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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 5  |  Page : 971-974
Ethical disputes in living donor kidney transplantation: What should we do to save lives?

1 Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran
2 Dr. Taheri Medical Research Group, Tehran, Iran

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Date of Web Publication31-Aug-2010


Living donor kidney transplantation has strong opposition and proponents. Opponents argue that this would exploit poor and female while proponents discuss the high mortality rate of ESRD patients and the low risk of a living donation. In this debate, we reviewed disputes in ethical aspects of living donor kidney transplantation to reach to a good overview of the current concepts on the issue.
"To save an innocent human life is equal to saving the humankind." Holy Quran; AlMaeda:32

How to cite this article:
Khedmat H, Taheri S. Ethical disputes in living donor kidney transplantation: What should we do to save lives?. Saudi J Kidney Dis Transpl 2010;21:971-4

How to cite this URL:
Khedmat H, Taheri S. Ethical disputes in living donor kidney transplantation: What should we do to save lives?. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2022 Oct 2];21:971-4. Available from: https://www.sjkdt.org/text.asp?2010/21/5/971/68909

   Introduction Top

It is generally speculated that living donor kid­ney transplantation (TX) represents the single best form of therapy for end-stage renal disease in terms of quality of life, life-saving and cost effectiveness. [1],[2],[3],[4] On the other hand, although with inferior results, because of no possible threat to a potential healthy living donor, renal TX from deceased donors is generally considered as the most preferred and absolutely ethical method of kidney transplantation for treating end-stage renal failure. However, there is a tough obs­tacle: as the practice is becoming more popular globally, the profound gap between supply and demand is widening. Therefore, the critique of using living donor renal transplantation has come into view.

Since 23 December 1954, when the first kid­ney TX from a living donor performed in Mas­sachusetts, USA, between identical twins, this method for kidney TX has become increasingly common, as a way for addressing the gap avai­lable between demand and supply for kidney transplants, worldwide. Despite this, the issue of living donor renal transplantation is oversha­dowed by cases of exploitation and corruption. A closer look at the literature [5],[6],[7] will show the magnitude of disagreement between the two groups.

   Using Living Donors for Kidney Transplantation Top

Sixty-thousand people are supposed to die each year lacking a kidney allograft just in the Uni­ted States [8] and the statistics could be much worse in the under-developed countries where health care services are not comparable to the United States. Only in India, the number of people developing ESRD each year comprises to 100,000. This increasing demand for the do­nor kidneys has led to the advertising for a donor on highway billboards, by consulting web­sites, by making personal please in the media, by listing themselves in multiple registries and by relocating. [9] This has involved into organ trade and lots of ethical concerns. Just consider a millionaire needs a kidney; and how many people in the world may be ready to vend a kidney for money?

   Altruistic Kidney Transplantation: a New Resolving Way Top

Considering serious shortage of transplantable organs, several authors proposed methods for increasing "altruistic donations". [10],[11] But, what exactly is an altruistic donation? For some, an altruistic donation is simply a non-paid practice. However, even a purely altruistic donation has its own operating expenditure attributed to the procedure (e.g. job disturbance) resulting in po­ssible barrier for altruistic donations for persons who depend on daily wages or lower socioeco­nomic status. On the other hand, financial agree­ments among recipient and donor is difficult to prove also. Sesso et al in their study on Bra­zilian transplantation proudly claim that "There has never been a financial incentive for LUD transplantation in our country, and our govern­ment and the National Medical Society proscribe the buying on selling of organs"; but in their study, they found that the number of altruistic donations between "emotionally related people" has been significantly raised compared to spouses through years. [13] Can this finding thoroughly be explained by only higher motivation between "emotionally related people" than their spouses! Spouses can simply be defined legally but, who can determine truly "the emotionally related" persons? Therefore presence of vague defini­tions and strict criteria would result in altruistic donations only rarely.

   Presumed Consent: Does it Make Sense? Top

Debate has also focused on moving toward a system of presumed consent, in an approach similar to the one adopted and publicized in parts of Europe, where consent for donation is presumed unless specific waivers have been sought out and signed. Introduction of such a law has resulted in substantial increase of organ supply in these countries [14] with its own down­side. The proponents argue that organ donation from potential donors are more readily availa­ble considerably more consistent with this me­thod than their close relatives: The percentage of refusal is noticeably greater when the ques­tion concerning organ donation is put to the close relatives. [11],[12] However, if the emotionally related persons such as spouse, parents etc can­not acknowledge the brain death of their be­loved, what would be the implications for the presumed consent donation. This further be­comes unacceptable if there are issues of pos­sible medical neglect.

