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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         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*This paper was prepared solely to aid discussion               for the September               2006 meeting, and does not represent the official views of the               Council or of the United States Government.*

**Staff Discussion Paper**
 Living Donors: Process, Outcomes, and Ethical Questions  Ginger A. Gruters, M.A.* 

 * With special thanks for the collaboration of my colleagues, Eric        Cohen and Dan Davis, Ph.D.
**Outline**
**I. Some General Background**
**II. Organ by Organ: Donation Process and Health Outcomes**-  Kidney 
-  Liver 
-  Lung 
-  Pancreas 
-  Intestine 
-  Conclusion 

**III. Some Ethical Questions**-  The Moral Obligation of Doctors 
-  Acceptable versus Unacceptable Risk 
-  The Moral Meaning of "Who Donates?" and "Why?"**�����**

**Appendix 1:** Living Kidney Donor Evaluation        Guidelines        

**Appendix 2:**  Living Liver Donor Evaluation Guidelines        Living Donors: Process, Outcomes, and Ethical Questions     
        The contemporary practice of organ transplantation began in 1954 with a        kidney transplant from a living donor to his identical twin brother.1 Since then, much has        changed: the field of organ transplantation has grown tremendously,        saving, improving, or extending thousands of lives. Thanks to advances        in immunosuppressive medications, it is no longer necessary to be a        close genetic relative to be a living donor; and thanks to improvements        in surgical techniques, the recovery time for living donors has        decreased for many procedures, while graft survival has improved. This        success has heightened interest in expanding the pool of living organ        donors, especially in light of the growing demand and need for        transplantation and the limited supply of deceased donors.

        Certain crucial facts remain, however. Removing organs from living        donors still involves performing surgery on a healthy patient for        reasons that have nothing to do with his or her physical health, and        with genuine risk of physical harm. Thus, living donation, by its very        nature, presents us with a unique ethical dilemma in the practice of        medicine, which has long been guided by the ethical maxim: "First, do        no harm." Although there are accumulating data on the perioperative        risks of being a living donor, there remains a dearth of data on the        longer-term outcomes for living donors.

        The aim of this working paper is to provide background on the process        of living organ donation, with particular attention to what we know        about the health outcomes for living donors, and especially the        significantly different risks between kidney donation and liver or lung        donation, the three most common types. Part I provides some basic        information on the state of organ donation from living donors. Part II        surveys the donation process and health outcome data organ by organ.        Part III raises some of the relevant ethical questions, which the        Council might discuss in light of the empirical information presented        here.

**I. Some General Background**
        A living donation takes place when an individual willingly allows the        removal of an organ (or part of an organ) for the purpose of        transplanting it into another. Most living donors are family members or        friends of the intended recipient, but there is also a growing number        of so-called anonymous altruistic donors. Prior to living donation,        potential donors must undergo rigorous evaluations of their physical        and psychological health, must be informed of the risks of living        donation, and must voluntarily consent to donation. OPTN/UNOS has not        issued specific policies to govern the process of living donation, but        two consensus statements have been developed by the transplant        community to ensure greater uniformity in the selection and pre- and        post-operative care of living donors: the Ethics Statement of the        Vancouver Forum on the Live Lung, Liver, Pancreas, and Intestine Donor        and the Consensus Statement of the Amsterdam Forum on the Care of the        Live Kidney Donor.2 Both        consensus statements emphasize the process of informed consent and the        opportunity for refusal.

        Although "the OPTN/UNOS Board of Directors has recommended the        development of a standardized tool to inform potential living donors        and recipients about the living donation process, a nationally        standardized informed consent process does not currently exist."3� It is thus within the        purview of the transplant center to establish its own procedures for        informing donors and recipients about the following kinds of issues:      
-           The fact that communication between the donor and the transplant          center will remain confidential        
-           The evaluation process        
-           The surgical procedure        
-           The availability of alternative treatments for the transplant          recipient        
-           The potential medical or psychosocial risks to the donor        
-           The national and transplant center-specific outcomes for both donors          and recipients        
-           The possibility that future health problems related to the donation          may not be covered by the donor's insurance and that the donor's          ability to obtain health, disability, or life insurance may be          affected        
-           The donor's right to opt out of donation at any time during the          donation process 4 

        In addition, the HHS Advisory Committee on Organ Transplantation (ACOT)        recommends that the following ethical principles and informed consent        standards be implemented, such that all living donors are:
-           competent, that is, they possess decision-making capacity;        
-           willing to donate;        
-           free from coercion;        
-           medically and psychosocially suitable;        
-           fully informed of the risks and benefits of donating; and        
-           fully informed of the risks, benefits, and alternative treatment          available to the recipient.        

        Two related ethical principles that ACOT endorses are:
-           The benefits to both the donor and the recipient must outweigh the          risks associated with the donation and transplantation of the live          donor organ; and        
-           A clear statement that the potential donor's participation must be          completely voluntary, and may be withdrawn at any time. 5 

        Ensuring that the decision to donate is voluntary and uncoerced is a        challenge considered in greater depth in the final section of this        paper.

        By far, the most common organ to be donated by living donors is the        kidney (about 95% of all living donations), but it is also possible to        donate all or part of the liver, lung, pancreas, intestine, and        heart.67 At this time, there are "no absolute age        limits to organ donation," but "individuals considered for living        donation are usually between the ages of 18-60 years of age."89� Additionally, UNOS reports, "a handful of medical        conditions will rule out organ donation, such as HIV-positive status,        actively spreading cancer (except for primary brain tumors that have        not spread beyond the brain stem), or certain severe, current        infections. However, for most other diseases or chronic medical        conditions, organ donation remains possible."10� In the process of clinical evaluation,        potential living donors generally undergo the following tests: blood        test, tissue typing, crossmatching, antibody screen, urine tests,        X-rays, arteriogram, psychiatric and/or psychological evaluation,        gynecological examination, and a final blood test.11

        In 1988, the effort to compile various types of data on living donation        was launched in the United States, and since then there have been        80,516 living donors in the U.S., with the percent of living donor        transplants compared to cadaveric donor transplants rising in the last        decade.12 In 1995, living        donation accounted for 35.1% of all transplants; in 2005, living        donation accounted for 47.6% of all transplants.

**II. Organ by Organ: Donation Process and Health Outcomes**
        Although it is possible to generalize about certain features of living        donation *per se*, it is important to analyze this increasingly        significant source of human organs on an organ by organ basis, to        review briefly the history of the relevant procedures, to look more        closely at donor evaluation, and, especially, to survey what is known        about perioperative and long-term risks to donors. After reviewing the        available statistics on morbidity and mortality associated with living        donation, the transplant community's recommendations for improved        tracking and response to longer-term health outcomes of living donation        will be discussed. Most of the information and data concern living        donation of kidneys, livers, and lungs; for the other organs and parts        of organs, living donation is relatively rare and significant data do        not exist.

