Ethical challenges in living organ donation.

In an editorial published in the February 2007 supplement to Critical Care Medicine, Dr. Aulisio and colleagues (1) discuss ethical challenges posed by living organ donation. We disagree with some of their conclusions. The authors state that removal “of an organ . for no therapeutic benefit to the patient constitutes a prima facie harm. ” There are two problems with this claim. First, it implies that donors incur unbalanced risk. Yet, many donors experience large psychological benefits through lasting increases in self-esteem (2). Furthermore, donation (and successful transplantation) may actually be therapeutic for donors who are closely related to their recipients because it can alleviate troubling anxiety about the poor health of their loved ones. Consider the reflections of two parental donors, each of whom had donated a kidney to their daughter (3): “There is no doubt in our minds that we, as kidney donors, have gained much more than we lost. Of inestimable value, of course, is the restoration of our daughter’s life and health. ” Second, while it is true that donor nephrectomy constitutes a prima facie harm, the authors imply that living donation is unique in this regard. However, all surgeries cause some injury. As Dr. Moore pointed out (4), “The ancient dogma of ‘first do no harm’ . seems to have been mere window dressing for the necessary hurt that has accompanied much of medical practice over the centuries. ” Justification of potentially harmful medical procedures is based on the expectation of benefit for the person acted upon, which balances the risk; we believe that this applies equally to living organ donation (2). Although offsetting benefits for donors are usually psychological and less obvious than medical ones, they can be at least as large and as important (2); consider the tremendous benefit donation provided to the parents mentioned previously (3). Also, given the importance of respecting pluralistic values, which the authors rightfully emphasize, it is disappointing that they refer to living organ donation as “unneeded surgery. ” Unneeded from whose point of view? We doubt those parental donors would consider their nephrectomies any less necessary than say a coronary bypass operation. Dr. Aulisio and colleagues (1) also suggest that unrelated living organ donation is particularly problematic. Their discussion is reminiscent of the attitude prevailing years ago “of distrust for the motivation and mental health of these donors” (5). There is now much evidence showing that there are many psychologically healthy people who are willing to donate an organ to help a stranger in need. A recent study found that 21 of 43 unsolicited people who expressed interest in donating a kidney to a stranger and participated in a study met rigorous criteria for donorship (6). The authors (6) concluded the following: “Contrary to our medical community’s fears, there are a significant number of psychologically stable, altruistically motivated individuals who want to donate a kidney anonymously to a stranger, and seek no material compensation in return. ” Also, in some cases the use of a completely unrelated donor may actually be “more moral than the use of the genetically related donor” because strangers are not subject to the internal or external pressure that some relatives experience (5).