The Ethics of Promoting Living Kidney Donation Using Nonargumentative Influence: Applications, Concerns, and Future Directions

Abstract

Recommendations from the 2014 Consensus Conference on Best Practices in Living Kidney Donation reflect increasing attention to overcoming barriers to donation as a means of expanding access to living donor kidney transplantation. "High priority" initiatives include empowering transplant candidates and their loved ones in their search for a living kidney donor. Transplant programs are assuming an unprecedented role as facilitators of patients' solicitation for donors, and nonprofits are promoting living kidney donation (LKD) in the community. New strategies to promote LKD incorporate "nonargumentative" forms of influence (i.e. approaches to shaping behavior that do not attempt to persuade through reason) such as appeals to emotion, messenger effects and social norms. These approaches have raised ethical concerns in other settings but have received little attention in the transplantation literature despite their increasing relevance. Previous work on using nonargumentative influence to shape patient behavior has highlighted implications for (1) the relationship between influencer and influenced and (2) patient autonomy. We argue that using nonargumentative influence to promote LKD is a promising strategy that can be compatible with ethical standards. We also outline potential concerns and solutions to be implemented in practice.

Outcomes for individuals turned down for living kidney donation

“…Third, some individuals turned down for living kidney donation may be encouraged to spread the word in their community about the donor evaluation process, in case another donor might emerge. Motivated individuals might even be offered training on how to effectively attract the interest of other potential donors …”

“…Transplant professionals should accept potential donors when a reasonable balance of risk and benefit to the donor exists. 42 Nonetheless, transplant professionals should consider the social and psychological outcomes as well as medical outcomes of donor selec- 44,45 The study has several limitations. As a single-center study, the findings may not be broadly generalizable.…”

Survival in Living Kidney Donors: An Australian and New Zealand Cohort Study Using Data Linkage

“…492 The ethical appropriateness of strategies for promoting living donation may vary with the entity employing the strategy. 493 For example, direct promotion of donation by transplant programs may raise ethical concerns for conflict of interest and risk eroding public trust and the quality of donor decision-making, but training and support of advocated (eg, "live donor champions") can be an appropriate alternative if employed conscientiously, including the careful use of anticoercion training. Nonprofit groups separate from transplant programs may have more freedom in promoting donation without challenging ethical norms underlying the physician-patient relationship, but still bear ethical responsibilities to present evidence-based information and maintain public trust.…”

“…492,496,497 Research on strategies to promote living donation should evaluate not only efficacy in increasing donation but also effects on attitudes, quality of donor decisionmaking, and informed consent. 493 • Examine the experiences of individuals exposed to different forms of "nonargumentative" influences promoting living donation (ie, approaches to shaping behavior that do not attempt to persuade through reason, such as appeals to emotion, messenger effects, and social norms) and whether exposed individuals feel the influence was appropriate. 493 • Examine strategies for reducing financial barriers to living donation, with particular attention to impact on current disparities in living donor kidney transplantation.…”

“…493 • Examine the experiences of individuals exposed to different forms of "nonargumentative" influences promoting living donation (ie, approaches to shaping behavior that do not attempt to persuade through reason, such as appeals to emotion, messenger effects, and social norms) and whether exposed individuals feel the influence was appropriate. 493 • Examine strategies for reducing financial barriers to living donation, with particular attention to impact on current disparities in living donor kidney transplantation. 432,502 • Determine optimal approaches to allowing or restricting contact between nondirected kidney donors and their recipients.…”