**A. Kidney**
*Living Donors:*        1995: 3,392                2005: 6,564                To date (from January 1, 1988-April 30, 2006): 76,29713

        Nephrectomy, the surgical removal of a kidney, was apparently first        performed by the German surgeon Gustav Simon on August 2, 1869.� This        proved that a human being could still live with only one functional        kidney-the first step toward the age of living donor kidney donation.        At present, "potential kidney transplant candidates constitute        approximately 70% of the individuals on the entire Organ Procurement        and Transplantation Network (OPTN)/United Network for Organ Sharing        (UNOS) waiting list," while, as said above, kidney donation constitutes        roughly 95% of all donation from living donors.14

        For recipients of kidneys from living donation, the evidence is        encouraging. The survival rate for recipients of living donor kidneys        is measurably better than that of deceased donor kidneys: at one year,        research shows a 97.9% survival rate for living-donor kidneys versus a        94.6% survival rate for deceased-donor kidneys; at five years, the        living-donor kidney survival rate is 90.2% versus 81.1% for        deceased-donor kidneys.15        The National Kidney Foundation also notes certain additional advantages        with living donor kidneys:

A kidney from a living donor usually functions immediately, making it        easier to monitor.� Some nonliving donor kidneys do not function        immediately and, as a result, the patient may require dialysis until        the kidney starts to function.
Potential donors can be tested ahead of time to find the donor who is        most compatible with the recipient. The transplant can take place at a        time convenient for both donor and recipient.16

        Thus, with living donor kidney donation, the outcome for recipients is        generally better, and due to progress in preventing immune rejection        complications, the outcome for recipients of living unrelated donors is        equivalent to that of related donors.17  In addition, laparoscopic nephrectomy is an option today,        where "smaller incisions make for faster recovery time and less pain"        for the donor (though, as we will see, not necessarily better long-term        outcomes).18        Nonetheless, all of these advantages exist alongside a major        comparative disadvantage: "a living donor . is required to have a major        operative procedure that is associated with morbidity, mortality and        the potential for adverse long-term consequences of living with a        single kidney."19�        

*Donor Evaluation*

        The OPTN/UNOS Ad Hoc Living Donor Committee has offered potential        Living Kidney Donor Evaluation Guidelines, and although they are not        current OPTN/UNOS policy, it is possible that these guidelines could        become the standard for practice in living kidney donor evaluation (see        Appendix 1).20   At this        time, however, the precise procedures and process are within the        purview of the transplant center.

        The process of evaluating a potential living donor begins with        educating the donor about the donation process and reviewing the        donor's health history.� The donor's blood type is determined early on,        so as to determine the potential donor's compatibility with the        recipient.21 � The        importance of full disclosure is central to the whole process of        eliciting the potential donor's consent or refusal to donate, including        discussion of "the impact of donation on their social and financial        well-being, short-term morbidity and mortality directly related to the        surgery, future risk for renal insufficiency and failure, risk for de        novo medical problems with renal and overall health (i.e.,        hypertension, diabetes), and risk for allograft failure in the        recipient because of rejection, technical problems, recurrent disease,        and/or comorbid medical problems."22� The more detailed health evaluation consists of myriad        tests to assess the following: "donor hypertension, body mass index,        dyslipidemia, renal function, malignancy, and a history or current        presence of infectious diseases such as tuberculosis or hepatitis."23� In addition, the        potential donor's age, amount of proteinuria, degree of hematuria, and        the evaluation performed in those with a history of nephrolithiasis and        a strong family history of diabetes are taken into account.2425262728� This is necessary, as factors        such as obesity, hypertension, type II diabetes, and infectious        diseases have potentially detrimental effects to the *donor*, in        addition to making the donor candidate's organs potentially ineligible        for transplant.      

*Perioperative Risk and Long-Term Risk*

One study of the kidney donation process notes the following: "the risk        of donating a kidney includes both the short-term perioperative risk,        including pain and discomfort, and the long-term risk of having only        one kidney. Exactly what information potential donors are told about        the risks involved in renal donation appears to vary substantially from        center to center."2930 Moreover, with living        kidney donation, "information on perioperative risk comes from three        sources: published data on the risk of any major surgery, published        data on the specific risk of donor nephrectomy, and the personal        experiences of the transplant team."31�

        In living kidney donation, the donor may opt for one of two types of        surgery: an open nephrectomy or a laparoscopic nephrectomy. The *open        nephrectomy* involves making an incision of several inches (6-10        inches) in the donor's abdomen area, and it requires the removal of all        (or part of) a rib, in order to allow removal of the kidney.3233 The *laparoscopic nephrectomy* requires        3 to 5 small incisions (1-inch or less) to be made in the donor's        abdomen, and this procedure is characterized by its use of a        laparoscope, a telescopic device which is inserted into the incisions        in order to provide viewing capabilities for the surgeon.3435 Surgical instruments are then inserted into        the incisions as well, and with the help of the laparoscope, the        removal of the kidney is made possible. In the end, the incisions        require cutting through three layers of muscle, and the kidney is then        removed through the largest incision (about 2.5 inches).36 Studies to date have shown        that laparoscopic procedures usually result in less pain, shorter        hospital stays, and faster recovery, yet there is also evidence of a        higher relative incidence of complications.37�

        For an open nephrectomy, hospital stays average 6 days; with        laparoscopic nephrectomy, hospital stays average 4.1 days. Those who        have the open procedure typically return to work in about 12 weeks,        while those who have the laparoscopic procedure typically return in 5        weeks. After open surgery, one can drive a car after 6 weeks; with        laparoscopic surgery, the wait is 2 weeks. One can exercise after 11        weeks with open surgery and after 4 weeks with laparoscopic surgery.38� Due to this greater ease        of recovery, laparoscopic nephrectomy is now the more common surgical        procedure used with living kidney donation today. 39404142 Yet the laparoscopic procedure        is also relatively new, first conducted in 1995 at Johns Hopkins        Bayview Medical Center.43        Unlike open nephrectomy, laparoscopic nephrectomy is an intraperitoneal        operation (i.e., takes place within the area that holds the abdominal        organs), meaning that the risks of reoperation for hemorrhage or bowel        obstruction are typically higher.44 Matas and colleagues conducted a survey which "found some        differences between donation techniques in the rates of reoperation,        complications, and readmissions-all higher with laparoscopic        nephrectomy."45 It should        also be noted that there are surgical variations, such as        "hand-assisted laparoscopic" and "mini-open" nephrectomy that involve        characteristics of both laparoscopic and open nephrectomy, and if at        any time complications arise in the course of laparoscopic surgery, the        procedure can be changed to an open nephrectomy. 4647

