Ethical issues in living organ donation: donor autonomy and beyond.

Despite nearly 50 years of experience with living kidney donation, ethical questions about this practice continue to haunt us today. In this editorial I will address two of them: (1) Given the possibility of limited understanding and coercion, how can we be sure that a person who offers to donate an organ is acting autonomously? and (2) Do people have a right to donate? The universal requirement for informed consent is the traditional method for ensuring that a person is acting autonomously. But, while obtaining fully informed consent is desirable, it may not always be achievable or necessary. When the recipient is very dear to the potential donor, the donor may base his decision primarily on care and concern rather than on a careful weighing of risks and benefits. I will argue that consent that emanates from such deep affection should be considered just as valid as consent that is fully informed. But consent is not enough. There is no absolute right to donate an organ. If there were such a right, then some physician would be obligated to remove an offered organ upon request, regardless of the risks involved. I do not believe that physicians have such an obligation. Physicians are moral agents who are responsible for their actions and for the welfare of their patients. Therefore, while the values and goals of the potential donor should be given great weight during the decision-making process, physicians may justifiably refuse to participate in living organ donation when they believe that the risks for the donor outweigh the benefits.