: Iran has had a program of compensated kidney donation from living unrelated (LUR) donors since 1997. The aim of the program was to address the increasing demand for kidney transplantation in a morally sound manner. The program was successful in terms of increasing the number of kidneys available for transplantation. This paper presents a critical review of the program and its ethical status. Denying organ donors legitimate compensation because of the understandable fear of an organ trade is not (...) morally justifiable, and the Iranian model of compensated LUR kidney donation offers substantial benefits that overcome these concerns. Despite its benefits, the program lacks secure measures to prevent the risk of a direct monetary relationship between donors and recipients, and it must be revised in order to be morally justifiable. (shrink)

In this article, I argue we have collective duties to people who suffer from kidney failure and these duties are best fulfilled through a government-monopsony market in kidneys. A government-monopsony market is a model where the government is the sole buyer, and kidneys are distributed according to need, not ability to pay. The framework of collective duties enables us to respond to several of the most pressing ethical and practical objections to kidney markets, including Cécile Fabre's objection that (...) it is unjust to be paid to do one's duty, Simon Rippon's objections that it is harmful to be pressured to sell a kidney and that a market is unfair, Richard Titmuss's crowding out objection, and Ronald Dworkin's objection that body parts should not be among the goods we owe each other. (shrink)

This paper defends an in principle understanding of the authority of persons over themselves and, in consequence, argues for significant limits on morally permissible state authority. It also defends an account of the limits of permissible state action that distinguishes between the ability of persons to convey authority to common projects and what may be judged virtuous, good, safe, or proper to do. In terms of organ transplantation policy, it concludes that it is morally acceptable, and should be legally permissible, (...) for individuals to sell one of their kidneys while living, pocketing the cash to use as that person sees fit to advance their own understanding of their own best interests. Morally objectionable policy proposals, I argue, are not those that encourage individuals to sell a redundant kidney while living or families to sell the organs of a recently deceased loved one, but those that seek coercively to confiscate the organs of the recently deceased. Recognizing the authority of persons over themselves, and their ability to convey moral authority to common projects, including the sale of human organs for transplantation, would shed light on the medical marketplace and clarify public policy, while increasing the efficiency and effectiveness of procuring human organs for transplantation. (shrink)

Kidney donation by young children and the mentally retarded has been supported by court decisions, arguments based on obligations inherent in family relationships, an array of contextual factors, and the principle of beneficence. These justifications for taking organs from people who cannot protect themselves are problematic and must be weighed against our obligation to protect the vulnerable. A compromise solution is presented that strongly protects young children and the mentally retarded but does not abdicate all responsibility to relieve suffering. Guidelines (...) are proposed that prohibit the retrieval of kidneys from young children and the mentally retarded but permit one exception. They would allow retrieval of a kidney when the consequence to a first order relative with whom the donor has a meaningful and valuable relationship is otherwise imminent death. This would be done in accordance with additional guidelines that minimize harm to the donor. Since most patients with end stage renal disease can be maintained on dialysis the need for a kidney to prevent death should be an uncommon occurrence. This compromise is proposed as a solution to a dilemma that exists because two ethical principles are in conflict and one cannot be honored without violating the other. (shrink)

This paper challenges the view that bans on kidney sales are unjustifiably paternalistic, that is, that they unduly deny people the freedom to make decisions about their own bodies in order to protect them from harm. I argue that not even principled anti-paternalists need to reject such bans. This is because their rationale is not hard paternalism, which anti-paternalists repudiate, but soft paternalism, which they in principle accept. More precisely, I suggest that their rationale is what Franklin Miller and Alan (...) Wertheimer call ‘group soft paternalism’. Group soft paternalistic policies restrict the freedom of autonomous individuals, not for their own good (hard paternalism), but as an unavoidable consequence of seeking to protect other, non-autonomous individuals from harms that they have not voluntarily chosen (soft paternalism). Group soft paternalism supports prohibiting kidney sales on three conditions: (1) that such sales are potentially harmful to vendors, (2) that many vendors would suffer impaired autonomy, and (3) that distinguishing between autonomous and non-autonomous vendors and interfering only with the latter is unfeasible. I provide reasons for thinking that these conditions will often hold. (shrink)

