Letter to the Editor in Response to: Gordon et al., Elective Surgical Patients as Living Organ Donors: A Clinical and Ethical Innovation by Testa et al.

Abstract

Dear Editor: We are pleased that Gordon et al. are intrigued by our proposal even though they urge caution before going forward. On the matter of caution, we agree entirely. In fact, our decision to publish our concept paper in the AJT before operating on the first case was aimed at promoting openness and transparency and critical scrutiny of our ideas. This approach of inviting public comment before performing the first innovative procedure is based on a model we developed at the University of Chicago in 1989, when we began the first protocol series of living donor liver transplantation (1Singer PA Siegler M Lantos JD et al.Ethics of liver transplantation with living donors.N Engl J Med. 1989; 321: 620-622Crossref PubMed Scopus (270) Google Scholar). We will move forward on this concept only after conducting rigorous qualitative and quantitative research exploring the feasibility of this idea for the key stakeholders involved—patients, general surgeons, transplant surgeons and payers. This research will study whether public trust of the transplantation system will be affected by our proposal and whether payers, public and private, will support an effort to increase kidney transplantation and thus decrease the overall costs of end stage renal disease care. Dr. Gordon's letter also raises questions about a number of ethical issues that we discussed in detail in our paper, including donor risk, the potential vulnerability of surgical patients, and strategies for improving the informed consent process. Certain points deserve repeating for emphasis. On the issue of donor risk, Dr. Gordon claims that ‘reducing the number of surgeries…does not help the donor’. No one knows if Dr. Gordon's claim is correct. For the patient who is scheduled for elective abdominal surgery and who wants to be a kidney donor, there is no data on whether the incremental risk of adding the donor nephrectomy to the elective surgery is more or less than the de novo risk to a healthy person who volunteers to be a kidney donor. As we indicate in the study, this would be one important issue to study when a protocol series of cases was done. Regarding donor advocates and their ability to protect surgical patients—whom we agree may be subject to distinctive, though not necessarily greater, vulnerabilities—our experience differs from Gordon's ‘prior experience’ when she questions the independence of advocates. In 1989, the University of Chicago was one of the first programs in the world to implement a vigorous independent living donor advocate program, a program which continues to the present time. Based on our 20 years of experience, we respectfully disagree with Gordon's views and believe that donor advocates can maintain their independence and integrity. However, we do agree with Gordon that there are several potential consequences of this proposal that require careful exploration, including the potential for gender inequities in patients who would be most likely to be asked to donate, and the possibility of slowing the evaluation process for other living donors. Both concerns raise important ethical issues that require empirical investigation. Finally, the decision on whether to move forward may turn ultimately on patient/donor attitudes, preferences, desires and public acceptance. If elective surgery patients who wish to serve as altruistic donors request that their general surgeons give them the opportunity to donate, then there is a strong possibility that our proposal might succeed and help to reduce the current shortage of abdominal organs for transplantation. Sincerely,