Is it unethical for doctors to encourage healthy adults to donate a kidney to a stranger? No
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7140 (Published 15 November 2011) Cite this as: BMJ 2011;343:d7140
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
It’s a funny thing. If I were to submit an article to the BMJ about a medical treatment, I would be expected first to do a systematic review, and I would have to list all the previous publications that I had used to reach my conclusions. But when it’s an ethical issue, it’s as if no one had ever thought of the subject before. I have not done a systematic review, but I used to have a passing interest in the ethics of transplantation. Taking a quick look at my notes I find that in 1989 Evans wrote [1] that non-related donation should be welcomed “where clinically appropriate and truly voluntary”. He also stated categorically that, “The principal arguments for a ‘genetic-relative’ restriction have been shown to fail…”
Levinsky in 2000 [2] reviewed the history of unrelated donation in the USA, and took more the view of “first do no harm”. Levinsky was particularly worried about the financial interests of hospitals that did both retrieval and transplantation, although this is not relevant in the UK.
When I searched on Evans’ paper, PubMed suggested some related citations. Just by scanning the titles, some seem to me to be highly relevant to this head-to-head ethical debate [3-5]. I have not done a more detailed search, but then I am not writing an article.
Admittedly, the head-to-head in this issue of the BMJ is restricted by the precise question of whether doctors should encourage donation by strangers, but nonetheless the question is if Evans, in 1989, considered the ethical objections had failed, why did Cronin not cite him in support, and why did Glannon not specifically refute his already constructed argument?
My views are with Stephen Potts: it depends what you mean by “encourage”, but my response is emotionally not ethically based.
References
1. Evans M. Organ donations should not be restricted to relatives. J Med Eth 1989;15:17-20.
2. Levinsky NG. Organ donation by unrelated donors. NEJM 2000;343:430-432.
3. Peters DA. J Med Humanit Bioeth Rationale for organ donation: charity or duty? 1986;7:106-21.
4. Prottas JM. Altruism, motivation, and allocation: giving and using human organs. J Soc Issues 1993;49:137-50.
5. Spike J. What's love got to do with it? The altruistic giving of organs. J Clin Ethics. 1997;8:165-70.
Competing interests: No competing interests
Antonia J. Cronin (1) claims that “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.” Glannon does not argue for this claim; it is merely assumed. To focus on the shortage of organs and the deaths of potential organ recipients does not address the issue of potential harm to the organ donor. It is that issue that must be addressed to show that autonomy trumps beneficence in living donor donation.
A number of studies of living kidney donation have revealed complication rates ranging from 7.2% to 23.9%, including several deaths (2). The fundamental responsibility of the physician is for the health care of the individual patients whom he or she serves. That responsibility is subverted when the physician performs a procedure that cannot benefit (except perhaps psychologically) and can only physically harm the patient. Autonomy does not trump the fundamental responsibility of the physician to “first, do no harm,” if an autonomous decision can even be made in many cases of living kidney donation. Pressure from the patient desiring the transplant, from the patient’s family, and from the doctor, may de facto be coercive for a potential donor whose guilt may lead to donate a kidney. For a doctor to take advantage of guilt or other feelings is an abuse of power. Even if the potential donor makes a truly “autonomous” decision, that “does not remove or reduce the physician’s responsibility for doing harm to a patient.” (2) Harming a patient, even to do good for another patient, amounts to an abuse of medical power and a violation of the fundamental end of medicine to benefit, not harm, a patient. To try to encourage healthy patients to donate a kidney to a stranger is, therefore, a fortiori, morally wrong.
References
1. Cronin, AJ. Is it unethical for doctors to encourage healthy adults to donate a kidney to a stranger? No. BMJ 2011;343:d7140 doi: 10.1136/bmj.d7140 (Published 15 November).
2. Potts M., Evans DW. Is solid organ donation by living donors ethical? In: W Weimar, MA Bos, JJ Busschbach (eds.). Organ Transplantation: Ethical, Legal, and Psychosocial Aspects—Towards a Common European Policy. Lengerich: Pabst Science Publishers, 2008, 377-81.