I shall argue, first, that potential kidney donors may be subject to harmful pressure to donate. This pressure may take almost any form; people have diverse interests, and anything that could set them back may qualify as pressure. Given features of the context—the high stakes, the involvement of family, and the social meaning of donation—such pressure may be especially harmful. This problem is less tractable than the more familiar worry that pressure may compromise consent. Screening may ensure donors validly consent, (...) but it provides no protection against harmful pressure. I shall argue, second, that the use of such pressure is the predictable consequence of the prohibition on kidney sales. Potential donors have something—a transplantable kidney—that is both valuable and scarce. Many of them, informed about donation, decide against it. Those in need of a transplant may seek to persuade the unwilling. Given the prohibition, the donation cannot be made more attractive in absolute terms by, say, the addition of money. However, it can be made more attractive in relative terms. If declining the option is made worse, then, by comparison, accepting it is made better. The application of harmful pressure has the desired effect. With so much at stake, and no good alternatives, its use is predictable. I conclude that potential donors' interests should figure more prominently in the discussion of transplant policy. Those who defend the prohibition have made virtually no attempt to account for its impact on that group. (shrink)

Proponents of permitting living kidney sales often argue as follows. Many jobs involve significant risks; people are and should be free to take these risks in exchange for money; the risks involved in giving up a kidney are no greater than the risks involved in acceptable hazardous jobs; so people should be free to give up a kidney for money, too. This paper examines this frequently invoked but rarely analysed analogy. Two objections are raised. First, it is far from clear (...) that kidney sales and dangerous jobs involve comparable risks on an appropriately broad comparison. Second, and more importantly, even if they do involve comparable risks it does not follow that kidney sales must be permitted because dangerous jobs are. The analogy assumes that kidney sales are banned for paternalistic reasons. But there may be other, non-paternalistic reasons for the ban. And paternalists, too, can consistently defend the ban even if kidney sales are no riskier than occupations that they find acceptable. Soft paternalists may want to protect would-be vendors from harms that they have not voluntarily chosen. Egalitarian hard paternalists may want to protect already badly off vendors from further worsening their situation. For neither species of paternalist is the size of the risk prevented decisive. I conclude that the analogy with dangerous jobs, while rhetorically powerful, pulls little real argumentative weight. Future debates on living kidney sales should therefore proceed without it. (shrink)

Canada has a marked shortfall between the supply and demand for kidneys for transplantation. Median wait times for deceased donor kidney transplantation vary from 5.8 years in British Columbia, 5.2 years in Manitoba and 4.5 years in Ontario to a little over 2 years in Quebec and Nova Scotia. Living donation provides a viable option for some, but not all people. Consequently, a small number of people travel abroad to undergo kidney transplantation by commercial means. The extent to which (...) they are aware of the potential risks to their health and the health of the kidney vendors is unclear. Travel abroad to obtain a kidney commercially i.e. transplant tourism (TT), raises ethical issues which include the exploitation of the poor, uncertainty of donor informed consent to nephrectomy, poor clinical care and lack of follow up for the donor, commodification of the body and inequity of access to medical care for donors. Also, TT widens socioeconomic disparities in access to transplantation, differing from the Canadian system of universal coverage for healthcare. The Canadian transplant community has discussed how to respond to patients who plan to travel abroad for TT or return with a purchased kidney. Unease rests in the tension between the duty to care for legitimate Canadian residents and the unwillingness to enable TT. This paper discusses three anonymized cases and the Canadian responses to TT as recorded in academic literature and a formal statement by relevant professional bodies. (shrink)

In this paper, we seek to re-conceptualize the ethical framework through which ethicists and medical professionals view the practice of live kidney donations. The ethics of organ donation has been understood primarily within the framework of individual rights and impartiality, but we show that the ethic of care captures the moral situation of live kidney donations in a more coherent and comprehensive way, and offers guidance for practitioners that is more attentive to the actual moral transactions among donors and recipients. (...) A final section offers guidelines for the practice of live kidney transplants that emerge from an ethic of care. (shrink)

The best treatment for end-stage renal disease is the transplantation of a live donor kidney, but many people cannot donate to their loved ones because they are incompatible. Kidney exchange promises relief. Kidney exchange programmes use centralised procedures to match donors with recipients in a way that maximises the quantity and quality of transplants. However, the transplant laws in many countries render kidney exchange programmes impossible because of ethical concerns against these programmes or against kinds of kidney donations on which (...) these programmes rely. I give two novel arguments for the implementation of kidney exchange programmes. The first is that they are instrumental in meeting a moral obligation, namely to donate effectively. The second is that they may increase the motivation for altruistic donations, because the donation of one kidney may trigger >1 life savings. Moreover, ethical concerns are considered that are embodied in transplant laws preventing the implementation of kidney exchange, and it is argued that they can be overcome. (shrink)

