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with the requisite training andexpertise to evaluate donors fully,to ensure that donations are vol-untary, and to perform living-donor surgery. In addition, betterdata about the outcomes of liv-ing donors should be forthcom-

ing. The OPTN is also workingtoward requiring that transplan-tation centers report within 72hours the death of a living donoror the donors need for organtransplantation. Finally, OPTN/UNOS will develop a nationwidemechanism for allocating organsfrom living donors who have notdirected their donation to specificpersons.5The principles will besimilar to those for allocating or-

gans from cadaveric donors. Even-

tually, there might be a registryfor altruistic kidney and liver do-nors, such as the National Mar-row Donor Program, which listsvolunteer marrow donors.

The controversy over the pub-lic solicitation of organs has

forced the transplantation com-munity to address a diff icult issueand to reexamine its approach toliving donors. As long as there isa profound organ shortage, thechallenge of trying to help pa-tients in need of transplants whileupholding the integrity of theoverall allocation system will notgo away.

Dr. Steinbrook is a national correspondentfor theJournal.

Hartman T. Donor fails lie detector teston organ transplant. Rocky Mountain News.March 11, 2005:6A.

Delmonico FL. Exchanging kidneys advances in living-donor transplantation.N Engl J Med 2004;350:1812-4.

Letter from Dr. James F. Burdick, direc-tor, Division of Transplantation, HealthcareSystems Bureau, Health Resources and

Services Administration, Department ofHealth and Human Services, to Walter K.Graham, Executive Director, United Networkfor Organ Sharing, October 29, 2004.

OPTN/UNOS board opposes solicitationfor deceased organ donation. Press releaseof the United Network for Organ Sharing,November 19, 2004. (Accessed July 14, 2005,at http://www.unos.org/news/newsDetail.asp?id=374.)

OPTN/UNOS board addresses informa-tion needs of potential living donors. Pressrelease of the United Network for OrganSharing, June 24, 2005. (Accessed July 14,2005, at http://www.unos.org/news/newsDetail.asp?id=456.)

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public solicitation of organ donors

The Ethics of Organ Donation by Living DonorsRobert D. Truog, M.D.

Related articles, pages 441 and 447

M

ost organs for transplanta-tion come from cadavers,

but as these have failed to meetthe growing need for organs, at-tention has turned to organs fromliving donors. Organ donation byliving donors presents a uniqueethical dilemma, in that physi-cians must risk the life of a healthyperson to save or improve the lifeof a patient. Transplantation sur-geons have therefore been cau-tious in tapping this source. As

surgical techniques and outcomeshave improved, however, this prac-tice has slowly expanded. Today,according to the United Networkfor Organ Sharing (UNOS), al-most half of all kidney donors inthe United States are living. In

2004, living organ donors alsoprovided a lobe of the liver inapproximately 320 cases and alobe of a lung in approximately15 cases.

Three categories of donationby living persons can be distin-guished: directed donation to aloved one or friend; nondirecteddonation, in which the donorgives an organ to the general poolto be transplanted into the recip-ient at the top of the waiting list;

and directed donation to a strang-er, whereby donors choose to giveto a specific person with whomthey have no prior emotional con-nection.

Each type of donation promptsdistinct ethical concerns. With di-

rected donation to loved ones orfriends, worries arise about theintense pressure that can be puton people to donate, leading thosewho are reluctant to do so to feelcoerced. In these cases, transplan-tation programs are typically will-ing to identify a plausible medicalexcuse, so that the person canbow out gracefully.1Equally im-portant, however, are situationsin which people feel compelled todonate regardless of the conse-

quences to themselves. In one in-stance, both parents of a childwho was dying of respiratoryfailure insisted on donating lobesof their lungs in a desperate butunsuccessful attempt to save herlife.2Such a sense of compulsion

