Ethics of organ donation by living donors

The growing need for organs has led to an increase in living organ donation as a way of complementing deceased organ donation, and a lot of successful transplantations have been performed. The safety of both the living donor and the recipient has also improved remarkably over the years. Yet, ethical questions arising around this practice are legion.

Living organ donation (LOD) occurs when a living person donates an organ, or part of an organ, for transplantation to another whose organ is no longer functioning properly. The most common organ received from living donors is the kidney, mostly because donors are able to lead normal lives with their remaining kidney after donation. Over time, donation of liver portions has also become common, as the remaining liver regenerates, growing back to its normal size and continuing to function as before. Part of the lung, pancreas and small bowel can also be donated.

LOD is categorised into three forms, each instigating distinct ethical concerns. Direct donation received from family members or friends, non-direct donation involving a donor giving their organs to a general pool for the recipient who is on top of the waiting list and directed donation to a stranger where a donor chooses a specific stranger to give their organ to. Here in Kenya, we rely heavily on direct living donation from family members. According to a study involving all living related kidney donors at the Kenyatta National Hospital renal unit from the year 2010 to 2014, most of the donors were first-degree relatives at 84.5 per cent followed by second-degree relatives at 14.3 per cent.

To clearly understand the ethical concerns around LOD, it is important to note that these donations are meant to benefit the recipient and not the donor, and this raises the issue of whether or not we have a duty to ourselves. This issue is at the heart of the ethical concerns surrounding the practice of LOD.

Further, it is important to note the rights and obligations that arise among the critical players of the LOD cycle, starting with the donor, who has the right to individual autonomy, that is, the right to self-determination, to make decisions that affect their lives and act on those decisions, in this case, the decision to be a living donor. Second, there is the recipient who has the right to the highest attainable standard of health, in this case, receiving a functioning organ. Then, there is the physician who is obligated to inform both the recipient and the donor of the risks and benefits involved in the procedure and is also entitled to financial compensation for carrying out the procedure.

Even with the right to self-determination, living donors must clearly understand the risk assessment and the benefits involved. This way, they are able to give informed consent. But how can we say with certainty that the informed consent given by the donor is without any form of coercion? Think of a family member whose organ is genetically compatible to a relative in need of an organ and they are not willing to be donors, yet they are expected to act within the solidarity of the family. Doesn’t this amount to indirect coercion?

At least we can tell that the motivational force behind direct living donation from a family member is altruism, but what drives a non-direct living donation? Why would a person donate an organ to a total stranger? To try and answer this, think of a person whose leg is to be amputated for the sake of their own health, wouldn’t they agree to it? If so, then they most likely would agree to selflessly give their organs for the sake of another person’s health if it does not cause their own death. If this is the case, should these donors be compensated for their organs; financially or otherwise? Or would this amount to commercialisation of organs?

Given that physicians involved in LOD should always act in the best interest of their patients, is this an entitlement to cause harm to another person, in this case the donor, for the benefit of their patient, the recipient? Through LOD physicians are seen to overstep the ‘do no harm’ ethical rule in the Hypocritical Oath. However, while looked at from biomedical ethics perspective, the principle of self-determination takes precedence over the principle of ‘do no harm’.

Notwithstanding the ethical uncertainties surrounding LOD, many patients are having their lives prolonged, and physicians should continue acting in the best interest of their patients where the chances of success supersede the risks involved, so that if their actions are to be questioned in future, they can rest in consolation that they saved a life.

Elizabeth is an Advocate of the High Court. Associate at Ibrahim Yakub & Associates Advocates. She is passionate about Medical Law and Ethics most especially the ethics of both living and deceased organ donation and transplantation.