In the Eurotransplant region transplantable kidneys from cadaveric donors are allocated according to the Wujciak-Opelz algorithm. This paper shows that the algorithm as it stands fulfils certain normative standards of a more formal nature while violating others. In view of these insights, it is explored how the algorithm could perhaps be improved. Even if issues of substantial rather than formal adequacy need to be addressed separately, analyses as presented in this paper can prepare the ground for a discussion of (...) substantive normative issues. In any event, axiomatic accounts can tell us something about what we are in fact doing when using a procedure like the Wujciak-Opelz algorithm. (shrink)

Much of the opinion scandalized by recent reports of kidneys being sold for transplant is significantly inconsistent. The sale of kidneys is not substantially different from practices espoused, and indeed endorsed, by many of those who condemn the former. Our moral concern, I suggest, needs to focus on the customer's actions rather than the seller's; and on the implications for larger questions of the considerations to which this gives rise.

We study the allocation of cadaveric donor kidneys for transplantation based merely on waiting time. This simple allocation rule turns out to possess very attractive ethical and medical properties. Current allocation rules, on the other hand, violate some basic requirements of distributive justice. Perhaps for fear of exacerbating these problems, these rules also fail to consider criteria such as sex, age and race although certain combinations of these criteria are known to affect graft survival rates. We demonstrate that allocation (...) by waiting time automatically protects disadvantaged patient types and puts them in a near to optimal position. The inclusion of sex, age and race will therefore not lead to morally unacceptable allocations. This allows individual patients to improve the expected survival time of their graft relative to the status quo without being penalized by the allocation rule. Moreover, decisions ab out when to start compromising on expected graft survival rates in favour of shorter waiting times are made locally by patients and their medical advisers rather than by a centralized protocol. (shrink)

There is a global shortage of organs for transplantation and despite many governments making significant changes to their organ donation systems, there are not enough kidneys available to meet the demand. This has led scientists and clinicians to explore alternative means of meeting this organ shortfall. One of the alternatives to human organ transplantation is xenotransplantation, which is the transplantation of organs, tissues, or cells between different species. The resurgence of interest in xenotransplantation and recent scientific breakthroughs suggest that (...) genetically-engineered pigs may soon present a realistic alternative as sources of kidneys for clinical transplantation. It is therefore important for nurses and allied health professionals to understand what is involved in xenotransplantation and its future implications for their clinical practices. First, we explore the insufficiency of different organ donation systems to meet the kidney shortage. Second, we provide a background and a summary of the progress made so far in xenotransplantation research. Third, we discuss some of the scientific, technological, ethical, and economic issues associated with xenotransplantation. Finally, we summarise the literature on the attitudes of healthcare professionals toward xenotransplantation. (shrink)

This article probes the voucher program from an ethical perspective. It focuses mainly on an issue of inequity. A disparity exists in US kidney transplantation. Although African-Americans suffer far higher rates of ESRD than whites, African-Americans are much less likely than whites to get a transplant. The article explores the voucher program in light of this disparity. It motivates the view that, at least in the short term, more whites than African-Americans are likely to take advantage of the voucher program. (...) The program is, thus, likely to increase the gap in transplantation rates between the two groups. If this is correct, what impact does it have on the moral acceptability of the program? (shrink)

Janet Radcliffe Richards’ The Ethics of Transplants outlines a novel framework for moral inquiry in practical contexts and applies it to the topic of paid living kidney donation. In doing so, Radcliffe Richards makes two key claims: that opponents of organ markets bear the burden of proof, and that this burden has not yet been satisfied. This paper raises four related objections to Radcliffe Richards’ methodological framework, focusing largely on how Radcliffe Richards uses this framework in her discussion of kidney (...) sales. We conclude that Radcliffe Richards’ method of inquiry hinders our ability to answer the very question that it ought to help us resolve: What is there best reason to do, all things considered? (shrink)

