Correspondence
Paired-Kidney-Exchange Programs
N Engl J Med 1997; 337:1392-1393November 6, 1997
- Article
To the Editor:
The International Forum for Transplant Ethics strongly supports paired kidney exchange, as proposed by Ross et al. (June 12 issue).1 It is ethically acceptable and would allow more living-donor kidneys to be transplanted. There are countries, however (such as the United Kingdom), where such a program would require a change in the law, as the following case illustrates:
A child was admitted from overseas for a renal transplant to be donated by his father. After their arrival in England, the crossmatch between donor cells and recipient serum was positive. The transplantation was canceled. The boy's father then suggested a kidney exchange; he offered one of his kidneys to the British cadaveric donor pool in exchange for a place for his son on the national cadaveric waiting list.
Such an exchange would conflict with the Human Organ Transplants Act of 1989,2 which allows transplants from living genetically related donors. Offers from unrelated donors are referred to the Unrelated Live Transplant Regulatory Authority, which may approve them if they are free of coercion and are clinically appropriate. The act prohibits payment by the recipient of “money or money's worth” for any organ; officials advised that the quid pro quo offered constituted “money's worth” and therefore could not be allowed. This offer meant that a British recipient would have received a kidney transplant that was physiologically perfect and optimally matched, and was an elective donation from a living unrelated donor, and the son would have had the chance of receiving a reasonably well-matched cadaveric graft. Thus, the law stated that the child's predicament in this case could not be helped by the father's offer, despite the unique possible benefit available to the best-matched British recipient of his kidney and the “cost neutral” nature of the deal.
Such legal provisions seriously restrict a bold initiative, the controlled exchange of kidneys involving living or cadaveric donors, that if generally employed in the United Kingdom, for example, could considerably increase the number of renal transplants from living donors. Kidney exchange has worked well in Korea for years,3 and the protocol described by Ross et al.1 is, in my view, an ethically acceptable model. Most European transplant laws prohibit sale (“remuneration,” “financial exchange,” “financial gain,” “offers for profit”),4 and although they do not explicitly prevent payment in kind, would presumably allow a kidney-exchange system to develop.
I hope that a less restrictive interpretation of the 1989 act would permit the expansion of the living-donor program in the United Kingdom, at a time when the cadaveric-donor supply is inadequate and static.5
5 ReferencesRobert A. Sells, F.R.C.S.
International Forum for Transplant Ethics, Liverpool L7 8XP, United Kingdom1
Ross LF ,Rubin DT ,Siegler M ,Josephson MA ,Thistlethwaite JR Jr ,Woodle ES . Ethics of a paired-kidney-exchange program. N Engl J Med 1997;336:1752-1755
Full Text | Web of Science | Medline2
The Human Organ Transplants Act 1989. London: Her Majesty's Stationery Office, 1989.
3
Park K ,Suh JS ,Kim SI , et al. Single-center experience of 600 living donor renal transplants: univariate analysis of risk factors influencing allograft outcome. Transplant Proc 1992;24:1447-1449
Web of Science | Medline4
Neilsen L. Living organ donors: legal perspectives from Western Europe. In: Price DPT, Akveld H, eds. Living organ donation in the nineties: European medico-legal perspectives. London: European Commission, 1996.
5
New W, Solomon M. A question of give and take: improving the supply of donor organs for transplantation. Research report 18. London: King's Fund Institute, 1994:25-9.
Author/Editor Response
The authors reply:
To the Editor: The case described by Dr. Sells differs from the kidney-exchange program we proposed, because the potential donor offers to donate a kidney to a donor pool rather than as a direct exchange. Whether that arrangement is ethical depends on many factors, including the degree of voluntariness and whether donors receive psychological benefits that outweigh the risks and costs.
We discussed whether a direct exchange is a form of barter that should be prohibited as a “transfer [of a] human organ for valuable consideration.”1 We believe that U.S. law was not designed to proscribe altruistic donations. We do not know whether British law is flexible enough to permit direct paired exchanges.
As far as we know, there are no published reports describing paired kidney exchanges. Dr. Sells's reference to the Korean transplant program 2 appears to be to the use of living unrelated donors rather than to a direct-exchange program.
2 ReferencesLainie Friedman Ross, M.D., Ph.D.
E. Steven Woodle, M.D.
Mark Siegler, M.D.
University of Chicago, Chicago, IL 606371
National Organ Transplant Act Pub L. No. 98-507 (1984).
2
Park K ,Suh JS ,Kim SI , et al. Single-center experience of 600 living donor renal transplants: univariate analysis of risk factors influencing allograft outcome. Transplant Proc 1992;24:1447-1449
Web of Science | Medline
- Citing Articles (5)
Citing Articles
1
Guido Pennings. (2007) Mirror gametes donation. Journal of Psychosomatic Obstetrics & Gynecology 28:4, 187-191
CrossRef2
A. Hamza, H. Loertzer, A. Wicht, O. Rettkowski, E. Koch, P. Fornara. (2006) Umfrage zur Überkreuznierentransplantation in Deutschland. Der Urologe 45:1, 60-66
CrossRef3
Sommer E. Gentry, Dorry L. Segev, Robert A. Montgomery. (2005) A Comparison of Populations Served by Kidney Paired Donation and List Paired Donation. American Journal of Transplantation 5:8, 1914-1921
CrossRef4
Matas, Arthur J., Garvey, Catherine A., Jacobs, Cheryl L., Kahn, Jeffrey P., . (2000) Nondirected Donation of Kidneys from Living Donors. New England Journal of Medicine 343:6, 433-436
Full Text5
Lainie Friedman Ross, E. Steve Woodle. (2000) ETHICAL ISSUES IN INCREASING LIVING KIDNEY DONATIONS BY EXPANDING KIDNEY PAIRED EXCHANGE PROGRAMS. Transplantation1539-1543
CrossRef
