Bioethics in Practice: Anonymous Living Donor Transplantation: Ethical or Medically Reckless?

When I was a fellow in transplantation, a patient who was being treated at our center made a plea on National Public Radio for a living donor. Donation rates at the time required many patients to wait more than a year, and the patient who made the public appeal felt that he was dying and could not wait for a suitable deceased donor. With the advent of social media (eg, Facebook), such pleas have become increasingly common in North America. After a public event such as this, transplant centers are often faced with a huge influx of potential donors and are tasked with sorting through them to find those who are actually medically suitable and legitimately interested in taking on the risk of being a donor, keeping in mind that these individuals are willing to risk their lives in a surgical procedure that is of no medical benefit to them for someone with whom they have no personal relationship.

This scenario raises the question of whether it is ethically sound for us as physicians—who all took the Hippocratic Oath to “first do no harm”—to allow individuals to undergo a painful surgery that requires 6-8 weeks of recovery time and carries significant medical and psychological risks for the benefit of an individual who is largely or completely unknown to the potential donor.

Organ shortages continue to be a major barrier to transplantation across the world. Currently in the United States, more than 120,000 patients await transplantation. With so many patients on the wait list, clearly not every patient will receive a transplant. Some patients may wait more than 5 years for a transplant, and many will ultimately die waiting to receive a life-saving organ. For some recipients, living-donor transplantation offers the potential to avoid death on the wait list. In addition, because many organs are allocated based on disease severity, living donation offers patients the opportunity to undergo transplantation when they are healthiest. In most cases, living-donor transplants are elective, and recipients are optimized for the surgery, potentially minimizing perioperative morbidity and improving recovery time.

For the donor, living donation carries risk, with donor morbidity rates in some cases up to 40% for living liver donors, and cases of death from donation have been reported for both living donor nephrectomy and partial hepatectomy.

In most cases, the living donor is a close family member or friend who is intimately involved with the potential recipient and well aware of the recipient's daily struggles with end-organ failure. Anonymous donors, or altruistic donors, are individuals who come forward to donate their kidney or part of their liver to the general donor pool in the hope of helping an anonymous individual. A self-directed anonymous donor is an individual who answers the specific public plea of a person in need of a transplant but who does not know the potential recipient. In cases of both anonymous and self-directed anonymous donation, transplant centers are required to follow the general donation guidelines that typically do not allow contact between the two parties for at least one year.

All donors, related or anonymous, undergo rigorous evaluation, including consultations with several medical and surgical specialists, extensive imaging, and any other tests deemed necessary to rule out any significant medical conditions. Donors also routinely undergo psychological testing, and a social worker meets with prospective donors to determine if they are of sound mind and able to understand the procedure and the risks associated with it. In the case of anonymous donors, particular attention is paid to this part of the evaluation to rule out ulterior motives for donation such as thrill-seeking or the desire for media attention. Even after these donors undergo rigorous evaluation, many physicians are still skeptical as to whether they are psychologically stable enough to undergo donation.

In 2005, the Ethics Committee of The Transplantation Society held a consensus conference in Vancouver to debate the issue of whether living donation is ethically sound. The consensus of the committee was that the use of living donors is ethical provided that the aggregate benefits to the donor-recipient pair outweigh the risks to the donor-recipient pair. The United Network for Organ Sharing (UNOS) has also developed specific guidelines for anonymous donation. According to UNOS, living, nondirected donation is an ethically justifiable form of organ donation provided that a strict standard of informed consent is followed, the competent potential donor undergoes appropriate evaluation, and organs are allocated in an equitable manner.

Staff at many centers experienced in living donation have evaluated anonymous donors and have allowed them to donate. Several series of anonymous kidney and anonymous partial liver donors have been reported. In all series, outcomes following anonymous donation have been comparable to related living donation outcomes for both the donors and the recipients. Importantly, anonymous donors also reported satisfaction that they were able to successfully donate. No long-term consequences have been reported for anonymous living donors.

Many people have asked what drives an individual to be an anonymous donor, with a common assumption being that some donors who wish to subject themselves to a major surgery with significant risk are “thrill-seekers” or “lunatics.” Several studies have attempted to delve into the motivation of these donors. Despite what many might think, on the whole, anonymous donors are largely just good people and not thrill- or attention-seekers. Many of these individuals have a history of other altruistic behaviors (eg, they are blood donors or volunteers) and generally have an interest in helping people. Some individuals have even donated other organs; one individual who donated part of a liver later donated a kidney.

Anonymous donors in general are altruistic individuals who wish to donate organs in the interest of helping others. When they are properly assessed, these individuals can safely donate to a recipient, and both excellent donor and recipient outcomes have been reported. Such outcomes adhere to the ethical principle that the aggregate benefits to the donor-recipient pair outweigh the known risks. As long as individuals are aware of the risks associated with donation and undergo rigorous medical and psychological evaluations in which ulterior motives are ruled out, they should be allowed to be anonymous donors. Continued efforts should be made to increase the public's knowledge about organ donation to increase the rates of both living and deceased donation.

• © Academic Division of Ochsner Clinic Foundation