Rejecting Heroic Kidney Donors Protects Much More Than Public Trust

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To the Editor: In his recent editorial, Dr. Steiner suggests four criteria for determining the suitability of living kidney donors (1). I have several concerns about his approach. One of the proposed criteria for rejection of a potential donor is irrational action. This is appropriate. However, I disagree that the definition of irrational action includes ‘incurring great risk for little benefit.’ Is it irrational for a parent to wish to donate to her dying child even though the risk is great and the chance of success is low? I think not. Many caring parents will take whatever risks are necessary to save their children, however unlikely they are to succeed. So while it usually makes sense to reject volunteers when the risk is much higher than the likelihood of success, the rationale is not that the potential donor must be acting irrationally. Rather it is concern about harming her and the fact that it is not only the potential donor's view that counts—what the donor's physician thinks about donation also matters (2-4). This brings me to my second and most important concern about Dr. Steiner's proposal. Not included among the suggested criteria for determining the suitability of a potential donor is the need for her physician to believe that donation makes sense. This is a major omission. Because organ donation cannot take place without the physician's help, and because the physician has a duty to protect the donor's welfare, he shares responsibility for the outcome (2). As Carl Elliott points out (5): ‘the doctor is not a mere instrument of the patient's wishes… [he] is also a moral agent who… is in the position of deciding not simply whether a subject's choice is reasonable or morally justifiable, but whether he is morally justified in helping the subject accomplish it.’ Given their special fiduciary responsibility, physicians must try to act in the best interests of their patients (2). And because doctors are autonomous agents, they are not obligated to accept offers of organ donation that they think would cause more harm than good (3, 4). Consistent with this view, James Childress concludes (6): ‘the physician has no moral duty to satisfy the patient's desires if he finds them incompatible with acceptable medical practice. The physician's conscience merits protection too.’ Given these considerations, I believe that the major reason for rejecting a heroic volunteer is not, as Dr. Steiner suggests, concern about damaging public trust but rather concern about the high probability of harming her. Furthermore, I disagree that physicians should present an estimate of risk ‘with no recommendation as to what a donor candidate should decide.’ Included among physicians' responsibilities is a duty to evaluate and advise. And when the risk is very large, generally they should reject the volunteer, no matter how committed she may be. This is not to say that the views of potential donors are unimportant. On the contrary, I believe that potential donors should have a major say in determining their own suitability (4). But while it is essential that physicians try to incorporate their patients' point of view, there is no absolute right to donate and respect for autonomy extends to physicians as well (2, 3). In view of their medical expertise and their essential participation in the process, it makes sense that potential donors' physicians must give a green light for donation to proceed. This screen serves the important dual function of protecting volunteers from harm while preserving the integrity and consciences of physicians.