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is not unusual. In cases like these,simply obtaining the informedconsent of the relative is insuffi-cient physicians are obligatedto prevent people from makingpotentially life-threatening sacri-fices unless the chance of success

is proportionately large.Nondirected donation raises

different ethical concerns. Theradical altruism that motivates aperson to make a potentially life-threatening sacrifice for a strang-er calls for careful scrutiny. Onerecent case involved a man whoseemed pathologically obsessedwith giving away everything, fromhis money to his organs, sayingthat doing so was as much a ne-

cessity as food, water, and air.3After donating one kidney to astranger, he wondered how hemight give away all his other or-gans in a dramatic suicide. Oth-er psychologically suspect motiva-tions need to be ruled out as well.Is the person trying to compen-sate for depression or low self-esteem, seeking media attention,or harboring hopes of becominginvolved in the life of the recipi-ent? Transplantation teams havean obligation to assess potentialdonors in all these dimensionsand prohibit donations that arouseserious concern.1

Directed donation to a strangerraises similar ethical questionswith a few additional wrinkles.This type of donation usually oc-curs when a patient advertises foran organ publicly, on television or

billboards or over the Internet.Such advertising is not illegal, butit has been strongly discouragedby the transplantation communi-ty. Two central objections are thatthe practice is unfair and that itthreatens the view that an organ

is a gift of life, not a commodityto be bought and sold.

Some argue that just as wehave a right to donate to the po-litical parties and charities of ourchoice, so should we be able tochoose to whom to give our or-

gans. In practice, however, thismeans that those who have themost compelling stories and themeans to advertise their plighttend to be the ones who get theorgans rather than those mostin need. This strikes some ethi-cists as unfair. Unlike monetarygifts, they argue, organ trans-plantation requires the involve-ment of social structures and in-stitutions, such as transplantation

teams and hospitals. Hence, theargument goes, these donationsare legitimately subject to societalrequirements of fairness, andtransplantation centers should re-fuse to permit the allocation oforgans on the basis of anythingbut morally relevant criteria.4

The most ethically problem-atic cases are those in which therecipient is chosen on the basisof race, religion, or ethnic group.In one case, for example, the fam-ily of a brain-dead Florida managreed to donate his organs but insisted that because of themans racist beliefs, the recipientsmust be white. Although the or-gans were allocated accordingly,Florida subsequently passed a lawprohibiting patients or familiesfrom placing such restrictions ondonation.5

Even when the motives forchoosing a recipient may be un-ethical, however, there might bereasons for allowing the donationto proceed. Consider a case thatwas discussed at a recent publicforum hosted by Harvard Medi-

cal Schools Division of MedicalEthics: a Jewish man in New Yorklearned of a Jewish child in LosAngeles who needed a kidneytransplant. The man wanted tohelp someone of his own faithand decided he was willing to

donate a kidney to help this par-ticular child. Despite his discrimi-natory preference, one might viewthe donation as permissible, sinceat least some patients would ben-efit (the child would receive a kid-ney, and those below her on thewaiting list would move up onenotch) and no one would beharmed (those above the girl onthe waiting list would not receivethe kidney under any circumstanc-

es, because the man would notgive it to them). Whether direct-ed donation to strangers violatesstandards of fairness is thus con-troversial. But if it is permitted,it will be very difficult to prohibitdiscriminatory preferences, sincedonors can simply specify thatthe organ must go to a particularperson, without saying why.

