Head To Head

Is it unethical for doctors to encourage healthy adults to donate a kidney to a stranger? No

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7140 (Published 15 November 2011) Cite this as: BMJ 2011;343:d7140
  1. Antonia J Cronin, clinical research consultant nephrologist12
  1. 1NIHR Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust
  2. 2MRC Centre for Transplantation, King’s College, London SE1 9RT, UK
  1. antonia.cronin{at}kcl.ac.uk

Walter Glannon (doi:10.1136/bmj.d7179) argues that doctors should not encourage their patients to put themselves at risk for the benefit of others, but Antonia Cronin believes that encouraging altruistic donation is legitimate

Transplants save lives. Saving life is one of the most wonderful things anyone can do for another. Last year 3740 life saving transplant operations took place in the UK.1 Since implementation of the Organ Donation Taskforce recommendations, the number of deceased organ donors has increased every year.2 Last year there was a record high of 1010.1 Despite this increase, and considerable ongoing public support and recognition of the value of organ donation and transplantation, more than 10 000 people in the UK are currently waiting for a transplant. Of these, it is estimated that 1000 people a year—that is, three every day—will die waiting for a transplant.1

High levels of diabetes and hypertension have contributed to an increased incidence of chronic kidney disease, and demand for kidney transplants. Both public health initiatives and medical research that attempt to improve the health of the population, and extend the successful long term outcome of kidney transplants, have an important role in meeting that unmet demand. So too does living donor kidney transplantation and it must remain an integral part of the NHS strategy to save lives.

Living donors

Living donor kidney transplantation has an outstanding record, and is considered the treatment of choice for many people with chronic kidney disease.3 It now makes up 38% of the total kidney transplant programme in the UK.1

In 1986 UK medical opinion regarded all living donation as justifiable only in exceptional circumstances.4 However, the increasingly good outcome of live donation, not only to close genetic relatives but also to unrelated recipients, has made it a more attractive model and enhanced its ethical acceptability.1 5

In the UK, most living donations are directed, with donors usually related to the recipient either genetically or emotionally (such as a partner or close friend). However, over the past 10 years the number of genetically unrelated directed donations has increased.1 The Human Tissue Act 2004 provides the legal framework for living non-directed altruistic kidney donation (donation to strangers) in the UK. The first such donation took place in the UK in 2007, and it now contributes 3% of the total UK living donor kidney transplant activity.1 Kidneys are currently allocated to individuals waiting on the national transplant list using the same criteria as for deceased donation.3 6 Between July 2007 and July 2011, 80 non-directed donations took place in the UK. The mean age of the donors was 52 years (range 25-82 years), and 59% of donors were men. The mean age of the kidney transplant recipients was 46 years (range 3-76 years) and 57% of recipients were men. The average time recipients had waited for a kidney was over three years. Excellent transplant outcomes have been reported.1

Welfare of the donor

The welfare of living organ donors is paramount.3 According to the EU Organ Directive, “the highest possible protection of living donors should be ensured.”7 Living kidney donation exposes an otherwise healthy individual to the risks of major surgery for the physical benefit of another. The risk of death is cited as 1 in 3000 (0.03%), and the risk of significant postoperative morbidity is 2-4%.3

Demonstrating that living donation is harmful provides a powerful argument against it. Can it ever be right to try to meet transplant demand this way? Other things being equal, inflicting harm on people is wrong. A clinician’s duty is to first do no harm. The difficulty, however, with importing this kind of argument to the context of living donor kidney transplantation, and in particular stranger kidney donation, is that it does not take account of other morally relevant reasons, in particular individual autonomy, which may have contributed to an individual’s decision and motivation to donate a kidney. Nor does it adequately capture the circumstances in which an individual may be prepared to volunteer to incur or risk harm in order to benefit another. Restricting the risks that autonomous adults may freely run on the basis that this is legitimate paternalism because it might conflict with a clinician’s responsibility to “do no harm” is not a compelling ground for arguing that living kidney donation should be prohibited or further restricted.

UK guidelines on living kidney donation emphasise the importance of the welfare of the donor and set out a model for assessment of non-directed altruistic donation. People who offer to donate a kidney to a stranger require information about the operation and the risks involved, and are only accepted after a detailed medical and psychological assessment and approval from the Human Tissue Authority.3 The long term survival of living donors is good, and living donors express high levels of retrospective satisfaction with their decision to donate.3 8

Professional responsibility

Systems of organ donation based on altruistic voluntariness and systems involving some form or another of payment are not mutually exclusive. However, since any form of payment that exceeds the direct reimbursement of costs actually incurred by the living donor is forbidden in UK domestic law, and by European Directive, it would be irresponsible for doctors acting in their professional capacity to encourage it.

Doctors do not have a moral obligation to encourage stranger kidney donations. However, encouraging healthy competent adults to voluntarily donate one of their kidneys for the benefit of another by providing them with adequate information about the process involved and recognising the value of their donation is consistent with the ethos of the NHS, which exists for the common good.

Finally, whether it is ethical for doctors to encourage a healthy adult to donate a kidney to a stranger is also a question of how far society can or perhaps should go in trying to encourage people to donate their bodily material for the benefit of others.9 While the ethical acceptability of different forms of encouragement for donating bodily material is likely to vary in different circumstances, the key point is that if something is not wrong to do but actually a good thing, then it cannot be wrong to encourage the doing of it.

Notes

Cite this as: BMJ 2011;343:d7140

Footnotes

  • Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References