        Perioperative risks include, but are not limited to, the following:        pneumothorax, small peritoneal damage, superficial wound infection,        deep wound infection, pneumonia, urinary tract infection, renovascular        injury, bowel injury, bowel obstruction, hernia, hematoma, pulmonary        embolism, transfusion, orchalgia, transient neuromuscular injury,        fever, liver bleeding, acute renal failure, bradycardia, hemorrhage,        anaphylactic reaction, or even re-operation.4849505152

 Along with the perioperative risks, the long-term health outcomes for               living kidney donors are a topic of great concern in the transplantation               community. One of the major long-term concerns for living kidney               donors "is whether having a unilateral nephrectomy predisposes to               the development of kidney disease and/or premature death."53               According to the statistics available, mortality after living kidney               donation is .03% and morbidity is less than 10%." 545556               Yet, "of concern is the recent finding that mild renal dysfunction               or proteinuria correlates with cardiovascular risk.� All donors               lose 20% renal function; and. proteinuria is not uncommon after               kidney donation."57 Thus, the effects               of proteinuria and mild renal dysfunction need further investigation,               in light of the association of these phenomena with risks to the               cardiovascular health of living kidney donors. All of these findings               suggest that additional, systematic follow-up, especially concerning               long-term outcomes or effects on the health of living kidney donors,               is needed.� Arthur Matas, a transplant surgeon at the University               of Minnesota and an analyst of living donation, presents six pressing               questions in need of research:
-           Does kidney donation increase the long-term risk of developing End          Stage Renal Disease (ESRD)?        
-           Is the mild increase in blood pressure seen in some donors          progressive, and is it a risk for ESRD or survival?        
-           Does the incidence of protoeinuria increase after donation?        
-           Do donors with increased BMI or a history of smoking have increased          risk for development of proteinuria and renal dysfunction?        
-           Are donors who subsequently develop type II diabetes or hypertension          at increased risk for ESRD, and does ESRD develop more rapidly?        
-           Does the mild renal impairment, increase in blood pressure, and          proteinuria associated with uninephrectomy increase cardiovascular          risk?  58 

        While "studies to date have suggested that there is not an increased        incidence of ESRD vs. the age-matched general population" with living        kidney donors, there are insufficient data to prove that living donors        are not at an increased risk.59� As the Amsterdam Forum states:

        As in the general population, based upon age and other medical risk        factors (e.g., hypertension, proteinuria, hyperlipidemia, impaired        glucose tolerance test), kidney donors should undergo long-term        follow-up of body weight, blood pressure, blood sugar, serum        creatinine, and urinalysis.� Abnormalities should be treated promptly        by either the local medical physician or the transplant nephrologist.�        Long-term collaborative prospective studies and comprehensive national        registries should be established to determine whether the incidence of        medical risk factors and renal dysfunction is different from the        general population.60

**B. Liver**

*Living Donors:*        1995: 54                2005: 323                To date (since January 1, 1988-April 30, 2006): 3,066      

On November 27, 1989, the first successful liver transplantation with        an organ from a living donor took place at the University of Chicago        Medical Center. The donor was 29-year old Teresa Smith, the mother of a        21 month-old daughter, Alyssa, who suffered from biliary atresia, a        congenital condition that can prove fatal if not treated. Alyssa        graduated high school on May 27, 2006. She is completely recovered,        leads a "normal" teenage life, and for the past three years has been        free of taking anti-rejection medications. The mother is also reported        to be doing well, and is very thankful for the success of the        transplant that took place years ago.61�
*Donor evaluation*

A potential living liver donor must be in excellent physical and        psychological health, and is required to undergo extensive examinations        and testing, including a radiological imaging of the liver which        assesses the anatomy, liver volume, and size.62 It has been noted that "a liver biopsy may be        performed," but this practice is not mandated.6364� The OPTN Ad Hoc Living Donor Committee has issued Living Liver        Donor Evaluation Guidelines, but these are not currently OPTN/UNOS        Policy (see Appendix 2).65 There is no national standard of evaluation for living liver        donors at this time, leaving each transplant center to make the final        decision regarding the suitability and health of the potential live        liver donor.��

*Perioperative Risks and Long-term Risks*

        Today, live liver donation is considered one of the most dangerous        living donations in terms of risks to the donor, even though the        donor's remaining liver segments have the ability to regenerate        themselves after donation and recover total function. It is necessary        to remove the gallbladder and in general to remove 25 to 65% of the        liver.66 The Vancouver        Forum maintained that live liver donation should take place "only if        deceased donor transplantation is not possible," and "after careful        analysis of the recipient risk to benefit ratio as it relates to        severity of liver failure, quality of life, and expected wait list time        for a deceased donor."67        Recipients of living liver donation are usually genetically or        emotionally related to the donor; non-directed living liver donation is        "unusual."68

        The perioperative risks associated with living liver donation include:        infection (e.g. urinary tract infection), pneumonia, blood clotting,        allergic reaction to anesthesia, injury to the bile duct or other        surrounding organs or tissues (e.g. spleen or bowel), obstruction of        the intestine, liver failure, biliary strictures, and/or possible        death. 69 Additionally,        with a living liver donor, it is necessary to remove a portion of the        saphenous vein in the donor's leg to connect the donated liver to the        recipient.70 This        procedure usually takes from 5 to 8 hours, and the resultant hospital        stay usually lasts about 7 days.� Barring complications, the donor then        may return to work or normal activity (if not overly physically        strenuous) in 4 to 6 weeks.