The other substantial cause forconcern about this type of dona-tion is its potential for makingpossible the buying and selling oforgans. These practices are strict-ly prohibited by law, yet they seemto be an inherent risk in directeddonations to strangers. Wealthypatients in need and healthy do-nors looking for a quick fix totheir financial problems will al-ways be able to find ways aroundeven the most earnest attempts

to prevent money from changinghands.Despite these concerns, efforts

to direct organ donations tostrangers are not new, datingback at least to the celebrated1982 case of Jamie Fiske, whose

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father successfully mounted a na-tionwide appeal for someone todonate a liver to her. Today, manysuch solicitations are transmittedover the Internet, where, whenthe practice was relatively limited,organ solicitation was managed

quietly, on a case-by-case basis,by individual transplantationcenters. All this changed, how-ever, with the emergence in 2004of MatchingDonors.com (as dis-cussed by Steinbrook in this is-sue of the Journal,pages 441444).This Web site currently claimsto have more than 2100 regis-tered potential donors and tohave brokered 12 transplanta-tions, with about 20 more recip-

ientdonor pairs matched andawaiting surgery.

Although the business con-ducted on this organizations Website does not raise any funda-mental ethical issues not alreadyposed by other methods of solici-tation, it does introduce a newdegree of visibility that increasesthe magnitude of the issue. Willcompeting commercial Web sitesbegin to emerge? How will thesesites be held accountable? Dr.Jeremiah Lowney, the medical di-rector of MatchingDonors.com,recently argued that just as adating service could not be heldresponsible for a bad date, hisWeb site has no responsibility forthe outcomes of its matches. Fur-thermore, the Web site has nomechanism for ensuring the qual-ity of the information it provides

about transplantation and dona-tion by living persons or for check-

ing the accuracy of informationsubmitted by potential donorsand recipients.

Given the life-or-death conse-quences of the procedure, organdonation should not be governedby the ethics of caveat emptor.

Nevertheless, MatchingDonors.com has clearly identified a need,and if this need is not met by aservice that can address the eth-ical challenges, the vacuum willbe filled by other enterprises. En-trepreneurs commonly open upuseful new markets and servicesthat must eventually become sub-ject to rigorous standards andregulations.

The solicitation of organs over

the Internet is probably here tostay, but it will require higherstandards of responsibility andaccountability than are currentlyin place. UNOS has more than20 years of experience in manag-ing the cadaveric-donor pool andis in a good position to extend itsjurisdiction to include donationby living donors. The organizationrecently considered the topic ofsolicitation and decided not topursue building a Web site simi-lar to that of MatchingDonors.com but, instead, to provide ed-ucational information for any-one who is willing to be a livingdonor of a kidney and to developa nationwide mechanism for al-locating organs for nondirecteddonation by living donors.

This effort, however, does notgo far enough. The proposal does

not address directed donation andleaves many critical aspects of

donation by living donors to thetransplantation centers. Organtransplantation is big business,and each center is highly moti-vated to expand its share of thepie. They therefore have intoler-able conflicts of interest when it

comes to regulating themselves.Instead, UNOS should be chargedwith standardizing the processfor evaluating potential donors,ensuring that independent advo-cates are assigned to help donorsmake an informed choice, devel-oping mechanisms to deal withpotential injury or death to thedonor, setting standards for bothdirected and nondirected dona-tion, and prohibiting transplan-

tation when the chance of suc-cess is insufficient to justify therisks. Comprehensive oversight isnecessary if the ethical pitfalls areto be adequately addressed.

Dr. Truog is a professor of medical ethicsand anesthesia (pediatrics) in the Depart-ment of Social Medicine at the HarvardMedical School and the Division of CriticalCare Medicine at Childrens Hospital Boston.

An interview with Dr. Truog can be heard at

www.nejm.org.

Abecassis M, Adams M, Adams P, et al.Consensus statement on the live organ do-nor. JAMA 2000;284:2919-26.

Kolata G. Lungs from parents fail to savegirl, 9, and doctors assess ethics. New YorkTimes May 20, 1991:A11.

Parker I. The gift: Zell Kravinsky gave awaymillions: but somehow it wasnt enough.The New Yorker. August 2, 2004:54-63.

Kluge E-HW. Designated organ donation:private choice in social context. HastingsCent Rep 1989;19(5):10-6.

Veatch RM. Transplantation ethics.

Washington, D.C.: Georgetown UniversityPress, 2000.

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