{"id":3339,"date":"2018-07-04T23:25:10","date_gmt":"2018-07-04T22:25:10","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=3339"},"modified":"2018-07-04T23:52:04","modified_gmt":"2018-07-04T22:52:04","slug":"a-moral-framework-for-living-donor-transplantation","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2018\/07\/04\/a-moral-framework-for-living-donor-transplantation\/","title":{"rendered":"A Moral Framework for Living Donor Transplantation"},"content":{"rendered":"

By Lainie Friedman Ross and J. Richard Thistlethwaite<\/p>\n

Living donor transplantation has been controversial since its inception because it exposes donors to medical risks for the medical benefit of their intended recipients. The usual bioethics argument about the moral permissibility of living kidney donation focuses on the concept of respect for persons which is often articulated as respect for autonomy: adults with decisional capacity have the right to decide whether the risks of donation outweigh the harms. The problem with this analysis is threefold.\u00a0 First, living donation is only undertaken because of the lack of a readily available, comparably effective alternative treatment for end stage renal disease. If there were an adequate alternative treatment that did not place a separate individual at risk, living donation would cease. Second, the focus on the competent adult\u2019s right to be independent in his or her decision making employs an exclusively negative conception of autonomy whereas respect for persons also includes a positive conception of autonomy in which health care providers go beyond the provision of mere facts and translate the information into concepts comprehensible and empowering to the average patient who can then participate more effectively in a shared decision making process. \u00a0It entails providing support and structure in order for potential living donors to get a better grasp of the risks and benefits including the psychosocial and emotional consequences of the decision in order to make a decision that reflects their considered judgement. Third, the decision to be a living donor is usually done within the social context of the specific potential donor.\u00a0 As such, any living donors is potentially vulnerable to multiple social pressures to donate, some of which she might not be fully aware.<\/p>\n

Living donation is not unique in its exposure of one person to risks for the benefit of other(s). Research involving human participants exposes the participants to risks for the benefit of future patients. This is not to deny that many living donors describe benefits to donation, as do research participants about their participation.\u00a0 Nevertheless, the analogy to human subjects research suggests that the moral considerations of human subjects protection may help us think more clearly about the protections for living donors.<\/p>\n

In the late 1970s in the United States, the National Commission for the Protection of Human Subjects of Biomedical and Behavior Research [National Commission] published the Belmont Report in which the National Commission articulated 3 principles to serve as the basis for a research ethics framework–respect for persons, beneficence and justice which were operationalized into informed consent, risk: benefit analyses and the fair selection of subjects with a focus on \u201cvulnerable populations\u201d. Twenty years later, in a paper commissioned by the National Bioethics Advisory Committee (NBAC), a successor to the National Commission, Kenneth Kipnis argued that the National Commission\u2019s concept of \u201cvulnerable populations\u201d failed to explore in what ways particular groups of people were vulnerable thereby risking unnecessary protections for some and inadequate protections for others. He proposed a vulnerabilities taxonomy that explored the different types of vulnerabilities that research participants may feel, a taxonomy that he continued to modify and develop even after its initial publication.\u00a0 All told, he identified 8 vulnerabilities: cognitive, juridic, deferential, social, medical, situational, allocational and infrastructural.<\/p>\n

In our article, we propose an ethics framework for living donors, incorporating the three principles of the Belmont Report (respect for persons, beneficence and justice) supplemented by a vulnerabilities taxonomy. We also add a fifth principle, the moral responsibility of the transplant team.\u00a0 This principle is derived from Robert Goodin\u2019s book entitled Protecting the Vulnerable <\/em>(Chicago:\u00a0 University of Chicago Press, 1985) in which he argues that, because health professionals stand in special relationship with patients, they are therefore responsible for both promoting and protecting their well-being. In living donor transplantation, then, the donor transplant team is responsible for empowering prospective donors to address their vulnerabilities, and\/or for protecting those who cannot by disqualifying them from donation.<\/p>\n