Is the lower rate of kidney transplantation into African Americans medically and ethically justifiable? Or is it a form of racial discrimi nation comparable to if not worse than denial of employment opportunities, housing, and educational opportunities? This essay focusses on the medical problems associated with matching antigens in donors and recipients, and the implications of those problems for social justice.1 Racially discriminatory practices in bank lending, education, and hiring provide a context for understanding how medical criteria treat black recipients (...) unfairly. Although antigen matching is only one aspect of the general problem of finding medically suitable black recipients, it presents an especially interesting challenge for theories of justice, as well as for medical research. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Narrative Symposium:Living Organ DonationLaura Altobelli, Sherri Bauman, Janice Flynn, Andy Heath, Joseph Jacobs, Tim Joos, Amy K. Lewensten, Donna L. Luebke, Sarah A. McDaniel, Donald Olenick, Laurie E Post, Vicky Young, Blake Adams, Anonymous One, Michael Sauls, Christine Wright, Shannon D. Wyatt, and Cara Yesawich• An Altruistic Living Donor’s Story• Surgery for the Soul• Kidney Donation Story• The Essence of Giving—A Transplant Story• Love—the Risk Worth Taking• My Donation (...) Journey• A Life For A Life: My Gift To My Dad• Lessons Learned: The Realities of Living Organ Donation• Sarah’s List Exchange Experience• Accelerated Living Donation• Liver Donor Nightmare• Adrift After Donation• Getting Our Child Off Dialysis• A Living Donor’s Journey• The Spare Kidney• Living Donors are People Too• The Gift of Life—Walking by Faith• Journey of an Altruistic, Non–designated Living DonorCopyright © 2012 The Johns Hopkins University Press... (shrink)

Recent evidence, from both epidemiological and animal experimental studies, suggest that the very first environment, the intrauterine, is extremely important in determining the future health of the individual. Genetic and ‘lifestyle’ factors impinge on, and can exacerbate, a ‘programming’ effect of an adverse fetal environment. In this review, we present compelling evidence to suggest that one of the major organs affected by an unfavourable prenatal environment is the kidney. Many of the factors that can affect fetal renal development (i.e. exposure (...) to excess glucocorticoids, insufficient vitamin A, protein/calorie malnutrition (in rats) and alterations in the intrarenal renin angiotensinogen system), also produce hypertension in the adult animal. When nephron number is compromised during kidney development, maladaptive functional changes occur and can lead, eventually, to hypertension and/or renal disease. Surprisingly, it is during the very earliest stages of kidney development that the vulnerability to these effects occurs. BioEssays 25:212–220, 2003. © 2003 Wiley Periodicals, Inc. (shrink)

Much of the opinion scandalized by recent reports of kidneys being sold for transplant is significantly inconsistent. The sale of kidneys is not substantially different from practices espoused, and indeed endorsed, by many of those who condemn the former. Our moral concern, I suggest, needs to focus on the customer's actions rather than the seller's; and on the implications for larger questions of the considerations to which this gives rise.

For the past two decades, agricultural workers in regions of Central America have reported an epidemic of chronic kidney disease of undetermined etiology (CKDu) that is not associated with established risk factors of chronic kidney disease. Several hypotheses have emerged, but the etiology of CKDu remains elusive and controversial. The aim of this literature review was to describe the potential risk factors of CKDu in Mesoamerica and implications for the U.S. agricultural worker population. PubMed and CINAHL databases were searched for (...) articles published between 2000 and 2018 that examined CKDu in Mesoamerica; 29 original studies were included in this review. CKDu is a multifactorial disease that is often asymptomatic with hallmark characteristics of elevated serum creatinine and blood urea nitrogen (BUN), low glomerular filtration rate, electrolyte abnormalities, and non-nephrotic proteinuria. Reducing the global prevalence of CKDu will require more robust studies on causal mechanisms and on interventions that can reduce morbidity and mortality in vulnerable populations. (shrink)

Luke Semrau argues that the documented harms of existing organ markets do not undermine the case for establishing regulated systems of paid kidney donation. He offers two arguments in support of this conclusion. First, Semrau argues that the harms of kidney selling are straightforwardly amenable to regulatory solution. Second, Semrau argues that even in existing black markets, sellers would likely have experienced greater harm if the option of selling a kidney were not available. This commentary challenges both of Semrau’s claims. (...) I argue that there is no reason to believe that kidney sellers benefit from the current black market trade in organs, and highlight a number of potential issues regarding the effectiveness and feasibility of Semrau’s proposed market regulations. (shrink)

