were largely absent from media reporting. Only one article mentioned privacy concerns, yet this is a significant issue as public solicitation makes it possible to breach the wall of anonymity that typically exists when an organ is transplanted from a stranger. The Wagner story perfectly illustrates this issue, as an anonymous stranger violated the donor's privacy by contacting Mrs Wagner and disclosing his identity.[34,35] The potential for commercial exchange of organs when the wall of privacy is breached is also a significant concern in the literature and has even been described as “the most powerful argument against public solicitation.”[31] In a study involving interviews with patients who participated in public solicitation, all participants indicated they received offers from people to provide an organ in exchange for a monetary or “in kind” payment.[30] Despite this reality and the prominence of this concern, this issue was raised in only 3 newspaper articles as an ethical concern and a small number of additional articles in the context of discussing the legal prohibition against commercially exchanging organs under Canadian law.

It was against this backdrop that the CST position paper emerged with a notably positive stance toward public solicitation. It is possible the positive coverage of this issue and lack of ethical scrutiny in the media helped facilitate this outcome. Although more nuanced discussion of the benefits and concerns with this practice may be desirable, the generally positive newspaper coverage may be encouraging to transplant centers or bodies seeking to develop policy accepting of public solicitation. The fact that fairness was the only ethical issue receiving significant attention may also indicate that policies favorable to public solicitation ought to squarely address this concern. For those opposed to public solicitation, the fact that the media was largely supportive highlights the need for clear and transparent reasons for denying donations sourced in this way. This may be particularly important if neighboring transplant centers have taken a different stance.

Following the Melnyk and Wagner stories, there were news reports of an 8-month-old girl in need of a liver transplant whose parents' efforts to find a donor through Facebook were thwarted by the Alberta transplant program's stance against anonymous living liver donation.[36] As Melnyk and the Wagners were able to source a donor using similar methods at a different transplant center, this story raised questions about fairness and equality across Canada in terms of being able to access organ donors in this way. Shortly after this story broke, the transplant program changed its position.[37] Although this study does not demonstrate or measure the impact of media reporting on policy decisions, it is clear that media attention can highlight disparities between transplant programs, and in this case, raise tough questions for transplant programs opposed to public solicitation.

Understanding media reporting can also help clinicians in their discussions with patients expressing a desire to engage in public solicitation. While the Wagners were portrayed very positively, the anonymity of their donor was compromised. Although Melnyk's coverage was mostly positive, there was negative coverage suggesting he was “jumping the queue.” These stories can provide practical examples for clinicians discussing the risks of this practice with patients.

In addition, patient expectations may also need to be managed, particularly if solicitations are being made following a high-profile case. Although media coverage can showcase public solicitation as a successful method of finding a donor,[18] it is transient in nature. This was demonstrated by the stories focused on the “others” in this analysis, following the initial Melnyk and Wagner stories. None of these stories attracted the same individual attention as Melnyk and the Wagner twins. This could be the result of media saturation and public fatigue on this issue.[38]

Finally, this study sheds light on the media's role in public solicitation. It is clear that the media amplified both requests, but the framing of the stories was very different. With respect to the Wagners, only 48% of articles mentioned the issue of public solicitation. Although the Wagners set up a Facebook page to find a donor and welcomed the attention of the press for that purpose,[39] media coverage of the Wagners focused on their situation rather than their request. As a result, their own solicitation efforts were shrouded, and the media reporting of their story essentially served as a request to the public on their behalf. In contrast, Melnyk's use of the media to find a donor was much more explicit, as a press conference was specifically called for that purpose. His act of requesting a donor from the public was central to the story and mentioned in 94% of articles focused on him. This may explain, in part, why his solicitation invited more controversy. As more solicitation stories arise, there is room for further research examining and comparing the framing of media coverage of these requests.

A limitation of this study is that it relied solely on print media. Analysis of television, radio, or social media might have revealed different results. The particular cases of public solicitation analyzed in this study also arose within the Canadian organ donation and transplantation system and the Canadian media landscape. The generalizability of the study's findings may, therefore, be limited in other jurisdictions. That said, public solicitation is occurring around the world, and the Canadian experience may provide useful insights as other jurisdictions grapple with similar policy issues. Certainly, there is a need for more research examining public representations, attitudes, and beliefs about public solicitation,[29] and this study sheds some light on how this issue is being discussed and communicated to the public.

ACKNOWLEDGMENTS

The authors would like to thank Genome Alberta and the Canadian Institutes for Health Research for their generous support of Precision Medicine CanPREVENT AMR, and the Canadian Institutes for Health Research and the Kidney Foundation of Canada for their support of The Canadian National Transplant Research Program: Increasing Donation and Improving Transplantation Outcomes. Additionally, the authors thank Carina Chiu for assisting in background research, Morgan Barber for assisting in conducting intercoder reliability, Evan Horbay for copy-editing, and Robyn Hyde-Lay for providing coordination assistance throughout the project.