Ethical guidance essential for living organ donors

Physicians at Northwestern Memorial Hospital in Chicago recently performed transplant surgery on their second patient who found a living donor online (link). The Web site's aim is to link potential donors with individuals who post their profiles on the site because they need an organ transplant.

This form of solicitation, as well as billboards and other means of advertising for a living donor, is growing in popularity. That's not surprising, given that nearly 90,000 people are waiting for an organ transplant.

In the site's relatively short 12-month history, 13 living donors and patients who have been matched through the Web site have gone to surgery. These donors are members of the growing club of people willing to give up an organ or a part of one so that another person can experience a fuller life. In the past 10 years, the number of living donors has more than doubled. In 2001, 2002 and 2003, the number of living donors surpassed that of deceased donors, primarily due to kidney transplantation.

Often the donor is a family member, a friend or someone the patient knows in some way. A small but growing number are strangers. And while the process of donating organs from a deceased person is standardized and monitored, the same cannot be said for living donor transplants. Nor have there been any uniform guidelines for the way in which a living donor is to be advised and prepared for becoming a donor.

The AMA has taken a lead role in filling that void by adopting a report by its Council on Ethical and Judicial Affairs. The report addresses several issues associated with living organ donation.

In noting the fact that living organ donors are exposed to potential harms with no physical benefits, the report suggests that each potential donor should be assigned an advocate team.

To avoid actual or perceived conflicts of interest between potential donors and recipients, the team -- which includes a physician -- should be as independent as possible from those caring for the recipient.

The team's primary concern is the potential donor.

After a complete medical evaluation and a psychosocial evaluation, the team should determine whether a potential donor is an appropriate candidate. These advocates also should provide information regarding the procedure and its possible complications and keep the decision to donate free of any undue pressure.

Should a potential donor choose to withdraw at any time, it is the team's job to keep the reason for withdrawing confidential.

The report also addresses other key issues in the distribution of living organ donations, noting that it is ethically appropriate for donors to designate a recipient, whether it's a relative or a known unrelated person. It is also ethical to designate a stranger as a recipient as long as it produces a net gain of organs in the pool, without unreasonably disadvantaging others on the waiting list.

It remains illegal to receive payment for solid organs, but living donors can receive reimbursement for travel and lodging, meals, lost wages and the medical care associated with the donation. And the report notes that organs from living donors who do not designate a recipient should be allocated in the same way as those from deceased donors. It also calls for physicians to support a national database of living donor outcomes so that the benefits and the harms of living organ donation can be better understood.

The report acknowledges that public solicitation of organs and paired kidney exchanges are variations of organ donation that are receiving attention of late. In a paired kidney exchange, a relative or friend of someone who needs a kidney is willing to donate but doesn't match. That pair would then be matched with a second pair in the same situation. These methods, the report states, require further study and ethical examination to evaluate their fairness on organ allocation. Meanwhile, the United Network for Organ Sharing is also preparing its own report.

As many as 7,000 people die while waiting for transplants each year. To this already urgent situation, the latest wrinkles in living donor transplantation add both new hope and more complexity. Ethical guidance is essential to ensure that all living donors are given the special protection they need when they voluntarily put themselves at risk to help another.