Simon Rippon, revising an earlier argument against kidney sales, now claims that offers involving the performance of invasive acts, when extended to people under pressure, constitute a kind of rights violation, Impermissibly Disrespectful Demands. Since offers involving kidney sales so qualify, Rippon finds prima facie reason to prohibit them. The present article levels four independent objections to Rippon’s argument: the account of Impermissibly Disrespectful Demands implausibly condemns kidney donation as much as kidney sales; the normative importance of having autonomous veto (...) control over bodily incursions does not plausibly underwrite a right to not be extended invasive offers under pressure; Impermissibly Disrespectful Demands can easily be transformed into innocuous offers; and the prohibition has greater welfare costs than Rippon acknowledges. (shrink)

In the Eurotransplant region transplantable kidneys from cadaveric donors are allocated according to the Wujciak-Opelz algorithm. This paper shows that the algorithm as it stands fulfils certain normative standards of a more formal nature while violating others. In view of these insights, it is explored how the algorithm could perhaps be improved. Even if issues of substantial rather than formal adequacy need to be addressed separately, analyses as presented in this paper can prepare the ground for a discussion of (...) substantive normative issues. In any event, axiomatic accounts can tell us something about what we are in fact doing when using a procedure like the Wujciak-Opelz algorithm. (shrink)

In Canada, there are currently no guidelines at either the federal or provincial level regarding the provision of kidney transplantation services to foreign nationals (FN). Renal transplant centres have, in the past, agreed to put refugee claimants and other FNs on the renal transplant waiting list, in part, because these patients (refugee claimants) had health insurance through the Interim Federal Health Programme to cover the costs of medication and hospital care. However, severe cuts recently made to this programme have forced (...) clinicians to question whether they should continue with transplants for FNs, for financial and ethical reasons. This paper first examines different national policies (eg, in Canada, USA, France and the UK) to map the diversity of approaches regarding transplantation for FNs, and then works through different considerations commonly used to support or oppose the provision of organs to these patients: (1) the organ shortage; (2) the free-rider problem; (3) the risk of becoming a transplant destination; (4) the impact on organ donation rates; (5) physicians’ duties; (6) economic concerns; (7) vulnerability. Using a Canadian case as a focus, and generalising through a review of various national policies, we analyse the arguments for and against transplantation for FNs with a view to bringing clarity to what is a sensitive political and clinical management issue. Our aim is to help transplant centres, clinicians and ethicists reflect on the merits of possible options, and the rationales behind them. (shrink)

Terminal kidney patients are faced with lower quality of life, restricted diets and higher morbidity and mortality rates while waiting for deceased donor kidney transplantation. Fortunately, living kidney donation has proven to be a better treatment alternative (e.g. in terms of waiting time and graft survival rates). We observed an inequality in the number of living kidney transplantations performed between the non-European and the European patients in our center. Such inequality has been also observed elsewhere in this field and it (...) has been suggested that this inequality relates to, among other things, attitude differences towards donation based on religious beliefs. In this qualitative research we investigated whether religion might indeed (partly) be the explanation of the inequalities in living donor kidney transplants (LDKT) among non-European patients. Fifty patients participated in focus group discussions and in-depth interviews. The interviews were conducted following the focus group method and analyzed in line with Grounded Theory. The qualitative data analyses were performed in Atlas.ti. We found that religion is not perceived as an obstacle to living donation and that religion actually promotes helping and saving the life of a person. Issues such as integrity of the body were not seen as barriers to LDKT. We observed also that there are still uncertainties and a lack of awareness about the position of religion regarding living organ donation within communities, confusion due to varying interpretations of Holy Scriptures and misconceptions regarding the process of donation. Faith leaders play an important educational role and their opinion is influential. This study has identified modifiable factors which may contribute to the ethnic disparity in our living donation program. We argue that we need to strive for more clarity and awareness regarding the stance of religion on the issue of living donation in the local community. Faith leaders could be key figures in increasing awareness and alleviating uncertainty regarding living donation and transplantation. (shrink)

Kidney markets are prohibited in principle because they are assumed to undermine the seller’s dignity. Considering the trade-off between saving more lives by introducing regulated kidney markets and preserving the seller’s dignity, we argue that it is advisable to demand that citizens restrain their own moral judgements and not interfere with the judgements of those who are willing to sell a kidney. We also argue that it is advisable not only to limit the political implications of the moral argument of (...) dignity concerns toward a market-based solution but also to re-evaluate the dignity argument itself. First, if the dignity argument is to be given normative force, it must also consider the dignity violation of the potential transplant recipient. Second, there seems to be no compelling notion of dignity that demonstrates why it is morally permissible to donate but not to sell a kidney. (shrink)