Competing interests: No competing interests
It is unfortunate that the framing of the question for this debate allows only two responses - Yes or No. It thereby fails to recognise reality, and artificially restricts the arguments on both sides.
In this context “encouragement” spans a wide range: from the neutral presentation of relevant facts to already interested members of the general public, via websites and the like - all the way to personally urging a previously uninterested patient in the course of consultation about another matter.
There is nothing wrong in the former: but the latter would be so highly unethical as to warrant sanction.
The relevant factors include:
1. the nature of the relationship between the recommending doctor and the potential donor. Is the doctor making the recommendation as part of his/her role as physician to the donor, or in a more general sense?
2. the setting in which information is passed and any recommendation made (website, leaflet, media appearance, personal lecture, or one-to-one clinical encounter).
3. who triggers the discussion: a potential donor who wished to further explore such donation; or a doctor raising the subject with a previously unaware patient?
Having been involved in the assessment of some 16 potential altruistic donors, leading to 6 transplants to date (all successful for donor and recipient), I have no doubt that these procedures can be of great benefit. But they are not risk-free, and they are still novel in the UK, requiring us as professionals to proceed very cautiously.
Furthermore, paternalistic though it may sound, there is a need to protect those whose wish to donate arises from mental disorder. This is recognised by the HTA in guidance which requires mental health assessment of potential altruistic donors at an early stage in the assessment process, to which neither author makes reference.
Finally the charity newly established to promote altruistic donation might wish to reconsider its title. “Give a kidney: one’s enough” combines a peremptory command with the implication that anyone walking round with two kidneys is selfish in retaining more than they need. I’m sure this isn’t the intention, and that the charity’s work is valuable: but branding matters.
Reference:
Guidance for transplant teams and Independent Assessors: Living Donor Transplantation. Human Tissue Authority
http://www.hta.gov.uk/bodyorganandtissuedonation/organdonations/independ...
Competing interests: No competing interests
Thank you sir for your support for this topic. It is the best thing that a person can do for another person or rather mankind.
I am in full support of it, as it is advice so it has nothing to do with ethical or not. But the advantage is that it can help another person to live life & what better thing can a person do in his/her life?
Competing interests: No competing interests
Re: Is it unethical for doctors to encourage healthy adults to donate a kidney to a stranger? No
In 2010-2011 NHS Blood and Transplant reported a reduction in the number of patients on the UK transplant list for the first time over the last decade. This has coincided with a steady increase in transplant activity over recent years.
The increase that has been seen in donor numbers contributing to this trend has been largely attributed to the growing number of live donor transplants taking place, with donor numbers in this group growing at a marked and steady rate. Deceased donor numbers however seem to have remained largely static.
Although altruistic donor numbers as mentioned contribute to a small proportion of organ transplants taking place in the UK at present, I have no doubt that its proportion will grow and become increasingly important in the future.
Whether or not doctors should actively promote this form of organ donation to their patients however remains a rather different matter altogether.
As somebody who has benefited from a live donor renal transplant I am obviously in favour of most strategies that will improve national rates of organ donation and give other patients the same opportunity as I had to regain my life.
Despite this however, while I believe that altruistic donation is an ethically valid and acceptable mode of organ donation, it is one that causes several conflicts within our moral code as healthcare professionals. Actively promoting the idea of altruistic donation to patients who have not actively initiated or expressed interest in discussing such issues would be wholly unacceptable, as we would be failing to place the best interests of the patient who sits before us as our primary concern. It would also contradict the basic ethical value of non-maleficence by introducing our patient to the idea of risk taking for the “greater good” of society.
Of course those patients who are actively seeking knowledge on the idea of donation by whatever mean should be offered counselling and balanced information giving in a professional and non-biased manner, but a definitive line needs to be drawn and the focus of the consultation kept purely patient centred.
Organ donation and transplantation remains an emotive and ethically challenging branch of medical practice where public health and frontline medicine merge. The social conscious of society on issues surrounding organ donation continue to evolve, as is evident by the recent public consultation of the Welsh Assembly Government on the issue of introducing “soft” presumed consent.
Our aim as doctors however is to remain unbiased in the face of this and make decisions on a professional basis with the health of each individual patient kept in mind, however difficult this can sometimes be.
Competing interests: No competing interests