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To the Editor:

In a recent editorial, Professor Veatch asserts that kidney donations by O donors to non-O recipients ‘squander’ a valuable resource (1). To rectify this, he argues for a ‘voluntary compatible living donor exchange’. Under this plan, an O individual who wants to (and can) donate directly to a known non-O person would be asked to donate instead to an unknown O recipient in exchange for a compatible kidney from the unknown recipient's intended but incompatible (non-O) donor. Ross and Woodle have labeled this an ‘unbalanced exchange’ because for one pair direct donation is possible while for the other it is not (2). Ross and Woodle rejected this plan for several reasons.

First, if the outcome for the intended (non-O) recipient of the O donor might be compromised by the exchange, this would ask for more altruism on the part of the donor as well as some altruism on the part of the recipient (2). Veatch deals with this by stipulating that ‘the non-O recipient [should get] an organ in exchange that [is at least] as good or better than what would be obtained from his or her paired donor …’ (1). But this requirement poses the major problem of finding exchanges for which this is possible and then predicting correctly that the results would indeed be as good or better than those of direct donations. Making reliable predictions of comparative outcomes would be difficult at best. Given this uncertainty, I suspect that for most people forecasts of ‘as good’ will not be good enough. As Ross and Woodle suggest, many people will likely want ‘psychological assurance’ regarding organ quality that comes from knowing the donor well (2). If true, the plan is reduced to cases in which the non-O recipient would fare better with an exchange. However, even if we could predict outcome with certainty (which we cannot), such a situation is unlikely and thus further limits the applicability of the proposal.

Another reason given by Ross and Woodle for rejecting unbalanced exchanges is that because of the greater social benefit that may result, requests for such exchanges ‘may be construed as quite coercive’(2). While coercion is probably not the right word here (3), one could at least reasonably argue that a living donor who wishes to and is able to give directly to a loved one is making a large enough sacrifice as it is without asking her to be even more generous and enter a complex plan that increases the chance that something might go wrong.

Another disadvantage of exchange programs is that the surgeries are often performed at separate hospitals; this prevents the originally intended donor and recipient from being together postoperatively and makes it difficult for families to visit both of their involved relatives. How many pairs would be willing to accept this if they didn't have to?

The suggestion that some O potential donors might be willing to participate in a deceased donor exchange program even though they could donate directly to a relative (1) is even less likely to be correct. In contrast to Veatch's implication, I believe that the originally intended recipient would rarely if ever gain ‘enough to offset the disadvantage of moving from a living to a cadaveric donor organ…’ (1).

I conclude that when limited to cases in which non-O recipients (with eligible O donors) would likely be better off than they would be with direct donations, Veatch's exchange plan sounds good on paper, but I doubt it would work in practice. Not only would such cases be infrequent, but because predictions of superior outcome are never certain, I suspect that very few pairs who could exchange kidneys directly would be willing to participate and thus give up the comfort of knowing the donor intimately, jeopardize family visits after surgery and risk compromising the outcome by adding complexity and unknowns to the process.

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