Respecting living kidney donor autonomy: an argument for liberalising living kidney donor acceptance criteria

Abstract

Doctors routinely refuse donation offers from prospective living kidney donors with certain comorbidities such as diabetes or obesity out of concern for donor wellbeing. This refusal occurs despite the ongoing shortage of kidney transplants and the superior performance of living donor kidney transplants compared to those from deceased donors. In this paper, we argue that this paternalistic refusal by doctors is unjustified and that, within limits, there should be greater acceptance of such donations. We begin by describing possible weak and strong paternalistic justifications of current conservative donor acceptance guidelines and practices. We then justify our position by outlining the frequently under-recognised benefits and the routinely overestimated harms of such donation, before discussing the need to respect the autonomy of willing donors with certain comorbidities. Finally, we respond to a number of possible objections to our proposal for more liberal kidney donor acceptance criteria. We use the situation in Australia as our case study, but our argument is applicable to comparable situations around the world.

Is it ethically permissible for GPs to promote non-directed altruistic kidney donation to healthy adults?

“…However, any GP exercising his conscience in this manner would be duty-bound to arrange for such counselling to be provided by an appropriate colleague to ensure the patient's autonomy is upheld. [41][42][43][44][45] It is important to note that, if the relevant information is communicated in a truthful and value-neutral manner, honouring the patient's request to provide counselling regarding NDAKD would not constitute indirect awareness raising or direct promotion. This is because this counselling is directed towards a specific individual (while indirect awareness raising is aimed at whole groups or subgroups), and the necessary information is provided in a value-neutral manner designed to empower the individual to make well-considered decisions (while direct promotion aims to provoke particular kinds of behaviour as determined by a third party).…”

Implications of identity-relative paternalism

“…In a recent paper, Weightman and colleagues have argued that such exclusion criteria are unjustifiably paternalistic, and should be liberalised. [7] But Weightman et al accept that transplant programs should still exclude donors like RiskyBeth who are at high risk of complications. How might we justify this?…”