Because the committee’s mandate calls for primary attention to ways to increase the rates of organ donation from deceased donors, this report will not provide a detailed discussion of the scientific, clinical, and ethical issues involved in organ donation by living donors. However, the committee believes that it is important that living donation be the subject of intense discussion and study. This chapter can do little more than flag a number of issues and concerns that warrant further attention.

The committee believes that it would be appropriate for the Health Resources and Services Administration (HRSA), perhaps in conjunction with other organizations, to establish an appropriate mechanism to conduct this full and long overdue review, a portion of which has been undertaken by the U.S. Department of Health and Human Services (DHHS) Advisory Committee on Transplantation (ACOT). Nevertheless, even before a full review is conducted, the committee finds warrant for two recommendations to increase and improve the available data and to protect donors’ rights and welfare (see Summary and Recommendations below).

This chapter begins with an overview of the statistics regarding living donation followed by a discussion highlighting a number of the ethical issues. The chapter concludes by focusing on the need for further examination of this issue and on the committee’s recommendations to provide independent donor advocate teams and to follow up on the health of living donors.

BACKGROUND

The first successful organ transplantations involved living donors. In 1954, surgeons at Peter Brent Brigham Hospital in Boston removed a kidney from a young man and implanted it in his identical twin brother (Merrill et al., 1956). Through the 1960s developments in transplantation technology enabled kidney transplantation to evolve into a viable alternative to hemodialysis (Surman et al., 2005). As developments in immunosuppressive medication allowed the use of organs from unrelated deceased donors—at first from individuals declared dead by the use of circulatory criteria and subsequently from individuals declared dead by the use of neurologic criteria—it also expanded the pool of potential living donors of kidneys (Abecassis et al., 2000; Surman et al., 2005). Transplant centers initially allowed only genetically related family members to donate kidneys. Over the years, however, more and more patients have received kidneys from emotionally related donors (those who do not have a genetic link to the donor but who are nevertheless close, e.g., spouses and friends), from acquaintances, and even from altruistic strangers (those who are not currently known by the recipient) (HRSA and SRTR, 2006).



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