Commentary: Making the most of strangers' altruism

Lainie Ross, in her article in this issue, criticizes on ethical grounds a number of factors in the University of Minnesota program that allows unrelated strangers to donate kidneys for transplant.1 I have to admit that when the transplant center at the University proposed allowing the practice of

what came to be called "nondirected donation," I was skeptical about a number of the same issues that trouble Dr. Ross. But as my colleagues and I examined and discussed the ethics of such a plan, along with the risks to prospective donors, their possible motivations, and the logistics of performing the surgeries under conditions of anonymity between donor and recipient, among other factors, we came to believe that such donations can be ethically acceptable. As a product of frequent meetings over the course of a year in advance of the first nondirected donation, we set out to craft a process that would first and foremost meet the test of an ethical approach to organ donation and transplant, the description of which was published in the New England Journal of Medicine in August 2000.(2)

I agree with the general conclusions of Ross' arguments - that organ donation by altruistic strangers is acceptable, and that the organs procured this way ought to be allocated equitably - though take issue with her fundamental claim that related donors are ethically permitted to take greater risks due to their relationship to the recipient, along with her conclusions about how to allocate organs that come from nondirected donors, both in terms of selection of donors and the waiting list that is used.

THE MOVE TO UNRELATED DONORS

The chronic shortage of transplantable organs, along with improved transplant techniques, has led to an increased willingness and ability to accept organs from living donors. While living organ donors were initially limited to blood relatives to reduce the risk of immune rejection, improved immunotherapy has expanded the pool of potential donors far outside of those related by blood, to those who are emotionally related to each other. This has resulted in expanding the notion of "relatedness" to include people related by marriage (spouses and in-laws) as well as those who aren't traditionally considered relatives - friends, co-workers, members of the same church or other community group, and even those with very limited emotional ties, such as good samaritans. With this extension of the concept of living donation, it became a logical and relatively short step from tangentially related directed living organ donors to organ donations from altruistic strangers.

How far should living donation be allowed to go? We asked the question, in deliberating about a policy for living unrelated donation, is informed consent sufficient to justify any living donation to which a prospective donor would voluntarily consent? I argued that consent was not enough, and that there were limits to the risk to which healthy subjects related or not - should be allowed to consent. For me, increasing risk to the donor tilts the balance away from ethical acceptability, and at some upward level of risk, no living donor should be allowed to undertake organ donation, even with adequate informed consent. We can easily imagine a parent volunteering to donate his heart to his child, with full knowledge that it would result in the parent's death, but we refuse such offers. The reason is not so much the physician's own moral agency, as Ross suggests,3 but a clear moral obligation not to cause harm without both sufficient offsetting benefit and a fair distribution of the risks and benefits entailed. Extremely risky organ donation fails on both counts, since it effectively sacrifices the health or life of one person to save another.

DOES RELATIONSHIP MATTER?

One of the concerns in nondirected living donation is that strangers should not be allowed to accept the same level of risk as related donors. The argument is that relatedness matters, such that related donors have more to gain from the donation and so can be allowed to accept greater risk. On this line of reasoning, seeing a loved one's life saved or health improved is a greater benefit than the psychological benefit to a stranger of performing an altruistic act. But both types of donors stand to realize substantial benefits, albeit of different varieties, and it is difficult to understand why one sort of benefit is of greater value than the other, particularly when they are both of such subjective nature.

Ross may well be right that transplant surgeons and the community at large may view the risks and benefits of donation differently for related and nondirected donors,4 but it is not clear what weight such perceptions ought to carry. The donation of an organ to a stranger is likely to be something that is difficult for most of us to understand and something few of us would do, but those are the same feelings we might have for other acts that we have no problem heralding as heroic.

Ross' claim that intimates may actually have an obligation to be a living organ donor seems to impose a duty of heroism, which is a difficult moral argument to make and a position that is not supported by our laws and public policies. There is a history of courts refusing to require beneficent acts on the part of individuals, even if they would be lifesaving.5 In moral philosophy, this is the distinction between actions that are obligatory and those that are supererogatory. We laud people to perform acts that are "above and beyond the call of duty," but don't require such acts of them - to do so would create a duty of heroism, demanding too much of individuals in the process and undermining the value of what it means to be truly heroic.

That being said, we may think it is more understandable, and even expected, for relatives to donate an organ to someone within their family. That neither implies that the risks of donation are more acceptable for relatives to take, nor that there is an obligation to donate on their part that does not extend to strangers. However, if a person makes the decision to donate, then it certainly ought to be to a relative in need before it goes to a stranger.

WHOSE ORGANS ARE THEY?

Among the most difficult questions to address in nondirected donation has been how to allocate the donated organs. Ross suggests that the requirement that the donated organ be transplanted at the University of Minnesota was arbitrary,6 but it was more a function of logistics than anything else. When the University's nondirected donation program was undertaken, there was (and remains) no infrastructure for allocating the organs to patients outside of the University's waiting list. We recognized from the beginning that the organs represent a national resource and ought to be allocated as such, and have repeatedly stated that a national system ought to be developed so that organs from nondirected donors can go to the first patient on a national list rather than to the first patient at the center where the organ is donated. Such an approach has been developed on a local basis by the consortium of transplant centers in the Washington, D.C. area, and may serve as a model for national expansion.

The decision to use the first kidney from a nondirected donor for a patient with the best chance of success was made in part in consideration of public perception issues (which Ross acknowledges are important), and the desire to give the program its best chance for early (and continuing) success. Subsequent nondirected kidneys have been allocated strictly by "running the list" of patients waiting for a cadaveric kidney at the University, allocating them in just the same way as cadaveric organs. Ross' claim - that allocating the first kidney to assure its greatest chance of success is somehow equivalent to the selection of arbitrary (or worse) characteristics by donors - cannot be supported. Unlike some of the programs that have been created since the University of Minnesota's program was announced, our program has a nonnegotiable policy that rejects donor requests that their organs go only to particular types of patients, such as patients of a particular age, gender, religion, or race, since such requests may have discriminatory motives that must be explicitly rejected.

CONCLUSION

The growing gap between the available supply and the demand for solid organs means that the search will continue for new sources of organs. We can all agree that living donation is a growing source of solid organs, as evidenced by the fact that the number of transplanted kidneys from living donors has surpassed the number from cadaveric donors at some of the leading transplant centers in the United States. The question is not whether living organ donation will continue, but rather what conditions and policies ought to apply to make it ethically acceptable.

REFERENCE

REFERENCES

REFERENCE

1. L.F. Ross, "Solid Organ Donation Between Strangers," Journal of Law, Medicine &Ethics, 30, no. 3 (2002): 440-445.

2. A.J. Matas et al., "Nondirect Donation of Kidneys from Living Donors," Nl. Engl. J. Med., 343 (2000): 433-36.

3. Ross, supra note 1, at 442.

4. Id. at 439-444.

5. See McFall v. Shimp, 10 Pa. D. & C.3d 90 (Allegheny County Ct. 1978).

6. Ross, supra note 1, at 442.

AUTHOR_AFFILIATION

Jeffrey Kahn, Ph.D., M.P.H., is Director of the Center for Bioethics and Professor of Medicine at the University of Minnesota. Dr. Kahn works in a variety of areas of bioethics, exploring the intersection of ethics and public health policy. He publishes extensively in the medical and bioethics literature, and also writes the biweekly bioethics column Ethics Matters for CNN.com.