   Gender Imbalances in Organ Receipt and Donation Top

The worldwide gender disparity in receiving and donating living organs has produced the most intentional debates in the context of living transplantation. Supporters of living unrelated transplantation argue that the advantage of nondirected living donation (as it is practiced in Iran) is that it excludes pressure on the donor resulting from the relationship to the prospec­tive recipient or family members. In genetically and even emotionally related living donations, decisions are always made within the family system with a non-obvious pressure on the re­lative donor. Significant gender imbalances have been reported with higher donation rates for mothers, wives, and sisters donating much more frequently than their male counterparts in Ger­many, [15],[16] Norway, [17] Switzerland, [18] the United States, [19] Canada, [20] Thailand, [21] Hong Kong, [22] India [23] and Turkey, [24] but not in Korea, [25] Oman, [26] and Iran. [27] The decisions of these women may well be motivated by their role within the family as the caring, supporting ones.

   Compensate a Kidney Donation: Is it OK? Top

Numerous arguments have been made about the ethical aspects of the kidney transplantation practice in Iran which is generally addressed as "Iranian model of kidney transplantation pro­gram". [1],[2],[3],[4],[5],[6],[7] The experience which was a compen­sated program for using living unrelated dona­tion (LURD) has fired up tenacious opponents as well as rigorous proponents since its intro­duction in 1988. [1],[2],[3],[4],[6],[7] However, one thing that generally commonly exists is the comment that there is no difference between a "compensated kidney donation" and "selling kidneys". Accor­ding to an Iranian model, patients needing a kidney allograft register their name to a govern­mental non-profit institution, as well as poten­tial altruistic donors. Compensation for this or­gan procurement must be thoroughly paid by the government with no financial relation bet­ween donors and recipients; although a gift by the recipients is not only is not prohibited but also is encouraged. One of the most important aspects of this system we should be aware of is that this gift should stay optional with no predefined amount of finance.

   What to do: Future Perspectives Top

Most authors against regulation of a living kid­ney transplantation program have no clear sug­gestions. [10],[11] As mentioned, a "presumed consent" is the most touted answer [12] although as men­tioned it also has its own ethical problems.

No doubt, the best way for addressing the pro­blem is to prevent development of End-Stage Renal Disease (ESRD) in the community. But despite all endeavors, still a large number of patients would lose their kidney function. The question still remains unanswered: "What should we do to save more lives?"

