The ever-increasing disparity between the number of organs available for transplant and the need for organs drives further exploration into the use of compromised or marginal donors. There is now an emerging advocacy for the use of kidneys with existing tumors, which may be rendered tumor free after surgical excision and reconstruction. This practice is based on reliable data that renal cancers <3 cm in diameter behave with minimal malignant potential and likelihood of transmission to the immunosuppressed recipient. However, in the case of live donors this creates a potential ethical conflict between those treating patients with renal masses and those with an interest in renal donation. The best available treatment for patients with a small renal tumor is a form of nephron-sparing tumor excision or ablation, as this approach provides for the maximum amount of residual kidney function and enhances survival. Thus, patients newly diagnosed with small renal tumors should be referred to centers with expertise in nephron sparing techniques, not transplant centers. In the case of an individual undergoing a live donor evaluation in which a small renal tumor is detected, a careful analysis of risk and benefit for the potential donor and the recipient is indicated.