*4.1.2 Pressure /threat/force/coercion*

Hançerlioğlu states that pressure leads to a situation that prevents free development naturally and socially and that it prevents free behavior [36]. Budak defines pressure as forcing the person to act one way or another and as excessive or stresscausing expectations from the person and states that what is felt as pressure changes depending on the person or education level [33].

Coercion exists when a person poses a credible and serious threat of harm or coercion in an attempt to control another person. Whether the pressure will occur or not depends on how the target person will receive this threat, and this response varies from person to person. Coercion occurs when the perpetrator behind a person's actions is not their own free will and their conscious behavior about areas in which they are knowledgeable ceases to be autonomous when they receive a credible threat [7]. It is the pressure that causes a person to act contrary to their will under a threat of harm. The threat of harm is an essential component of the concept of coercion, and a forced action reflects someone else's choices, not one's own choices, as it is based on a credible threat. Therefore, decisions made under coercion and actions carried out are not autonomous.

Following the coercion, the person makes their own decision. Therefore, although it is said that this, in a sense, is an autonomous choice and should be stated as a voluntary act, this kind of volunteering is volunteering that is not perfect, indirect, and negative. Therefore, as mentioned at the beginning, it is not a desired situation for organ donation. In terms of organ donation, the decision to be made after coercion, pressure or threat is not an autonomous and consensual choice.

Coercion entails a real, convincing, and intended threat that pushes a person into unwanted action and pushes his autonomy out of self-control. In this sense, threat involves applying force to a person to do something or to restrict their freedom. In principle, threat requires a genuine, reliable, intended, and willing orientation [26]. In these concepts, which we generally express, there is a use of physical or psychological force against the autonomy of the person. The plan of bringing the person to the level to do the desired thing lies at the heart of applying pressure, threat, force, and coercion.

Studies on the psychosocial effect of living kidney donation indicate that many living donors believe that the decision to donate is not a real choice and that they feel compelled to donate [38, 39]. In a similar study conducted in the USA, 40% of the donors who donated living organs between 2002 and 2005 reported that they felt some pressure to donate [40]. Understanding volunteer donation only as the absence of coercion will indicate a narrow meaning as it does not cover more sophisticated interventions such as persuasion and manipulation. In this sense, it is necessary to examine the concept of manipulation among the negative factors that affect volunteering.

### *4.1.3 Manipulation*

The concept of manipulation increasingly plays a central role in debates about free will and moral responsibility. Manipulation is essentially the orientation of

the person to do what the manipulator wants by means other than persuasion or coercion. In this sense, manipulation encompasses some forms of influence that are neither persuasion nor coercion/threat/force. The most likely type of manipulation in healthcare is informational. It is the presentation of information in such a way that the person is directed to do what the manipulator wants by understanding the situation differently. In this sense, informational manipulation is also against autonomy. Hiding certain information, telling lies, or exaggerating the meaning or importance of certain information to make people believe in unfounded things are the kinds of actions that can harm autonomous choices.

Manipulation is the deliberate and successful influence on the available choices one can make, either by non-coercively altering or by changing one's perception of those choices. "Being manipulated" is subjective in nature and depends on the person's reaction [35]. If the living donor accepts surgical intervention because of its benefits, they must also accept the possible risks. This is not a manipulative situation [26].

It is a fact that some living organ donors are also manipulated with financial support. Besides, due to the paternalistic approach of the physician to their recipient patient, they may attempt to manipulate the living donor candidate to affect their willingness. The assessment of the living donor candidate by a different transplant team is necessary so that the manipulation that may occur can be evaluated.
