Would You Give a Stranger Your Kidney? The Ethics of "Unknown" Kidney Donors
by Jeffrey P. Kahn, Ph.D., M.P.H.
Director, Center for Bioethics
University of Minnesota
Organ transplantation is in the news again, most recently because of a young boy who received his third set of multiple internal organs, reviving an ongoing debate about how many organs any single person ought to receive. This case, and many others, is compelling because of the critical shortage of available organs relative to the number of patients who need them.
How far should we go in creating new avenues for organ procurement? Federal law prohibits the buying and selling of human organs, and for good reason. Instead we allocate organs based on waiting time and severity of illness, and are trying to address geographical disparities by creating a single national allocation system.
Further, through required reporting of all deaths to procurement organizations and requests for donation by experts, the hope is that donations will increase by 20 percent in two years. But even a 20 percent increase will only begin to dent the un-met need for organs. In addition to these changes we need to create new pools of donors.
Currently, kidneys are the only organs that are regularly removed for transplant from live donors, though segments of the liver, the lung and the pancreas are also starting to be harvested from live donors in some centers. Refined surgical techniques and post-donation medical care have reduced the risk of kidney donation and there is little, if any, increased risk associated with living with only one kidney.
But a barrier exists to expanding the pool of live kidney (and other organ) donors, since to be eligible to donate a kidney to someone in need, a donor must be somehow related to the recipient, whether by blood, marriage, friendship or as members of a shared community. Unlike blood, bone marrow, sperm and even human eggs, in which we allow and encourage anonymous donation, we have never allowed anonymous or "unknown" donors to offer a kidney to any needy patient for whom their kidney would be a match.
This barrier has been staked to three issues: the physical risk and lack of offsetting benefits to the donor, concerns that the donation is not sufficiently voluntary, and the potential for exploitation of the organ-allocation system through payment to the donor. Each of these concerns can either be sufficiently addressed or are no greater a problem than in live donation by related individuals.Risk and benefits to donors
"Unknown" donation creates ethical concern since the risks of donation fall entirely to the donor and the medical benefits accrue entirely to the recipient. The argument is that splitting apart of risk and benefit in this way should limit the amount of risk donors ought to be allowed to undertake.
Related donors, on the other hand, should be allowed to undertake greater risk because they will realize the medical benefit to the recipient in some secondary way through their relationship to the donor. But this approach undervalues the benefits to individuals of their altruistic actions, which may in fact be greater than in cases where donors might feel expected to donate to a relative.Are all donors volunteers?
Just as in related donation, we must be sure that "unknown" donors are making a voluntary decision to donate. In practice, related donors who are an appropriate match often feel pressured to donate, and sometimes even request a "medical" excuse from the transplant team so that they do not have to refuse to help a friend or loved one. No such pressure would exist in truly unknown donation and so long as the usual psychological assessment is carried out there should be no greater concerns over the voluntariness of unknown donors than of any others. Clearly, the informed consent of all donors is crucial to assure that they understand what organ donation entails, but again this is no different than with other living donors.Preventing payment for donation
Another underlying concern over "unknown" donation is the motivation of donors. It is crucial that there be no quid pro quo between donors and recipients; no offers or expectations in either direction of payments, gifts or favors. Payments of any kind could lead to an unacceptable market in organs, which could quickly lead to exploitation of the allocation system and of potential organ donors.
The test must be whether donors are being encouraged to overlook the risks of donation in return for whatever returns they see in it. We must also be careful about future contact between donor and recipient and the expectations of indebtedness donation might create.
All these concerns can be addressed, and transplant centers report calls from prospective donors asking whether there are patients who might be able to receive one of their healthy kidneys. The answer is undoubtedly yes, but the question remains as to whether we are ready to accept such offers. With appropriate screening of donors, and vigilance to assure that improper relationships neither exist nor develop, "unknown" donation offers an important new avenue for obtaining lifesaving organs.
Center for Bioethics and CNN Interactive.
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