        The Vancouver Forum reports that "the estimated risk of mortality and        morbidity currently associated with live donor right hepatectomy is        0.4% and 35% respectively."71 These risks are thus dramatically higher than the risks        associated with living kidney donation-more than 13 times higher for        mortality and 3.5 times higher for morbidity. In looking at worldwide        statistics, "right lobe liver donation is associated with an increased        morbidity and more severe complications than that associated with left        lobectomy or left lateral segmentectomy."72� Specifically, "mortality approaches 0.5% for        the right lobe donor in contrast to approximately 0.1% for left lobe        donation.73

        It is recommended that a live liver donor's operative follow-up consist        of at least one year.74        Yet, there is concern in the literature that restrictions in donor        health insurance may influence the feasibility of such long-term        follow-up.75� The        Vancouver Liver Group maintains that "since the risk to the donor is        considerable, programs performing live donor liver transplantation        should institute procedures and protocols that insure that donor        mortality and morbidity is minimized."76 Given the high relative risks of this surgery        (compared to kidney transplantation involving living donors), ACOT has        recommended "that a process be established that would verify the        qualifications of a center to perform living donor liver (or lung)        transplantation."77�        Another recommendation, from the Vancouver Forum's Liver Group, states        that a registry of live donor complications should be established and        that donor deaths should be reported to the registry.78���

**C. Lung**

*Living Donors:*        1995:45                2005:2                To date (since January 1, 1988-April 30, 2006): 461������

        Live donor lung transplantation began in 1990, and this particular        transplantation "generally involves three simultaneous operations: two        donor lobectomies and a recipient bilateral pneumonectomy and lobar        implantation."79� In        other words, one donor gives the right lower lobe, the second donor        gives the left lower lobe.80� This living donation procedure thus "places two donors at risk        for each recipient."81

*Donor evaluation*

        Donor selection entails identifying donors with good health, who have        adequate pulmonary reserve for lobar donation, and are free from        coercion in making the decision to donate.82� Potential living lung donors "receive a        series of exams and tests including chest radiography, pulmonary        function testing, ventilation-perfusion scanning and computed        tomography, and a cardiac stress test" in order to determine personal        health and their further suitability and compatibility with the        recipient.83        Additionally, the potential donors' lungs must be the correct size and        volume, so that there are sufficient lung capabilities for the        recipient. For adult recipients, "the donors should be at least as tall        as the recipient."84�      

*Perioperative Risks and Long-Term Risks*

        The perioperative risks with living lung donation include, but are not        limited to, the following: allergic reaction to anesthesia, pneumonia,        urinary tract infection, pleural effusions, bronchial stump fistulas,        bilobectomy hemorrhage (necessitating blood transfusion), phrenic nerve        injury, atrial flutter, bronchial stricture, persistent air leaks,        pericarditis, arrhythmia, transient hypotension, atelectasis (lung        collapse), ileus, subcutaneous emphysema, loculated pleural effusions,        *Clostridium difficile* colitis, and infection.85� To date, there have been no reported        deaths from living lung donation, but "the perioperative morbidity is        high, with complication rates ranging from 20-50% of donors."86 Additionally, in some        long-term (>1 year) donor follow-ups, donor complaints included        chronic incision pain, dyspnea, pericarditis, and non-productive        cough.87� In response,        the Vancouver Lung Group has recommended that "comprehensive short-term        follow-up should be mandatory and long-term follow-up be strongly        encouraged and funded by government/insurance authorities."88

**D. Pancreas**
*Living Donors:*        1995: 7                2005: 2                To date (since January 1, 1988-April 30, 2006): 70

        Living pancreatic donation requires a portion of the pancreas to be        removed, and even though the pancreas is unable to regenerate, it still        maintains the ability to function at a reduced size. The first        successful living-donor (segmental) pancreas transplant took place in        the United States in 1979, by Dr. David Sutherland of the University of        Minnesota in Minneapolis. Compared to other organs, living pancreas        donors are quite rare. Pancreas transplants are almost always performed        in conjunction with a simultaneous kidney transplant, typically from        the same donor.89

        Post-operative hospitalization for a live pancreas donor usually        requires 5 to 7 days; although no donor deaths have been reported after        segmental pancreatectomy, 15% of donors may need a splenectomy        performed due to complications involving insufficient blood supply or        bleeding.90� This is a        rather serious complication, and merits further investigation. As with        other higher-risk areas of donation, the Vancouver Forum recommends        "the establishment of a pancreas donor registry and database for        lifelong follow-up."91�

**E. Intestine**
*Living Donors:*        1995: 1                2005:7                To date (since January 1, 1988-April 30, 2006): 33

        The first live donor intestinal transplant took place in 1989, as a        treatment for patients who are suffering with "life threatening        complications of intestinal failure."92 Without a transplant, the patient faces long-term        parenteral nutrition.

        Live intestinal donation, as with all other living donations in the        United States, is to be done out of voluntary, altruistic motives (no        coercion).93� A donor        must be at the age of legal consent and should be a first or second        degree relative of the recipient, or else they should have close        emotional ties. 94 It is        reported that with this operative procedure, "it is essential to        preserve at least two-thirds of the small bowel length in the donor."95� Several problems can        occur early in the post-donation period, including small bowel        obstruction, diarrhea, weight loss, and dysvitaminosis. The risk of        perioperative death is 0.03%.96� According to the Vancouver Forum, the minimum follow-up        schedule should include postoperative visits at 2 and 4 weeks, and        donor teams need to be aware of� B12 deficiency, as it must        be monitored at 6 months and annually for 3 years.97 Experience with intestinal living        donation is limited, and though live donor intestinal transplants are        not considered experimental, "this procedure should be regarded as an        innovative and an evolving technology." 9899

**F. Conclusion**
        From this brief survey of the process of organ donation from living        donors and the health outcomes for living donors, the following        preliminary conclusions can be drawn:

        (1) By far, the most common and least risky form of living donation        occurs with kidneys. It is critical, nonetheless, to remember that        there are genuine risks of both morbidity and (rarely) mortality, and        there has been an inadequate follow-up study of the long-term health        effects of kidney donation on living donors.

        (2) The second most common forms of donation from living donors involve        the donation of parts of livers or lungs. These procedures involve        significantly greater health risks compared with kidney donation, and        similarly lack adequate long-term follow-up study.

        (3) Other types of donation from living donors-such as pancreas or        intestine donation-are so rare that it is difficult to generalize in        any way.

        (4) Among the various groups that have examined current practices in        living donation, there is broad interest in developing binding policies        and protocols to ensure the health of living donors, or at least full        recognition of all the risks. To this end, ACOT recommends "that a        database of health outcomes for all live donors be established and        funded through and under the auspices of the U.S. Department of Health        and Human Services." 100        But, as of now, no such database exists, and its practical feasibility        remains a complicated question. In addition, ACOT recommends support        for "a consortium of investigators to conduct epidemiologic research on        the outcomes and health needs of live organ donors" that would focus on        "the medical and functional outcomes of individuals who have donated a        kidney or a lobe of a lung for transplantation."101

**III. Some Ethical Questions**
        Living organ donation raises myriad complicated ethical questions-three        of which have been selected to guide the Council's discussion in this        area: (1) the moral obligations of physicians performing surgery on        living donors; (2) the moral distinction between acceptable and        unacceptable levels of risk for living donors; and (3) the moral        meaning of who donates.      