Living kidney transplantation offers the best treatment in terms of life-expectancy and quality of life for those with end-stage renal disease. The long-term risks of living donor nephrectomy, although real, are very small, with evidence of good medium-term outcomes. Who should be entitled to donate, and in which circumstances, is nevertheless a live question. We explore the ethical dimensions of a request by an individual to donate both of their kidneys during life: ‘dual living kidney donation’. Our ethical analysis (...) is tethered to a hypothetical case study in which a father asks to donate a kidney to each of his twin boys. We explore the autonomy of the protagonists, alongside different dimensions of the public interest, such as the need to protect not only the recipients, but also the donor and even the wider community. Whilst acknowledging objections to ‘dual-donation’, not least by reference to the harms that the donor might be expected to endure, we suggest there is a prima facie case for permitting this, provided that both donor and recipients are willing and that due attention is paid to such considerations as the autonomy and welfare of all parties, as well as to the wider ramifications of acting on such a request. We argue for broader interpretations of the concepts of autonomy and welfare, recognizing the importance of relationships and the relevance of more than merely physical well-being. Equipped with such a holistic assessment, we suggest there is a prima facie case for allowing ‘dual living kidney donation’. (shrink)

In theory, a commercial market for kidneys could increase the scarce supply of transplantable organs and give impoverished people a new way to lift themselves out of poverty. In‐depth sociological work on those who opt to sell their kidneys reveals a different set of realities. Around the town of Sarghoda, Pakistan, the negative social and psychological ramifications of selling a kidney affect not only the vendors themselves, but also their families, communities, and even the country as a whole.

For live-related kidney donation, the current UK guidance specifies that the donor has a right to know the recipient’s HIV status. This guidance may prevent some potential recipients from asking friends or family to donate, as they do not wish them to know they are HIV positive. Currently, it is felt necessary that the donor should know the HIV status of the recipient in order to give fully informed consent to the operation. However, the specific medical details are not required (...) in order to allow for donor informed consent. This consent requires knowledge of the general expectation for survival of a graft and the specific expectation for survival of this graft in the recipient; it does not require specific knowledge of the recipient’s medical condition. (shrink)

Kidney for Sale by Owner discusses a range of different arguments that can be offered in defence of live donor kidney markets. Although Cherry’s case for establishing such markets does not rest on consequentialist considerations, Cherry nonetheless suggests that allowing the sale of organs would have net positive consequences. He argues that both renal failure patients and people living in poverty could benefit from participating in the market, and further claims that a legal trade in organs would not shape society (...) in harmful ways. This paper argues that the likely consequences of establishing an open market in kidneys are less benign than Cherry suggests. Specifically, I argue that a live donor kidney market could plausibly harm sellers, give rise to harmful pressures to participate in the market, and reinforce unjust political and social structures. I conclude by considering the implications of these arguments for the organ market debate. (shrink)

Sigrid Fry-Revere’s The Kidney Sellers: A Journey of Discovery in Iran, an allegedly first-hand examination of the Iranian paid kidney donation model, has been criticized by Koplin in an essay formerly published in the Monash Bioethics Review. Koplin especially challenges Fry-Revere’s claim that financially compensating kidney vendors might facilitate altruistic kidney donation. The current situation in Iran, according to Koplin, suggests that the market model has undermined altruistic donation. On this point, this commentary tries to show that healthcare policymakers in (...) Iran no longer see the Iranian paid kidney donation model as a sustainable and ethically justifiable status quo. Briefly touching on the criticisms that have been made even by some positive commentators of the Iranian model, this commentary aims to call attention to the fact that the current dynamic within healthcare policymaking in Iran seeks primarily to decrease its reliance on the organ market instead of revising and modifying it. This complicates the plausibility of any kind of extrapolation, replication or extracting empirical support from the Iranian model to create organ markets in other countries, for example, as Fry-Revere suggests to conduct a trial of a financially incentivized kidney donation scheme in the US. The conclusion is that the Iranian healthcare system should tackle the organ shortage through increasing altruistic living and postmortem kidney donations. This might also provide, finally, a space for conducting extensive and long-term follow-up studies on well-being, satisfaction and social integration of Iranian kidney vendors. (shrink)

