Elective Surgical Patients as Living Organ Donors: A Clinical and Ethical Innovation

Abstract

To the Editor: One of the principal reasons for publishing our concept paper regarding elective surgical patients as living kidney donors was to encourage criticism of the proposal from experienced transplantation physicians and surgeons such as Drs. Mortier and Rogiers. In this way, we hope to improve and refine our proposal. Mortier and Rogiers are correct in observing that the proposal aims to decrease donor risk in two very different ways: individually and collectively. First, the overall surgical risk would probably decrease for an individual who needs an elective cholecystectomy and who also is motivated or inclined to become an unrelated living organ donor, either now or the future. We believe that, for such persons, the incremental risk of combining the cholecystectomy with the donor nephrectomy during the same operation and anesthesia is likely to be less than the overall risk for the same individual in having two separate surgical procedures and two different general anesthesias. The second decrease in risk is to the collective society. If enough kidneys could be obtained from willing, voluntary elective surgery patients, there would be a decreased need for surgeons to use healthy, related living donors. Using living donors in this way exposes them to risks and harms from a surgical operation that they do not need for their own health but agree to, only to benefit a third party, usually a related recipient, who needs a kidney transplant. Mortier and Rogiers criticize both of these efforts at risk reduction. At the individual level, they claim that surgical patients who might become kidney donors are susceptible to coercion and cannot make an independent decision. While we state in our paper that coercion of living unrelated donors is a critical issue, we believe the same concerns have been raised for 50 years about living-related donors, who are also thought to be susceptible to subtle and overt coercion from family members and physicians (1, 2). We continue to believe that with proper ethical safeguards, such as those implemented in our living liver transplantation program in the 1980s and 1990s (3) and described in the current paper, donor coercion can be minimized. Such proposed safeguards include the use of an independent donor advocate, separate from both the general surgeon and the transplant surgeon, as well as the requirement that any elective surgical patient interested in discussing this idea further would not be asked directly to donate but would have to make a proactive effort to obtain more information about the possibility of donating. At the societal, collective level, we recognize the concerns expressed by Mortier and Rogiers that social trust in the transplantation enterprise could be undermined by this new approach. A different outcome is possible, however. We would hope that relying on voluntarism for unrelated donors would serve as a strong positive statement of altruism and community support and could actually increase the understanding and public acceptance of living donor organ transplantation worldwide. Sincerely, Giuliano Testa, MD