   References Top

1.Einollahi B, Pourfarziani V, Ahmadzad-Asl M, et al. Iranian model of renal allograft transplant­tation in 3028 recipients: survival and risk fac­tors. Transplant Proc 2007;39(4):907-10.  Back to cited text no. 1      
2.Einollahi B. Iranian experience with the non­related renal transplantation. Saudi J Kidney Dis Transpl 2004;15(4):421-8.  Back to cited text no. 2      
3.Simforoosh N. Kidney donation and rewarded gifting: an Iranian model. Nat Clin Pract Urol 2007;4(6):292-3.  Back to cited text no. 3      
4.Ghods AJ, Nasrollahzadeh D. Gender disparity in a live donor renal transplantation program: assessing from cultural perspectives. Transplant Proc 2003;35(7):2559-60.  Back to cited text no. 4      
5.Spital A, Jacobs CL. The beauty of the gift: the wonder of living organ donation. Clinical Transplantation, Clin Transplant 2007;21(4): 435-40.  Back to cited text no. 5      
6.Scheper-Hughes N. The tyranny of the gift: Sacrificial violence in living donor transplants. Am J Transplant 2007;7(3):507-11.  Back to cited text no. 6      
7.Griffin A. Kidneys on demand. BMJ 2007;334 (7592):502-5.  Back to cited text no. 7      
8.Kalantar-Zadeh K, Kilpatrick RD, Kuwae N, et al. Revisiting mortality predictability of serum albumin in the dialysis population: time depen­dency, longitudinal changes and population­attributable fraction. Nephrol Dial Transplant 2005;20(9):1880-8.  Back to cited text no. 8      
9.Daar AS. The case for a regulated system of living kidney sales. Nat Clin Pract Nephrol 2006;2(11):600-1.  Back to cited text no. 9      
10.Jendrisak MD, Hong B, Shenoy S, et al. Altruis­tic living donors: evaluation for nondirected kidney or liver donation. Am J Transplant 2006; 6(1):115-20.  Back to cited text no. 10      
11.Weimar W, Zuidema W, de Klerk M, Haase­Kromwijk B, IJzermans J. Altruistic kidney donation. Lancet 2006;368(9540):987.  Back to cited text no. 11      
12.Kennedy I, Sells RA, Daar AS, et al. The case for "presumed consent" in organ donation. In­ternational Forum for Transplant Ethics. Lancet 1998;351(9116):1650-2.  Back to cited text no. 12      
13.Sesso R, Josephson MA, Ancao MS, Draibe SA, Sigulem D. A retrospective study of kidney transplant recipients from living unrelated donors. J Am Soc Nephrol 1998;9(4):684-91.  Back to cited text no. 13      
14.Matesanz R. Cadaveric organ donation: com­parison of legislation in various countries of Europe. Nephrol Dial Transplant 1998;13(7): 1632-5 Review.  Back to cited text no. 14      
15.Voiculescu A, Ivens K, Hetzel GR, et al. Kid­ney transplantation from related and unrelated living donors in a single German centre. Nephrol Dial Transplant 2003;18(2):418-25.  Back to cited text no. 15      
16.Biller-Andorno N, Schauenburg H, Ringe B. Nondirected kidney donation from living do­nors. Transpl Int 2001;14(2):125.  Back to cited text no. 16      
17.(lien CM, Reisaeter AV, Leivestad T, Pfeffer P, Fauchald P, Os I. Gender imbalance among donors in living kidney transplantation: the Norwegian experience. Nephrol Dial Transplant 2005;20(4):783-9.  Back to cited text no. 17      
18.Thiel GT, Nolte C, Tsinalis D. Gender imba­lance in living kidney donation in Switzerland. Transplant Proc 2005;37(2):592-4.  Back to cited text no. 18      
19.Kayler LK, Rasmussen CS, Dykstra DM, et al. Gender imbalance and outcomes in living donor renal transplantation in the United States. Am J Transplant 2003;3(4):452-8.  Back to cited text no. 19      
20.Zimmerman D, Donnelly S, Miller J, Stewart D, Albert SE. Gender disparity in living renal transplant donation. Am J Kidney Dis 2000;36 (3):534-40.  Back to cited text no. 20      
21.Jirasiritham S, Sumethkul V, Mavichak V, Dan­viriyasup K, Jirasiritham SI. Spouse donor kid­ney transplantation in Thailand. Transplant Proc 2000;32(7):1600-1.  Back to cited text no. 21      
22.Tang S, Lui SL, Lo CY, et al. Spousal renal donor transplantation in Chinese subjects: a 10 year experience from a single centre. Nephrol Dial Transplant 2004;19(1):203-6.  Back to cited text no. 22      
23.Avula S, Sharma RK, Singh AK, et al. Age and gender discrepancies in living related renal transplant donors and recipients. Transplant Proc 1998;30(7):3674.  Back to cited text no. 23      
24.Tuncer M, Gurkan A, Erdogan O, Yucetin L, Demirbas A. Lack of impact of human leu­kocyte antigen matching in living donor kidney transplantation: experience at Akdeniz Univer­sity. Transplant Proc 2005;37(7):2969-72.  Back to cited text no. 24      
25.Kwon OJ, Kwak JY, Kang CM. The impact of gender and age matching for long-term graft survival in living donor renal transplantation. Transplant Proc 2005;37(2):726-8.  Back to cited text no. 25      
26.Mohsin N, Budruddin M, Khalil M, et al. Donor gender balance in a living-related kidney trans­plantation program in Oman. Transplant Proc 2007;39(4):803-6.  Back to cited text no. 26      
27.Ghods AJ, Nasrollahzadeh D. Gender disparity in a live donor renal transplantation program: assessing from cultural perspectives. Transplant Proc 2003;35(7):2559-60.  Back to cited text no. 27      

Correspondence Address:
Hossein Khedmat
Department of Internal Medicine Baqiyatallah University of Medical Sciences, Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah Hospital, P.O. Box 14155-6437, Tehran 1435915371
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Source of Support: None, Conflict of Interest: None

PMID: 20814148

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