The evolving approach to ethical issues in living donor kidney transplantation: a review based on illustrative case vignettes
Living donor kidney transplantation which involves performing a major surgical procedure on a healthy person solely to benefit another person has always involved dealing with difficult ethical issues. Beneficence, non-maleficence, donor autonomy, altruistic donor motivation, coercion-free donation, fully informed consent and avoidance of medical paternalism have been the dominant ethical principles governing this field ever since the first successful living donor kidney transplant in 1954. The increasing reliance on living donors due to the rapidly growing disparity between the number of patients awaiting transplantation and the availability of deceased donor kidneys has brought with it a variety of new ethical issues of even greater complexity. Issues such as confidentiality of donor and recipient medical information, the appropriateness of the invented medical excuse to avoid donation and the approach to misattributed paternity discovered during work-up for living donor transplantation have made the information to be disclosed prior to obtaining donor's consent much more extensive. In this article, we review the current thinking and guidelines (which have evolved considerably over the past several decades) regarding these ethical issues using five illustrative case vignettes based on donors personally evaluated by us over the past 35 years.