Is it unethical for doctors to encourage healthy adults to donate a kidney to a stranger? Yes

Ethical questions

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.

Balanced information

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.