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Advocacy Ethical Considerations Living Kidney Donor

Physicians Remind Transplant Industry of Their Responsibility to Living Donors

I was researching the other day and ran into this letter from 2010, a response to a study by Maples regarding the risk of live donor nephrectomies. It pleased me so much, I wanted to share it here:

http://jme.bmj.com/content/36/3/142/reply

[emphasis mine]

The practice of living organ donation requires living persons to be willing to donate and medical practitioners to perform the surgical interventions. In the case of the vast majority of kidney donors, there is no doubt of their altruistic motives; indeed one could argue that donating their kidneys constitutes a supererogatory act on their part. The moral difficulty, however, lies with the medical practitioner performing an invasive surgical procedure to remove a healthy organ from a healthy patient. Najma Maple and colleagues [1] assume that just because the majority of persons are willing to undergo medical procedure x with risk y, their willingness implies that it is morally acceptable for medical practitioners to perform x. This implication is problematic. Living kidney donation not only results in the obvious effects of any surgery (post- surgical pain, lost work time, etc.), but also carries both short- and long-term health risks. Short-term risks for donors range from infection to bleeding up to death [for a summary, see 2]. Long-term risks include a rise of an average of 5-mm Hg of systolic blood pressure ten years after kidney donation surgery [3] (in one study, 37.5% of donors became hypertensive [4]), and kidney problems up to end-stage renal failure [4,5]. From a population health perspective, living kidney donors are at high risk of progressing to end-stage chronic kidney disease and ultimately requiring either dialysis or a kidney transplant over their lifetime. Effectively, living kidney donation practice can no longer be considered as solving but exacerbating a future epidemic of end-stage kidney disease in a population, and for society to deal with in 20-30 years later. This population health problem will amplify future crisis of kidney shortage for transplantation and burden an already strained health care system.

The principle of nonmaleficence (do no harm) forbids a medical practitioner from performing actions that harm the health of a patient. In the case of renal transplantation (and a fortiori, in cases of transplantation of other solid organs), the risks to the donor are significant. Even if nonmaleficence were considered to be a prima facie duty, the risks to kidney donors are too great for the good gained for the recipient to override this fundamental principle of medicine.

Michael Potts, Michael Potts, PhD, Professor, Methodist University, Fayetteville, North Carolina USA
Mohamed Y. Rady, MD, PhD, Joseph L. Verheijde, PhD, Mayo Clinic, Phoenix, Arizona USA
David W. Evans, MD, Queens College, Cambrige, UK

References

1 Maple NH, Hadjianastassiou V, Jones R, Mamode N. Understanding the risk in living donor nephrectomy. J Med Ethics 2010;36:142-7, doi: 10.1136/jme.2009.031740.

2 Potts M, Evans DW. Is solid organ donation by living donors ethical? The case of kidney donation. In: Weimar W, Bos MA, Busschbach JJ (Eds.), Organ Transplantation: Ethical, Legal, and Psychosocial Aspects, pp. 377-81. Lengerich: Papst Science Publishers, 2008.

3 Boudville N, Ramesh Prasad GV, Knoll G et al. Meta-analysis: risk for hypertension in living kidney donors. Ann Intern Med 2003;145:185-96.

4 Azar SA. Nakhjavani MK, Faragi A et al. Is living kidney donation really safe? Transplant Proc 2007;39:822-3.

5 Kido R, Shibagaki Y, Iwadoh K et al. How do living kidney donors develop end-stage renal disease? Am J Transplant 2009;9:2514-19.

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