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ES cells. However, it was correctly pointed out that these markers are also expressed on targets outside of NK cells, including ILC1 and ILC3 cells which have been reported to express low levels of Ly49 receptors (1). Thus, differential engraftment of ES cells after anti-Ly49 administration may have been partially caused by depletion of ILCs. However, a direct role of ILCs is unlikely in this scenario given the lack of cytotoxic function in these cells except for ILC1 which have been reported to exhibit low cytotoxic potential (2). Additionally, these cells are largely localized in mucosal areas and therefore unlikely to mediate rejection of a subcutaneous ES graft. ILCs may play a larger role in the setting of ES engraftment through their production of cytokines and modulation of T-cell responses. However, to isolate NK cell responses, we chose to use severe combined immunodeficient mice which lack T and B cells. Thus, experimental models isolating ILC contributions to T-cellY mediated rejection of allogeneic grafts of undifferentiated cells as well as potentially direct effects would be informative.

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& Volume 98, Number 5, September 15, 2014

As Masuda et al. point out, current therapeutic strategies employing ES-derived or induced pluripotent stemY derived products aim to ensure that undifferentiated cells are excluded which may limit the applicability of our results to current clinical practice. However, the objective of our manuscript was to define the immunogenicity of ES cells in the context of NK cell biology. Natural killer cells have been reported to show increased sensitivity to undifferentiated cell types, with increasing tolerance because these cells differentiate (3). Therefore, NK cells may play an important role in rejecting residual pluripotent cells in the graft and preventing potential teratoma formation. A distinct role for ILCs and the extent of the effects on overall engraftment in this process remain to be determined as this nascent field progresses. Erik Ames William J. Murphy Departments of Dermatology and Internal Medicine

University of California Davis Medical Center Sacramento, CA The authors declare no funding or conflicts of interest. Address correspondence to: William J. Murphy, Ph.D., Department of Dermatology, UC Davis School of Medicine, 2921 Stockton Blvd, Suite 1630, Sacramento, CA 95817. E-mail: [email protected] Received 3 June 2014. Accepted 5 June 2014. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9805-e39 DOI: 10.1097/TP.0000000000000345

REFERENCES 1.

2. 3.

Klose CS, Flach M, Mohle L, et al. Differentiation of type 1 ILCs from a common progenitor to all helper-like innate lymphoid cell lineages. Cell 2014; 157: 340. Walker JA, Barlow JL, McKenzie AN. Innate lymphoid cellsVhow did we miss them? Nat Rev Immunol 2013; 13: 75. Tseng HC, Arasteh A, Paranjpe A, et al. Increased lysis of stem cells but not their differentiated cells by natural killer cells: de-differentiation or reprogramming activates NK cells. PloS One 2010; 5: e11590.

Thou Shalt Not Donate Organs: But It’s OK to Take? adela and Zaganjor (1) provide details of the relationship between religiosity and attitudes toward deceased organ donation in an American Muslim cohort of 97 respondents. Their findings identify negative religious coping (i.e. Muslims viewing difficulties in life as divine punishments) to be independently associated with negative attitudes to deceased organ donation, but higher levels of intrinsic self-rated religiosity had no similar association. They also identified that Arab Muslims had more favorable attitudes toward deceased organ donation in comparison with South Asian Muslims, with both more favorable than African American Muslims. These interesting results, using validated qualitative measures to assess religiosity among Muslims, provide an interesting insight into the complex decision-making process that influences Muslims with regard to organ donation. The reluctance for organ donation among Muslims is more pronounced for deceased versus living donation (2), and it is the former that was the subject matter for this analysis. The lack of association between intrinsic self-rated religiosity

