To the Editor: In response to Dr. Aaron Spital's concerns (1) about my article “Risk appreciation for living kidney donors: another new subspecialty?” (2), my coauthors and I clearly recognize that transplant centers have the right to pass judgment on all proposed donations and should abstain unless they can affirm that donors are well informed, acting freely, acting rationally, and do not desire to take excessive (heroic) risk. The center's responsibility to affirm these criteria is much greater than it is for people in ordinary life who ethically participate in the risk taking activities of others. In fact, the ethical importance of affirming these criteria has led us to develop written testing of rational thinking and knowledge of risk and benefit for all donors as part of a responsible donor selection process (3-5). “Acting rationally” indeed means to us that donation must “make sense for the donor,” to use Dr. Spital's phrase. Conversely, we call donation irrational when it will do no good or is in clear conflict with the donor's important beliefs, values and goals. Heroic action is expected to achieve benefit and is rational. It may be heroic to run out into traffic to save a child. It is irrational simply to run out into traffic. Dr. Spital does not really address our point that transplant centers should eschew heroic donors because centers are self-interested and may not adequately discharge their duty to confirm both the rationality and the understanding of risk of putatively heroic donors. As not many people really wish to be heroes, centers have a high ethical standard to meet here. We also argue that even just the appearance of center misconduct would threaten the larger transplant effort in the public mind (3-5). Dr. Spital feels that a better argument for not participating in a high-risk transplant is one's “concern for harming the donor.” This concern has prompted some physicians to refuse to participate in all living kidney donation and some centers to refuse donors with isolated medical abnormalities (2). But, because we are always concerned for donors, and because risk and harm are present for all donors (3, 6), one must still argue why donation is ethical or unethical in a given case. One then returns to the four fundamental considerations that we have already proposed. Transplant physicians may differ as to whether a given donor is unexceptional, at moderate risk, heroic, uninformed or irrational. Nevertheless, we can construct unambiguous paradigms. Dr. Spital would not characterize as heroic his hypothetical willing donor if she knew that her kidney would not function when transplanted into her child. That donor is perhaps compelling, but irrational. Clarifying the fundamental ethical issues this way leads to better practices. For example, if risk literally cannot be estimated, donation cannot proceed because it becomes irrational for most donors and heroic for the rest (2). To this end, we have supported factually educating donor counselors (6) so they may quantify risk as, e.g. “1 in 100” instead of just presenting it prescriptively as “high” or “low.” Dr. Spital feels that we could ethically then also recommend against donation to some donor candidates. Here, we must not confuse the process of finding a donor acceptable with telling an acceptable donor what to do. The center should decide whether it is “in” or “out” but be wary of abandoning its neutrality. One cannot defend the center's advising some acceptable donors not to donate without defending its “right” to urge others to proceed. Furthermore, any truly responsible attempt to advise acceptable donors would depend on a detailed elucidation of their individual priorities and would amount to donors making the decision themselves (3). Most of us will continue to agree on the vast majority of actual living kidney donor acceptance decisions, because the general ethical principals that we subliminally apply are the same. I am grateful that Dr. Spital critiqued this article, so that these principles can be better articulated to help to defensibly structure the vital activity of living kidney donor selection.
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Mar 1, 2008
Benita W Britton-Byrd + 3
Open Access