Erik Malmqvist defends the prohibition on kidney sales as a justifiable measure to protect individuals from harms they have not autonomously chosen. This appeal to ‘group soft paternalism’ requires that three conditions be met. It must be shown that some vendors will be harmed, that some will be subject to undue pressure to vend, and that we cannot feasibly distinguish between the autonomous and the non-autonomous. I argue that Malmqvist fails to demonstrate that any of these conditions are likely to (...) obtain. His argument involves two common errors. First, he, like many, proceeds on a mistaken understanding of how to assess harm. What matters is not the balance of costs and benefits of vending, but a comparison of potential vendors’ welfare across two possible courses of action. Second, Malmqvist's concerns about third-party pressure are predicated on an empirically unrealistic understanding of the operation of a regulated market. A widely underappreciated fact is that kidney sales will be relatively rare, and most who try to vend will be unable to. Because pressure on another to vend will not result in the desired outcome, few will exert it. (shrink)

ate program and identified the ethical commitments and threats living kidney donors perceive throughout the donation process. Method: This quality improvement project reflects a mixed-methods methodology. Qualitative as well as quantitative data were generated through the donor-advocate consultation sessions and the written Living Donor Satisfaction Survey. Thirteen living donors participated. Results: No threats to donor rights were identified by either the donor or the advocate. Nonrelated donors were motivated by altruism, whereas related donors were motivated by a sense of family. (...) A majority of donors reported being changed emotionally and spiritually by the act of serving as a living donor. The living kidney donors were overwhelmingly extremely satisfied with their decision to donate and perceived the living donor advocacy program as being very good. Discussion: Questions have been raised about what role the donor’s spouse should have during the informed consent process. Further research is needed to better understand the role and power of an advocate when threats to the donor’s rights are noted.... (shrink)

In 'Stakes and Kidneys' the author discusses various ethical issues surrounding the international trade in human organs.

Brecher argues that the practices of selling blood and kidneys are akin to the practices of prostitution and wage-labour since they all involve commodification and, by implication, should be subject to legal prohibition. I suggest that these practices need not involve commodification and that they should only be condemned if people are forced into them because of their lack of power. Rather than these practices being prohibited, I suggest that it would be preferable if they were subject to state (...) regulation in order to protect the weak from exploitation. (shrink)

Simon Rippon has recently argued against kidney markets on the grounds that introducing the option to vend will result in many people, especially the poor, being subject to harmful pressure to vend. Though compelling, Rippon’s argument fails. What he takes to be a single phenomenon—social and legal pressure to vend—is actually two. Only one of these forms of pressure is, by Rippon’s own account, harmful. Further, an empirically informed view of the regulated market suggests that this harmful pressure is easily (...) avoided. Thus, the harm that is the lynchpin of Rippon’s opposition is neither a necessary feature of the market nor is it likely to play a signicant role in its operation. (shrink)

Public surveys conducted in many countries report widespread willingness of individuals to donate a kidney while alive to a family member or close friend, yet thousands suffer and many die each year while waiting for a kidney transplant. Advocates of financial incentive programs or “regulated markets” in kidneys present the problem of the kidney shortage as one of insufficient public motivation to donate, arguing that incentives will increase the number of donors. Others believe the solutions lie—at least in part—in (...) facilitating so-called “altruistic donation;” harnessing the willingness of relatives and friends to donate by addressing the many barriers which serve as disincentives to living donation. Strategies designed to minimize financial barriers to donation and the use of paired kidney exchange programs are increasingly enabling donation, and now, an innovative program designed to address what has been termed “chronologically incompatible donation” is being piloted at the University of California, Los Angeles, and elsewhere in the United States. In this program, a person whose kidney is not currently required for transplantation in a specific recipient may instead donate to the paired exchange program; in return, a commitment is made to the specified recipient that priority access for a living-donor transplant in a paired exchange program will be offered when or if the need arises in the future. We address here potential ethical concerns related to this form of organ “banking” from living donors, and argue that it offers significant benefits without undermining the well-established ethical principles and values currently underpinning living donation programs. (shrink)

Background Advocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales. Methods This study (...) reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation. Results and discussion According to Islamic law, organ donation is an act of _sadaqatul jariyah,_ and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim _eethaar_, undermining donors of ‘selfless’ or ‘altruistic’ motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran’s unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran’s unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of ‘buyer and seller’, ensuring the philosophy of ‘donor and recipient’ is maintained. Conclusions Offering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors’ health and reducing human suffering without legalizing the human organ trade. (shrink)