*A. The Moral Obligations of Doctors*

        Since the Hippocratic era, one of medicine's core ethical precepts has        been *primum non nocere*, "First, do no harm." With the removal of        organs from healthy, living donors, this ethical maxim is, in effect,        suspended: in the interests of benefiting a patient suffering or dying        from organ failure, a surgical procedure is performed on the donor, an        intervention in the body that cannot benefit the donor himself        physically but does hold the potential for bringing physical harm. In        the usual circumstances, patients present themselves to physicians as        patients, as sufferers of some malady that demands and needs the care        that only physicians can provide. In the circumstances of living        donors, such individuals only *become* patients through their        encounters with the transplant surgeons.

        For most living donors, the physical risks of surgery are seen as        warranted by the desire to help another, usually a family member or        friend who is suffering or dying. Thus, the transplant physician can        help the living donor achieve some benefit, the benefit to be derived        from helping a loved one enjoy a better quality of life or even survive        through transplantation. In this non-bodily sense, the doctor does good        for the donor-patient by helping him do good for another. The physician        might serve the well-being of the donor as a whole, even if this        requires the donor to place his own physical health at risk. But we are        still left to ask: Is the doctor truly acting as a *doctor* by        achieving this sort of benefit for the donor, by serving this        non-bodily good? Or is the physician using a medical technique (e.g.,        kidney removal) to serve a non-medical end (e.g., the moral and        spiritual goal of helping another)?

        Interestingly, the Institute of Medicine reported that in "a survey of        100 liver transplant surgeons, Cotler and colleagues (2003) found that        77 percent experienced a moral dilemma in placing a living donor at        risk.� Nevertheless, 72 percent also agreed that transplant centers had        a duty to offer their patients the possibility of transplantation using        living donors."102103

*B. Acceptable versus Unacceptable Risk*
        The ethics of living donation turns, in critical ways, on the        assessment of acceptable vs. unacceptable risk. At the extreme, some        forms of living donation are clearly impermissible-such as a father who        wished to give his son a heart. Here, the risk of death is 100 percent.        The more complicated questions come in discerning how much risk (or how        much additional risk) of morbidity or mortality is morally        acceptable-both from the perspective of the physician who performs the        surgery and from the perspective of the donor who submits to it. As we        have seen, the risks of liver and lung donation are significantly        higher than the risks of kidney donation. The question is: Are they too        high?� And conversely, on what grounds might a physician turn down a        potential donor who wants to help a loved one, knowing full well what        the risks are?

        This points us to another major problem: to some degree, the risks are        unknown, especially the long-term risks of being an organ donor. As the        Institute of Medicine reports, "it is difficult for transplantation        teams, independent donor advocate teams, and prospective donors        themselves to perform their analysis and assessments of risks,        benefits, and risk-benefit ratios because of incomplete data about the        health outcomes of living donation."104 According to Robert Steiner, "centers may        justifiably reject certain donors because they feel that, try as they        might, the risk of donation cannot be estimated: that they have 'no        idea' of the risks taken by these donors."105

        According to one study, most transplant professionals believe that "the        risk assumed by the donor depends on the benefit of donation to the        donor, i.e., how their life will be enhanced if they donate.� For        instance, if a husband or wife donates to their spouse, their own        quality of life may improve; therefore, more risk is accepted for the        common benefit, whereas in the altruistic situation, there is no donor        benefit other than the sense of helping someone in need, and even        marginally increased medical personal health risk is especially        important if the prospective living donor is a minor."106107108�

*C. The Moral Meaning of "Who Donates" and "Why"*
        Some of the more complex ethical questions in living donation have to        do with who donates and why. It is well known that the majority of        living donors are close relatives or close friends, but there is also        an increasing number of so-called anonymous or non-directed living        donors, who give an organ (almost always a kidney) as an act of        altruism to a stranger. With donation to a loved one, the psychological        motivation is humanly intelligible and (in general) morally        praiseworthy, though the extent to which donation is voluntary or        coerced, subtly or explicitly, is still of concern. With non-directed        donation, anonymous donation, or donation to an individual whom one        does not intimately know, the psychology is more complicated. We must        evaluate: Does the donor understand fully what he or she is doing? Is        she doing it for the right reasons? Does she expect more than just the        psychic rewards of doing good for another? Might she believe that her        act of donation puts a claim on the recipient to repay her in some way,        or might she suffer post-donation troubles when her life returns to        normal, or when her normal life never returns due to unexpected health        problems from the donation? Of course every case is different. But the        increasing rate of anonymous/non-directed donation requires greater        attention to the procedures and regulations governing this practice.        Consequently, the Advisory Committee on Organ Transplantation has        recommended "that the Secretary of HHS direct the OPTN to develop        allocation policy pertaining to non-directed, living-donor organs."109

        It is interesting to note that not too long ago, non-directed donation        was a rather unaccepted practice.� In 1994, concerning living kidney        donation, a survey was conducted whose results "suggested that only 15%        of the transplant centers in the US would consider a non-directed        living kidney donor (NDLD)."110� Today, however, "the willingness to consider NDLD is        growing."111��� The        OPTN/SRTR Annual Report 2005 stated that "there was a general consensus        that the growing number of living non-directed donors results from two        factors: (1) increased public awareness of the organ donor shortage,        and (2) a new willingness on the part of transplant centers and OPOs to        participate in these cases."112 In fact, one study noted that "a total of 24 of 25 (96%) of        transplant centers and 23 of 25 (92%) of OPOs surveyed reported that        they had received inquiries from people interested in serving as an        NDLD."113 However, there        is justified concern about the recent growth in non-directed living        donation because "although non-directed living donation is growing,        there are no unified policy guidelines agreed on and accepted by those        organizations practicing (or planning to practice) NDLD."114

        Another set of ethical questions relating to who donates involves        potential disparities concerning the age and gender of living donors.        In living donation, there has consistently been a disproportionate        number of female living organ donors compared to males.115 In 2005, women constituted        59.1% of live organ donors.116� The underlying reasons for this significant disparity remain        unexplained. A British medical journal concluded that "instead of        congratulating women on their altruism, we need to ask about possible        reasons for the gender imbalance and check it for matters of fairness        and undue pressure on a vulnerable group."117�

        The data also suggest that living organ donors are often younger than        organ recipients. In 2004, 45.5% of living donors were between the ages        of 35 and 49 years old, while the next highest percentage were those        between the ages of 18 and 34 at 33.3%. By contrast, since 1998, the        majority of organ transplants were received by those between 50 and 64        years old (41% in 2005) and those between 35 and 49 years old (27.75%        in 2005), though the OPTN data does not distinguish between living        donors vs. deceased donors as the source of these received organs. This        leaves open an ethically significant question: Are we "using" the        younger generation as organ suppliers for a growing elderly        population?� And should the young put themselves even at minimal risk        to help the generation above them?      

