A Beach Head on an Untamed Shore--A Physician-Ethicist Addresses a Living Kidney Donor Selection.

Paper presented at the 1st International Symposium on Understanding Health Benefits and Risks: Empowering Patients and Citizens. Johns Hopkins University, Baltimore, Maryland. May 29, 2009The risks and benefits of living kidney donation are complicated and variable, and potential donors may be driven by emotion or feel pressured to donate. Transplant centers strive to be ethical, but debate continues over appropriate donor selection practices. Improved communication and involvement of potential donors in decision making has resulted from an effort to clarify the ethics of this emotionally charged area by Bernard Gert and myself. Our initial focus on donors with special medical risks led to a selection protocol that recognized a continuum of risk and new donor counseling techniques that were appropriate for all donors. So donors could provide valid informed consent and meet morally acceptable selection standards, explicit risk data were developed in a teachable form. In addition to teaching risk quantitatively (e.g., “1 out of 100”) using stick figure diagrams, we also advocate use of true/false questions for donors and employ structured testing for rational decision-making. This approach has been adopted by some centers and has increased center confidence in donor selection. It also invites a more sympathetic understanding of centers that have been criticized for paternalism when the applicable ethical principles have been unclear or when donation has been thought to be “too risky” because the risks were unknown, not because risks were known to be high