In our paper, we consider the real case of a parent who donated a kidney to his daughter. The kidney failed, and he requested to give her his second kidney, knowing it would leave him anephric and dialysis dependent. She was willing to accept it. Autonomy, as commonly conceived as independent decision making, would make the second donation ethically permissible. While we agree that it is necessary that both donor and recipient judge the benefits to outweigh the risks, this calculation is not sufficient if it would allow serious harm to either the donor or recipient. \u00a0In this case, the transplant team declined to perform the procedure. \u00a0As moral agents in a special relationship with the potential living donor, they accepted their responsibility to protect the father from his autonomous decision because they perceived the outcome as too harmful<\/a>.\u00a0 The hospital\u2019s ethics committee agreed.<\/p>\n

In sum, our paper develops an ethical framework for living donor transplantation using the 3 principles of the Belmont Report–respect for persons, beneficence, and justice–supplemented by 2 additional principles: vulnerability and responsibility. We believe this framework can be used to explore the ethical challenges raised by current and evolving living donor transplantation practices and policies.<\/p>\n

Paper:\u00a0Developing an Ethics Framework for Living Donor Transplantation<\/a><\/em>
\nAuthors: Lainie F Ross1,2,3<\/sup>, J Richard Thistlethwaite2,3<\/sup><\/em>
\nAffiliations:<\/em><\/p>\n

1<\/sup> Department of Pediatrics, University of Chicago, Chicago, Illinois, USA<\/em>
\n2<\/sup> Department of Surgery, University of Chicago, Chicago, Illinois, USA<\/em>
\n3<\/sup> MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA<\/em><\/p>\n

Competing interests: None declared.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

By Lainie Friedman Ross and J. Richard Thistlethwaite Living donor transplantation has been controversial since its inception because it exposes donors to medical risks for the medical benefit of their intended recipients. The usual bioethics argument about the moral permissibility of living kidney donation focuses on the concept of respect for persons which is often […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":353,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[968,2143,443,2144],"tags":[],"class_list":["post-3339","post","type-post","status-publish","format-standard","hentry","category-clinical-ethics","category-distributive-justice","category-jme","category-organ-donation"],"yoast_head":"\nA Moral Framework for Living Donor Transplantation - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2018\/07\/04\/a-moral-framework-for-living-donor-transplantation\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"A Moral Framework for Living Donor Transplantation - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"By Lainie Friedman Ross and J. Richard Thistlethwaite Living donor transplantation has been controversial since its inception because it exposes donors to medical risks for the medical benefit of their intended recipients. The usual bioethics argument about the moral permissibility of living kidney donation focuses on the concept of respect for persons which is often [...]Read More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/medical-ethics\/2018\/07\/04\/a-moral-framework-for-living-donor-transplantation\/\" \/>\n<meta property=\"og:site_name\" content=\"Journal of Medical Ethics blog\" \/>\n<meta property=\"article:published_time\" content=\"2018-07-04T22:25:10+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2018-07-04T22:52:04+00:00\" \/>\n<meta name=\"author\" content=\"Mike King\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Mike King\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"5 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2018\\\/07\\\/04\\\/a-moral-framework-for-living-donor-transplantation\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2018\\\/07\\\/04\\\/a-moral-framework-for-living-donor-transplantation\\\/\"},\"author\":{\"name\":\"Mike King\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#\\\/schema\\\/person\\\/b107957622bc42b2097d15e5e02a112c\"},\"headline\":\"A Moral Framework for Living Donor Transplantation\",\"datePublished\":\"2018-07-04T22:25:10+00:00\",\"dateModified\":\"2018-07-04T22:52:04+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2018\\\/07\\\/04\\\/a-moral-framework-for-living-donor-transplantation\\\/\"},\"wordCount\":911,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#organization\"},\"articleSection\":[\"clinical ethics\",\"Distributive justice\",\"JME\",\"Organ donation\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2018\\\/07\\\/04\\\/a-moral-framework-for-living-donor-transplantation\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2018\\\/07\\\/04\\\/a-moral-framework-for-living-donor-transplantation\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2018\\\/07\\\/04\\\/a-moral-framework-for-living-donor-transplantation\\\/\",\"name\":\"A Moral Framework for Living Donor Transplantation - 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