Cultural safety is increasingly recognised as imperative to delivering accessible and acceptable healthcare for First Nations Peoples within Australia and in similar colonised countries. A literature review undertaken to inform the inaugural Caring for Australians with Renal Insufficiency (CARI) guidelines for clinically and culturally safe kidney care for Aboriginal and Torres Strait Islander peoples revealed a timeline of the emergence of culturally safe kidney care in Australia. Thirty years ago, kidney care literature was purely biomedically focused, with culture, family and (...) community viewed as potential barriers to patient ‘compliance' with treatment. The importance of culturally informed care was increasingly recognised in the mid‐1990s, with cultural safety within kidney care specifically cited from 2014 onwards. The emergence timeline is discussed in this paper in relation to the five principles of cultural safety developed by Māori nurse Irihapeti Ramsden in Aotearoa/New Zealand. These principles are critical reflection, communication, minimising power differences, decolonisation and ensuring one does not demean or disempower. For the kidney care workforce, culturally safe care requires ongoing critical reflection, deep active listening skills, decolonising approaches and the eradication of institutional racism. Cultural safety is the key to truly working in partnership, increasing Indigenous Governance, respectful collaboration and redesigning kidney care. (shrink)

Background The allocation of scarce deceased donor kidneys is a complex process. Transplant providers are increasingly relying on constructs such as frailty and cognitive function to guide kidney transplant (KT) candidate selection. Patient views of the ethical issues surrounding the use of such constructs are unclear. We sought to assess KT candidates’ attitudes and beliefs about the use of frailty and cognitive function to guide waitlist selection.Methods KT candidates were randomly recruited from an ongoing single-center cohort study of frailty (...) and cognitive function. Semi-structured interviews were conducted, and thematic analysis was performed. Inductively derived themes were mapped onto bioethics principles.Results Twenty interviews were conducted (65% contact rate, 100% participation rate) (60% male; 70% White). With respect to the use of frailty and cognitive function in waitlisting decisions, four themes emerged in which participants: (1) valued maximizing a scarce resource (utility); (2) prioritized equal access to all patients (equity); (3) appreciated a proportional approach to the use of equity and utility (precautionary utility); and (4) sought to weigh utility- and equity-based concerns regarding social support. While some participants believed frailty and cognitive function were useful constructs to maximize utility, others believed their use would jeopardize equity. Patients were uncomfortable with using single factors such as frailty or cognitive impairment to deny someone access to transplantation; participants instead encouraged using the constructs to identify opportunities for intervention to improve frailty and cognitive function prior to KT.Conclusions KT candidates’ values mirrored the current allocation strategy, seeking to balance equity and utility in a just manner, albeit with conflicting viewpoints on the appropriate use of frailty and cognitive impairment in waitlisting decisions. (shrink)

Amit Sharma, Rajesh Ramanathan, Marc Posner, Robert A Fisher Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA, USA: Pediatric kidney transplantation is the preferred treatment for children with end-stage renal disease. The most common indications for transplantation in children are renal developmental anomalies, obstructive uropathy, and focal segmental glomerulosclerosis. Living donor kidney transplants are often performed pre-emptively and offer excellent graft function. Policy changes in deceased-donor kidney allocation have increased the proportion of such transplants in pediatric recipients. Adequate pretransplant workup (...) along with evaluation of urologic abnormalities is imperative in achieving good outcomes. Overall, patient and graft outcomes after kidney transplantation have improved, with five-year deceased donor and living donor graft survivals of 78.8% and 84.3%, respectively. Improvements in induction and maintenance immunosuppression have contributed to the gradual improvement in outcomes. Unique challenges in pediatric recipients include increased graft thrombosis, adverse growth, and abnormal development relating to immunosuppression, increased rejection due to nonadherence, increased susceptibility to opportunistic infections, and post-transplant malignancy. This review focuses on the current practices and outcomes in pediatric kidney transplantation in North America. We discuss the indications for transplantation, the evaluation process, some key surgical and immunologic considerations, and the common risk factors for graft dysfunction. Keywords: pediatric kidney transplantation, end-stage renal disease, dialysis, organ donors, immunosuppression. (shrink)

People tend to be repulsed by the idea of cash markets in kidneys, but support the trading of kidneys through paired exchanges or chains. We reject anti-commodification accounts of this reaction and offer an egalitarian one. We argue that the morally significant difference between cash markets and kidney chains is that the former allow the wealthy greater access to kidneys, while the latter do not. The only problem with kidney chains is that they do not go far (...) enough in addressing equality concerns, and we show how the introduction of cash payments by the state could remedy this. (shrink)