The weight of witness: Ethical issues in organ procurement

Background Organ procurement following death by neurological criteria can pose ethical challenges for transplant teams, yet the lived experiences of these professionals – particularly nurses – remain poorly understood, especially where donation rates are low. Research question/aim/objectives To explore ethical issues experienced by transplant team members during deceased donor organ procurement and examine coping strategies for morally and emotionally challenging experiences, with attention to nurses’ front-line perspectives. Research design Reflexive thematic analysis (Braun & Clarke, 2021). Semi-structured interviews (n = 15), structured reflection diaries (26 procedures, 2017–2023), and medical documentation (40 transplantations). Descriptive survey data (n = 22) contextualise qualitative themes. Moral distress served as a sensitising concept rather than a directly measured construct. Participants and research context Fifteen team members at a Serbian tertiary centre: 4 with nursing training (2 bedside nurses and 2 coordinators with nursing backgrounds), 4 surgeons, 3 anaesthesiologists, and 4 nephrologists. Experience ranged from 2–18 years. Ethical considerations Approved by institutional ethics committee (No. 00-15/2023). Written informed consent obtained. External interviewer used. COREQ guidelines followed. Findings/results Five themes emerged: (1) Navigating Family Grief (14/15) – moral labour of bridging medical reality and family perception; (2) The Weight of Witness (12/15) – accumulated emotional burden, particularly among nurses; (3) The Brain Death Paradox (11/15) – persistent uncertainty about brain death as death; (4) Time Pressure versus Certainty (9/15) – tension between organ viability and diagnostic thoroughness; (5) Institutional Abandonment (7/15) – perceived lack of formal support. Nurses described distinctive experiences shaped by continuous bedside presence and relational proximity to families. Conclusions Ethical challenges of procurement after brain death persist across experience levels and are inadequately supported by current institutional structures. For nurses and other front-line clinicians, recognising and supporting this moral labour is essential to sustaining ethical transplant practice.