**APPENDIX 1**

**APPENDIX 2**

_______________________ 
ENDNOTES
 1. A 23-year old patient,          Richard Herrick, was suffering and dying from chronic kidney failure;          his identical twin brother, Ronald, agreed to donate one of his          kidneys. Dr. Joseph Murray, a trained plastic surgeon who had become          interested in transplants during World War II, performed the surgery          at the Peter Bent Brigham Hospital (now Brigham and Women's Hospital)          in Boston. The procedure lasted five and a half hours and was lauded          a tremendous success. Ronald gave his brother eight more years of          life by agreeing to be a living donor; more than fifty years later,          he is still living and promoting organ donation.� In 1990, Dr. Murray          won the Nobel Prize in Medicine for introducing organ transplantation          to the world.
 2. The Vancouver Forum, "The Care of the Live Organ Donor: Lung, Liver, Pancreas and          Intestine Data and Medical Guidelines," *Transplantation* 81,          no. 10 (2006): 1372-1387, and The Amsterdam Forum, "Care of the Live          Kidney Donor," *Transplantation* 79, no. 6 (2005): S51-S66.          
 3. United Network for          Organ Sharing (UNOS), *Transplant Living: Organ Donation and          Transplantation Information for Patient,* 2006,          http://www.transplantliving.org/livingdonation/livingdonor/informedconsent.aspx          (accessed August 1, 2006).          
 4. Ibid.
 5. The Advisory Committee          on Transplantation (ACOT), *Recommendations to the Secretary of the          U.S. Department of Health and Human Services: Recommendation 1,*          November 18-19, 2002, http://www.organdonor.gov/acot.html (accessed          August 1, 2006).          
 6. Institute of Medicine          (IOM), *Organ Donation: Opportunities for Action* (Washington,          D.C.: The National Academies Press, 2006), 56.          
 7. Organ Procurement and          Transplantation Network (OPTN), *National Data Reports: Donors*,          2006, http://www.optn.org/latestData/viewDataReports.asp (accessed          August 15, 2006). Data is current to May 31, 2006.          
 8. UNOS, *Transplant          Living: Organ Donation and Transplantation Information for          Patients*, http://www.transplantliving.org/living donation/living          donor/gooddonor.aspx 
 9. Ibid.,          http://www.transplantliving.org/beforethetransplant/qa.aspx 
 10. Ibid.          
 11. Ibid.,          http://www.transplantliving.org/livingdonation/livingdonor/tests.aspx          
 12. OPTN, *National          Data Reports: Donors*. Data is current to May 31, 2006. �����          
 13. All living donor          (specific to organ) data was provided by OPTN National Data Reports,          as obtained on� http://www.optn.org/latestData/step2.asp (accessed          August 2006).          
�14. IOM, *Organ          Donation: Opportunities for Action*, 63.          
 15. The Organ          Procurement and Transplantation Network/ The U.S. Scientific Registry          of Transplant Recipients (OPTN/SRTR), *The OPTN/SRTR Annual Report:          Section 1.13*, 2004, http://www.optn.org/data/annualReport.asp 
 16. National Kidney          Foundation, *What are the advantages of living donation over          nonliving donation?*, 2006,          http://www.kidney.org/transplantation/livingDonors/infoQA.cfm          (accessed August 15, 2006).          
 17. Arthur J. Matas and          Hassan N. Ibrahim, *Kidney Transplantation*, "The Donor -          Long-Term Outcome." (In press, 2006), 2. 
 18. Ibid.          
 19. Ibid., 2-3.          
 20. OPTN/UNOS Ad Hoc          Living Donor Committee, *Living Kidney Donor Evaluation          Guidelines*, http://www.unos.org/ContentDocuments/Living_Kidney_Donor_Evaluation_Guidelines2(1).pdf#search=%22optn%2C%20living%20kidney%20donor%20evaluation%20guidelines%22 (accessed August 22, 2006).
� 21. Connie L. Davis,          "Evaluation of the Living Kidney Donor: Current Perspectives,"          *American Journal of Kidney Diseases* 43, no. 3 (2004): 508-530.          
�22. Ibid. 
 23. The Amsterdam Forum, "Care of the Live Kidney Donor," *Transplantation* 79, no. 6          (2005): S51-S66.          
 24. Davis, "Evaluation          of the Living Kidney Donor: Current Perspectives."          
 25. M.J. Bia, E.L.          Ramos, G.M. Danovich, *et al.*, "Evaluation of living renal          donors: The current practice of US transplant centers,"          *Transplantation* 60 (1995): 322-327.          
� 26. M. Gabolde, C.          Herve, A.M. Moulin, "Evaluation, selection and follow-up of live          kidney donors: A review of current practice in French renal          transplant centres," *Nephrology Dialysis Transplantation* 16          (2001):2048-2052.          
 27. J.A. Lumsdaine, S.J.          Wigmore, J.L.R. Forsythe, "Liver kidney donor assessment in the UK          and Ireland," *British Journal of Surgery* 85 (1999): 877-881.          
 28. P. Faucauld, "Living          donor kidney transplantation: Evaluation and selection of the donor,"          *Transplant Proc* 35 (2003):931-932.          
 29. B.L. Kasiske, M.          Ravenscraft, � E.L. Ramos, R.S. Gaston, M.J. Bia, G.M. Danovitch,          "The Evaluation of Living Renal Transplant Donors: Clinical Practice          Guidelines. Ad Hoc Clinical Practice Guidelines Subcommittee of the          Patient Care and Education Committee of the American Society of          Transplant Physicians," *Journal of the American Society of          Nephrology*� 7, no. 11(1996):2288-2313. 
 30. M.J. Bia, *et          al.*, "Evaluation of living renal donors: The current practice of          US transplant centers."�          
�31. B.L. Kasiske, *et          al*., "The Evaluation of Living Renal Transplant Donors: Clinical          Practice Guidelines. Ad Hoc Clinical Practice Guidelines Subcommittee          of the Patient Care and Education Committee of the American Society          of Transplant Physicians."          
 32. Cleveland Clinic,          *Kidney Donation Surgery*, 2004,          http://www.clevelandclinic.org/health/health-info/docs/1900/1988.asp?index=7457&src=news          (accessed August 17, 2006).          