P

and positive attitudes to organ donation contrasts with previous work analyzing Western Muslim and British Asian Muslim attitudes (3, 4). In these analyses, negative attitudes toward organ donation were identified with increasing scales of self-rated religiosity. There are likely to be a number of explanations for these contrasting results. First, the analysis by Padela and Zaganjor has used more robust qualitative measures to assess Islamic religiosity. Second, as the authors rightly point out, the respondent demographics are completely different. South Asians have more negative attitudes to organ donation, clouded by less clear guidance from Islamic scholars emanating from South Asia (2), which adds a cultural component to this debate. It is important to acknowledge that global Muslims are a heterogeneous group with varied social, cultural, linguistic, and historical values that overlap with religious affiliation. Teasing apart attitudes that are cultural rather than religious is difficult in this context and requires further research. The association between negative religious coping and negative attitudes toward deceased organ donation highlights

a new finding that suggests psychological obstacles that may require further investigation. Overcoming such negativity may require targeted psychosocial interventions and is likely to be resistant to standard organ donor awareness campaigns. However, before such interventions can be planned, unravelling the complexity of the organ donation debate within Islam requires further understanding. This requires further targeted qualitative and quantitative research within the Muslim community, carefully designed to shed light to and provide insight into the complicated debate that surrounds organ donation. Despite this ongoing need for further research, there is one poorly understood concept in this organ donation debate that seems untenable, that is, the notion that one can be negative about organ donation but positive about organ receipt. There is no sound theological argument within Islam that plausibly allows such a contradiction to be morally acceptable, but the irony is for many Muslims, this seems an acceptable paradox (3, 4). Perhaps, there is some theological basis to justify this position, but it

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Ferna´ndez-Ruiz et al.

* 2014 Lippincott Williams & Wilkins

is not clear on what basis such foundations are set. A clear distinction must be made with Jehovah’s Witnesses, who refuse to donate blood but will reciprocally refuse to take blood. Regardless of whether we as medical professionals agree with this, it is a tenable position that can be respected. It is unlikely that the average Muslim is (or ever will be) familiar with the overwhelming philosophical dilemmas, metaphysical intricacies, and juristic conundrums that have burdened this organ donor debate among Islam scholars for decades. Such debate is unlikely to be the major obstacle for Muslims signing up as organ donors; apathy and disinformation are probably more pertinent issues rather than theology. A famous Islamic parable, narrated by Abu Huraira, states, ‘‘A prostitute was forgiven by Allah, because, passing by a panting dog near a well and seeing that the dog was about to die from thirst, she took off her shoe, and tying it with her head-cover she drew out some water for it. So, Allah forgave her because of that

(act of kindness)’’ (5). This parable is often cited to support the importance of animal welfare within Islam, but it also demonstrates the magnanimity of human kindness and its cherished place in the eyes of Islam. Transplantation is dependent on the generous act of organ donationVsurely, there can be no kinder act than the gift of life. Those happy to receive such organs would therefore be wise to reflect carefully on their willingness to donate as, from a moral psychology perspective, ‘‘failure to follow one’s own expressed moral principles is termed hypocrisy’’ (6).

Received 19 June 2014. Accepted 7 July 2014. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9805-e40 DOI: 10.1097/TP.0000000000000390

REFERENCES 1.

2. 3.

Adnan Sharif Department of Nephrology and Transplantation Queen Elizabeth Hospital Birmingham, United Kingdom

4.

5. The author declares no funding or conflicts of interest. Address correspondence to: Adnan Sharif, M.D., Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, United Kingdom. E-mail: [email protected]

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Padela AI, Zaganjor H. Relationships between Islamic religiosity and attitude toward deceased organ donation among American Muslims: a pilot study. Transplantation 2014; 97: 1292. Sharif A. Organ donation and IslamVchallenges and opportunities. Transplantation 2012; 94: 442. Sharif A, Jawad H, Nightingale P, et al. A quantitative survey of western Muslim attitudes to solid organ donation. Transplantation 2011; 92: 1101. Karim A, Jandu S, Sharif A. A Survey of South Asian attitudes to organ donation in the United Kingdom. Clin Transplant 2013; 27: 757. Translation of Sahih Bukhari, Volume 4, Book 54, Number 538. Available at http:// www.usc.edu/org/cmje/religious-texts/hadith/ bukhari/054-sbt.php. Accessed June 17, 2014. Lammers J, Stapel DA, Galinsky AD. Power increases hypocrisy: moralizing in reasoning, immorality in behaviour. Psychol Sci 2010; 21: 737.

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Thou shalt not donate organs: but it's OK to take?

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