In Response to: Testa et al. –Elective Surgical Patients as Living Organ Donors: A Clinical and Ethical Innovation–

The proposal by Testa et al. to increase living kidney donations from elective surgical patients is intriguing. Other transplant surgery innovations have initially met with criticism but eventually become standard practice and Testa's proposal may do likewise. However, the idea raises important ethical issues. A justification for previous innovations in donor transplant surgery, such as laparoscopic nephrectomy, was reduced donor morbidity while possibly increasing donations. The justification for the proposed innovation is increasing the organ supply while reducing the number of surgeries to achieve this aim; yet it does not help the donor. It is unclear whether these benefits outweigh the violation of the ‘no harm’ principle. Cholecystectomy donors may have greater morbidity due to the bigger dissection for the nephrectomy, including surgical complications and will lack some of the benefits experienced by emotionally related donors. Although donor advocates ‘independent from the transplant team’ would contact the patient, their neutrality remains questionable given affiliation with and dependence on the institution's transplant enterprise. Prior experience has demonstrated that ‘neutral’ representatives often positively identify with the mission, rather than maintain skeptical independence. The authors posit that coercion would be no more than that experienced by other living donors; the opposite may apply. By virtue of being sick, vulnerable cholecystectomy patients may experience more pressure to accept the ‘invitation’ than healthy donors. Testa et al. did not consider unintended consequences. For example, patients electing to donate would require rapid donor evaluations so as not to delay cholescystectomy and to ensure donor safety. Given limited resources, this might slow the evaluation of other potential living donors, increasing waiting time for some recipients. The proposal may exacerbate distrust in the healthcare system and transplantation. Patients may fear clinicians will simply take their organs while anesthetized for unrelated surgery. The request to donate may create emotional distress by generating guilt. Given the power imbalance between patients and clinicians, patients may perceive the request as an expectation and may feel pressured into consenting. As most cholecystectomy patients are female, women will be asked to donate more often than men, raising questions about unequal burdens on women (1). What insurers for both donors and recipients will or will not accept may have profound implications on program participation. Will patients without insurance be asked to donate, with the hospital covering the costs of the cholecystectomy? Would such an invitation amount to a financial incentive to donate and thus violate federal law? This might exploit those without insurance. Alternatively, excluding financial incentives could unfairly prevent those without insurance from donating. Although Testa et al. noted their intent to investigate the feasibility of their proposal, they need clear outcome measures, such as the level of interest in donation among cholescystectomy patients and the costs and benefits of extra operating room time and hospital lengths of stay for the patients. We aim to further debate on this issue, not prematurely condemn what may become acceptable and feasible. As with any innovation, we urge caution to protect the public trust and avoid unintended and potentially irreversible complications. E. J. Gordon, J. Frader, A. M. Goldberg, D. Penrod, G. McNatt and J. Franklin have no conflicts or funding.

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