33. University of          California San Francisco Medical Transplant Center, *Becoming a          Living Kidney Donor*, 2006,�http://ucsfhealth.org/childrens/edu/living_donor.pdf#          search=%22risk%20of%20flank%20incision%20kidney%20          donation%2C%20rib%22 (accessed August 22, 2006).        
 34. Ibid.          
 35. The University of          Minnesota, The Transplant Center, *Kidney Transplantation: Living          Donor*, 2006,          http://www.fairviewtransplant.org/kidney/kidney_living_donor.asp          (accessed August 23, 2006).          
 36. University of Miami,          Department of Surgery, Division of Kidney and Pancreas          Transplantation, *Laparoscopic Organ Donor Surgery*, 2005,          http://surgery.med.miami.edu/kidney/areas_expertise.asp (accessed          August 17, 2006).          
 37. A.J. Matas, S.T.          Bartlett, A.B. Leichtman, F.L. Delmonico, "Morbidity and Mortality          After Living Kidney Donation, 1999-2001: Survey of United States          Transplant Centers," *American Journal of Transplantation* 3          (2003): 830-834.          
 38. J.R. Waller, A.L.          Hiley, E.J. Mullin, P.S. Veitch, M.L. Nicholson, "Living Kidney          Donation: A comparison of laparoscopic and conventional open          operations," *Postgraduate Medical Journal* 78 (2002): 153-157.          
 39. Davis, "Evaluation          of the Living Kidney Donor: Current Perspectives."          
 40. K.T. Perry, S.J.          Freedland, J.C. Hu, *et al.*, "Quality of life, pain and return          to normal activities following laporoscopic donor nephrectomy versus          open mini-incision donor nephrectomy," *The Journal of Urology*          169 (2003): 2018-2021.          
 41. L.E. Ratner, R.A.          Montgomery, L.R. Kavoussi, "Laporoscopic live donor nephrectomy:� A          review of the first 5 years," *Urologic Clinics of North          America* 28 (2001): 709-719.          
 42. F.G. Pradel, M.R.          Limcangco, C.D. Mullins, S.T. Bartlett, "Patients' attitudes about          living donor transplantation and living donor nephrectomy,"          *American Journal of Kidney Diseases* 41 (2003):849-858.          
 43. L.E. Ratner, L.J.          Ciseck , R.G. Moore, F.G. Cigarroa, H.S. Kaufman, L.R. Kavoussi, "Laparoscopic living donor nephrectomy," *Transplantation* 60          (1995): 1047-1049.          
 44. A.J. Matas, *et          al*., "Morbidity and Mortality After Living Kidney Donation,          1999-2001: Survey of United States Transplant Centers."          
 45. Ibid.          
 46. International          Association of Living Donors,� "About Living Kidney Donation," 2006, http://www.livingdonorsonline.org/kidney/kidney.htm (accessed August          20, 2006).          
 47. Li-Ming Su, L.E.          Ratner, R.A. Montgomery, T.W. Jarrett, B.J. Trock, V. Sinkov, R.          Bluebond-Langner, L.R. Kavoussi, "Laparoscopic donor nephrectomy:          trends in donor and recipient morbidity following three hundred and          eighty-one consecutive cases*," Annals of Surgery* 240, no. 2          (2004):358-363.          
 48. Anders Hartman, P.          Fauchald, L. Westlie, I.B. Brekke, H. Holdaas,"The risk of living          kidney donation," *Nephrology, Dialysis, Transplantation* 18,          no. 5 (2003): 871-873.          
 49. Amy L. Friedman,          T.G. Peters, K.W. Jones, L.E. Boulware, L.E. Ratner, "Fatal and          Nonfatal Hemorrhagic Complications of Living Kidney Donation,"          *Annals of Surgery* 243, no. 1 (2006): 126-130.          
 50. Li-Ming Su, *et          al.*, "Laparoscopic donor nephrectomy: trends in donor and          recipient morbidity following three hundred and eighty-one          consecutive cases.*"*
 51. Michael Siebels, J.          Theodorakis, N. Schmeller, S. Corvin, N. Mistry-Burchardi, G.          Hillebrand, D. Frimberger, O. Reich, W. Land, A. Hofstetter, "Risks          and Complications in 160 living kidney donors who underwent          nephrourectomy," *Nephrology, Dialysis, Transplantation* 18          (2003): 2648-2654.          
 52. Arthur J. Matas,          S.T. Bartlett, A.B. Leichtman, F.L. Delmonico, "Morbidity and          Mortality After Living Kidney Donation, 1999-2001: Survey of United          States Transplant Centers," *American Journal of          Transplantation* 3 (2003): 830-834.          
 53. Eric M. *Johnson,          M. J. Remucal, K.J. Gillingham, R.A. Dahms, J.S. Najarian, A.J.          Matas, "*Complications and risks of living donor nephrectomy,"          *Transplantation* 64 (1997): 1124-8.          
 54. J.S. Najarian, B.M.          Chavers, L.E. McHugh, A.J. Matas, "20 years or more of follow-up of          living donors," *Lancet*, October 3, 1992; 340 (8823): 807-810.          
 55. W.H. Bay and L.A.          Hebert, "The living donor in kidney transplantation,"*Annals of          Internal Medicine* 106, no. 5 (1987): 719-27.           
 56. Eric M.          *Johnson,**et al.,"*Complications          and risks of living donor nephrectomy."          
 57. Matas and Ibrahim,          *Kidney Transplantation*, 3.          
 58. Ibid., 24-25.          
 59. Matas and Ibrahim,          *Kidney Transplantation*, 25.          
 60. The Amsterdam Forum, "Care of the Live Kidney Donor."          
 61. John Easton, "First          living donor liver transplant recipient graduates from high school          May 27," *The University of Chicago Medical Center*, May 25,          2006, http://www.uchospitals.edu/news/2006/20060525-graduate.html          (accessed August 21, 2006).          
 62. National Kidney          Foundation, *Answering your Questions about Living Donation,*          2006, http://kidney.org/atoz/atozItem.cfm?id+48 (accessed August 18,          2006).          
 63. Ibid.          
 64. The Vancouver Forum, "The Care of the Live Organ Donor: Lung, Liver, Pancreas and          Intestine Data and Medical Guidelines."          
 65. OPTN/UNOS Ad Hoc          Living Donor Committee, *Living Liver Donor Evaluation          Guidelines*, http://www.unos.org/ContentDocuments/Living_Liver_Donor_          Evaluation_Guidelines2(1).pdf#search=%22optn%2C%20living%          20liver%20donor%20evaluation%20guidelines%22(accessed August 22, 2006).          
