Is it unethical for doctors to encourage healthy adults to donate a kidney to a stranger? YesBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7179 (Published 15 November 2011) Cite this as: BMJ 2011;343:d7179
Although the number of kidneys transplanted from deceased and living donors has increased, the number of people with end stage renal disease needing a transplant exceeds the supply of these organs. One year graft survival is better for recipients of kidneys from living donors (96.8%) than for recipients of kidneys from deceased donors (92%).1 Only 4% of the first group experience delayed graft function compared with 24% of the second group.2 Given the need for kidneys and the superior outcomes of transplants from living versus deceased donors, there are compelling medical reasons for transplant organisations and medical professionals to promote living over deceased kidney donation.
The estimated risk of death from donating a kidney is 1 in 3000. The risk of perioperative and postoperative complications from unilateral laparoscopic nephrectomy is 10-15%.3 These include, but are not limited to, bleeding, infection, bowel injury, hernia, and postanaesthesia depression. The loss of renal mass from nephrectomy can reduce renal function by 20%, as measured in terms of glomerular filtration rate, and cause a slight increase in hypertension, which correlates with an increased risk of cardiovascular disease. However, younger donors have a greater compensatory increase in actual glomerular filtration rate in the remaining kidney than older donors. When the donor is healthy and has been carefully screened, living kidney donation is relatively safe. The combined psychological benefit to the donor and physiological and psychological benefit to the recipient seem to outweigh any risk to the donor.
This does not imply that doctors should encourage healthy adults who are their patients to donate a kidney to a stranger. While the risk of complications from nephrectomy is relatively low, it should not be ignored. These complications may adversely affect a donor’s postoperative quality of life, which may explain why some donors’ expectations are not met after surgery.4 Doctors have an obligation of non-maleficence to their patients.5 This is not an absolute obligation, since drugs and surgical procedures needed to treat diseases may have harmful side effects. Yet it is one thing for a doctor to expose a patient to some risk in order to treat a disease; it is quite another to encourage a patient to put his or her own physical health at risk in order to benefit another. Doctors may have a secondary duty to promote organ donation and transplantation as one way of promoting public health. But this secondary duty should not supersede their primary duty to “first do no harm,” which prohibits actions or recommendations that would incline their patients to subject themselves to a risk of preventable harm.
As an expression of their autonomy, competent individuals have the right to expose themselves to a reasonable degree of risk. If a sufficiently informed healthy individual freely decides to donate a kidney to a stranger, then any attempt by a doctor to interfere with this action would be a violation of the individual’s autonomy. There is nothing ethically objectionable about a competent adult initiating this process. But it is ethically objectionable when a doctor initiates it. If a patient asks a doctor about living kidney donation, then the doctor should do no more than provide information about the process in an impartial and unbiased way.
The ethical issue here is not so much a conflict between patient autonomy and physician non-maleficence but the extent of the doctor’s duty not to do or allow harm. Some potential donors are willing to accept a greater degree of risk when the recipient is a family member than when the recipient is an unrelated stranger. The risk in nephrectomy may be justified because of the shared emotions, needs, and interests between family members. These factors are lacking when the recipient is unknown to the donor and provide a further reason against encouraging any action that would lead the patient to take on any risk.
Many patients perceive their doctors as authority figures and trust them to always act in their best interests. Encouraging a healthy patient to donate a kidney to a stranger may trade on this trust and unduly influence the patient’s reasoning about the probable benefit and harm. It may cause the patient to minimise or give insufficient consideration to the potential perioperative and postoperative complications of nephrectomy. This might suggest paternalism towards the patient and an underestimation of his or her capacity for risk assessment. Yet there is considerable variation among doctors in how they present information to patients about benefit and risk in living kidney donation.6 Some may present this information in a more positive or negative light than others. Value laden presentation of information may strongly shape the patient’s assessment of risk and the decision whether to donate a kidney. It could unintentionally limit the patient’s autonomy. Doctors may encourage their adult patients to be deceased organ donors because this does not affect their health. But encouraging these patients to be living kidney donors violates their obligation not to expose or incline them to a risk of harm.
Cite this as: BMJ 2011;343:d7179
Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from him) 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.