Ethical Gerrymandering

On the ethics committee today, we discussed an interesting historical change with kidney transplants. There have always been ethical considerations around the concept of live organ donation. With living donors, you are taking someone who is healthy and intentionally injuring them with no medical benefit to them. Doctors are violating that principle "primum non nocere" - first, do no harm. Medical ethicists have been drawing and redrawing the lines on what is acceptable; what risks can we allow perfectly competent adults to choose? What transgressions are our surgeons willing to undertake? It seems, over time, we keep redrawing those boundaries. As we realize we need more and more organs, and cadaveric donors can't meet the need, we seem more willing to gerrymander.

That's not a fair characterization of the situation; over time, our surgical and anesthetic techniques have improved and we have outcomes on these donors. Other than the minimal perioperative risk, their long-term mortality is the same. They are at slightly higher (still <1 a="" accepting="" an="" and="" are="" around="" be="" but="" can="" course="" decision="" do="" donate="" failure="" follow-up="" higher="" if="" kidney="" listed="" long-term="" majority="" much="" need="" not="" of="" organ.="" p="" pain="" priority.="" regret="" risk="" suffering="" suggests="" surgery="" the="" their="" these="" they="" to="" transplant="" vast="" volunteers="" willingly="" with="">
From an ethical standpoint, we've also started recognizing the social benefit of donation. Cutting someone and removing a kidney may do a person no medical good, but they may benefit if the recipient is a spouse, sibling, child, friend - or even, stranger. Now, we accept nondirected living donations. We even encourage this to become a "donor chain" where one donation motivates a recipient's family or friend to reciprocate. With adequate psychosocial evaluations in place to ensure there is no coercion and consent is proper, we think breaking that rule "primum non nocere" is ethically defensible.

Conversations like this is why I love medical ethics. It's endlessly fascinating and provides a lot of fodder for discussion, argument, and learning. What do you think?