 66. University of          Pittsburgh Medical Center, *Liver Transplantation*, 2006,          http://livertransplant.upmc.com/LivingLiverDonor.htm (accessed August          22, 2006).          
 67. The Vancouver Forum, "The Care of the Live Organ Donor: Lung, Liver, Pancreas and          Intestine Data and Medical Guidelines."          
 68. Ibid.          
69. H.P. Grewel , J.R.          Thistlethwaite, G.E. Loss, J.S. Fisher, D.C. Cronin, C.T. Siegel, K.          Newell, D.S. Bruce, E.S. Woodle, L. Brady, S. Kelly, P. Boone, K.          Oswald, J.M. Millis, "Complications in 100 living donors," *Annals          of Surgery* 228 (1998): 214-19. 
*70. A.C.Stieber, L. Makowka, and T.E. Starzl, "Orthotopic Liver Transplantation," in TE Starzl, R          Shapiro, and RL Simmons (eds),**Atlas of Organ          Transplantation. Gower Medical Publishing (New York, 1991).          As cited by The*University of Pittsburgh Medical Center,          Liver Transplant Program, *Technique of Liver Transplantation*,          2006, http://livertransplantprogram.upmc.com/InDepthTrans.htm          (accessed August 21, 2006).
 71. The Vancouver Forum, "The Care of the Live Organ Donor: Lung, Liver, Pancreas and          Intestine Data and Medical Guidelines."          
 72. Ibid.          
 73. Ibid.          
 74. Ibid.          
 75.�Ibid. 
 76. Ibid.          
 77. ACOT,          *Recommendations to the Secretary of the U.S. Department of Health          and Human Services*.          
 78. The Vancouver Forum, "The Care of the Live Organ Donor: Lung, Liver, Pancreas and          Intestine Data and Medical Guidelines."          
 79. Ibid.          
 80. National Kidney          Foundation, *Answering your Questions about Living Donation*.          
 81. National Institute          of Allergy and Infectious Diseases (NIAID), National Institute of          Diabetes and Digestive and Kidney Diseases (NIDDK), National Heart,          Lung, and Blood Institute (NHLBI), Health Resources and Services          Administration (HRSA), *Live Organ Donor Outcomes and Medical          Needs*, October 29, 2004,          http://grants.nih.gov/grants/guide/notice-files/NOT-AI-05-006.html          (accessed August 11, 2006).          
 82. The Vancouver Forum, "The Care of the Live Organ Donor: Lung, Liver, Pancreas and          Intestine Data and Medical Guidelines."          
 83. National Kidney                 Foundation, *Answering your Questions about Living Donation*.                 
 84. Ibid.          
 85. Richard J.          Battafarano, R.C. Anderson, B.F. Meyers, T.J. Guthrie, D. Schuller,          J.D. Cooper, G.A. Patterson, "Perioperative complications after          living donor lobectomy," *The Journal of Thoracic and          Cardiovascular Surgery* 120 (2000): 909-915.          
 86. NIAID, NIDDK, NHLBI,          HRSA, *Live Organ Donor Outcomes and Medical Needs*.          
 87. The Vancouver Forum, "The Care of the Live Organ Donor: Lung, Liver, Pancreas and          Intestine Data and Medical Guidelines."          
 88. Ibid.          
 89. The Mayo Clinic, "Pancreas Transplant: An insulin-free treatment for type 1 diabetes," December 15, 2005, http://www.mayoclinic.com/health/pancreas-transplant/DA00047          (accessed August 23, 2003).          
 90. The Vancouver Forum, "The Care of the Live Organ Donor: Lung, Liver, Pancreas and          Intestine Data and Medical Guidelines."          
 91. Ibid.          
 92. Ibid.          
 93. Ibid.          
 94. Ibid.          
 95. Ibid.          
 96. Ibid.          
 97. Ibid.          
 98. Ibid.          
 99. Ibid.          
 100. ACOT,          *Recommendations to the Secretary of the U.S. Department of Health          and Human Services*.          
 101. NIAID, NIDDK,� NHLBI, HRSA, *Live Organ Donor Outcomes and Medical Needs*.          
 102. IOM, *Organ          Donation: Opportunities for Action,* 307.          
 103. Scott J. Cotler,          Sheldon Cotler, Michele Gambera, Enrico          Benedetti, Donald M. Jensen, Giuliano Testa, "Adult          living donor liver transplantation: Perspectives from 100 liver          transplant surgeons," *Liver Transplantation* 9 (2003): 637-644.          
 104. IOM, *Organ          Donation: Opportunities for Action,* 314.          
 105. Robert W. Steiner, "Risk appreciation for kidney donors," *American Journal of          Transplantation* 4, no. 5 (2004): 694-697.          
 106. Davis, "Evaluation          of the Living Kidney Donor: Current Perspectives."          
 107. L.E. Boulware,          L.E. Ratner, J.A. Sosa , et al, "The general public's concerns about          clinical risk in live kidney donation," *American Journal of          Transplantation* 2 (2002): 186-193.          
 108. F.L. Delmonico and          W.E. Harmon, "The use of a minor as a live kidney donor," *American          Journal of Transplantation* 2 (2002): 333-336.          
 109. ACOT,          *Recommendations to the Secretary of the U.S. Department of Health          and Human Services*.          
 110. James C. Gilbert,          L. Brigham, D.S. Batty, Jr., R.M. Veatch, "The Nondirected Living          Donor Program: A Model for Cooperative Donation, Recovery and          Allocation of Living Donor Kidneys," *American Journal of          Transplantation* 5 (2005): 167-174.          
 111. Megan          Crowley-Matoka and Galen Switzer, "Nondirected Living Donation: A          survey of current trends and practices," *Transplantation* 70, 5          (2005): 515-519.          
� 112. OPTN/SRTR, *The          OPTN/SRTR Annual Report: Chapter 2.13*, 2004,          http://www.optn.org/data/annualReport.asp (accessed August 15, 2006).          
 113. Crowley-Matoka and          Switzer, "Nondirected Living Donation: A survey of current trends and          practices."          
 114. Ibid.          
 115. OPTN, *National          Data Reports: Donors*. Data is current to May 31, 2006.          
� 116. Ibid. 
 117. Nikola          Biller-Andorno, "Gender Imbalance in Living Organ Donation,"          *Medicine, Health Care and Philosophy* 5, no. 2 (2002): 199-204.                                                                                                                                                                               |