Giving 'Til it Hurts: How Far to Go in Living Organ Donation?

New rules governing organ transplants will take effect this month to remedy the wide geographic differences in how long sick patients wait for a kidney or heart transplant. But whatever the reasons why the wait is longer some places than others, the fact that there is any wait at all is due to an extreme shortage in the organs themselves. As the number of people waiting for organs increases, the waiting time grows longer and the number who will die waiting grows as well. Efforts to increase the supply have focused on increasing cadaver organs, with limited success.

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With improved surgical techniques, living donation has become commonplace -- the number of kidneys transplanted from living donors now rivals the numbers from cadavers. The latest trend is to increased partial liver transplant, which has moved from a rare procedure performed from parent to child into an increasingly common practice that recently involved a stranger donating part of his liver to a woman whose need he heard about on television.

Partial lung and pancreas transplants may be next for more widespread use, as surgeons become more skilled and outcomes for both donor and recipient improve. How far should living organ donation go? How much risk is too much for healthy donors to undertake? How limited can the connection between donor and recipient be before donations are unethical, and how can we assure that living donations are truly voluntary?

Whose risk, whose benefit?

The main issue in living organ donation is donor safety. How much risk should healthy people be allowed to undertake for health benefits that will go to someone else? Organ donation requires major surgery under general anesthesia, and no matter how skillfully performed, exposes the donor to pain, recovery time, and potentially serious health effects. The offsetting benefit to the organ recipient may be great, but the fact that the donor bears all the risk and the recipient reaps all the health benefits should cause us to ask how much risk is too much?

We don't allow people to donate their hearts to their children-even fully informed of the consequences-because it will lead to the death of the donor.

Of course donors who give kidneys or parts of other organs enjoy the benefits of a wonderfully altruistic act, but we should wonder whether that is enough to overcome the ages-old stricture on physicians to avoid harming patients unless it leads to sufficient benefit to them.

You're related to me how?

The experience with living kidney donors points to looser definitions of what counts as a "related" donor. Early on in living donation, only genetically related donors were allowed -- parents and children or siblings.

Then the notion of relative was extended to include donors related by Marriage -- spouses, in-laws or cousins. Now "community" or "social" relatives can donate kidneys, members of church or social groups, co-workers or friends. The thinking was that donors more closely related to recipients had more to gain from the improved health of a relative or loved one, so that the splitting apart of risk and benefit was less of an issue. But such concerns have all but disappeared, as evidenced by the first two living kidney donations from donors who were complete strangers to the eventual recipients.

The pressure continues to find greater number of organs for transplant, and until we can grow organs in the lab or use organs from animals, living donors will continue to be a burgeoning source. But as we undertake practices that will increase the numbers of healthy people undergoing major surgery to give up all or part of an organ, we must be sensitive to what might go wrong.

There is real risk to donors, especially in more complicated donations for portions of livers, pancreas and lungs. We must be on the lookout for strained and strange relationships between donors and recipients--including the possibility of pressure among relatives, and payment or even extortion in a black market--and create preventive policies and ways to screen potential donors accordingly.

How far will be too far? When we run the risk of trading one patient's health or even life for that of another. That is a tradeoff we cannot allow people to make, even if they willingly enter into it. When it comes to living organ donation, giving until it hurts may be exactly what we need but more than we can ask.