complications, or even death; the financial consequences of living donation, including out-of-pocket costs; or the impact of living donation on obtaining or maintaining health and life insurance. Hence, it is important to develop registries that can track such outcomes for living donors.

A few years ago the DHHS Advisory Committee on Transplantation made several recommendations about living donation that called for the creation of a database with data on the health outcomes of all living donors (ACOT, 2005). In May 2005, ACOT noted the continuing lack of a donor registry and reiterated its concern “that provisions in living donor informed consent cannot be fulfilled without the existence of a living donor registry” (ACOT, 2005).

Voluntary Consent

General ethical concerns focus on a potential donor’s competence, level of understanding, and voluntary choice, whatever the relationship between the donor and the recipient. When the prospective donor is related to the recipient, which usually involves close affective ties as well as the genetic relationship, specific concerns focus on the dangers of undue influence, pressure, and coercion, even if he or she is competent, has received adequate information, and appears to understand that information.

It is important to develop mechanisms and procedures to ensure the voluntariness of the prospective donor’s decision. Because the potential donor’s interests may sometimes conflict with the potential recipient’s interests (and, perhaps, with the interests of the recipient’s family, which is also the potential donor’s family), a confidential process is needed for the evaluation and selection of donors, with particular attention to their willingness to donate. Potential donors sometimes feel trapped in a process that they do not know how to stop without jeopardizing their relationships with members of their family or other people. A donor advocate can often be helpful in such circumstances. The transplantation team or donor advocate may sometimes believe that it is justifiable to offer a medical excuse to enable the potential donor to escape the pressure of donation and still protect his or her relationships with the family and others who have an interest in the transplantation. For example, in a survey of 100 liver transplant surgeons, 87 percent indicated that “they would provide a medical or technical reason that precluded donation” if the potential donor changed his or her mind regarding donation (Cotler et al., 2003, p. 640).

Transplantation teams and donor advocates also need to recognize that, for poorly understood reasons, a striking gender imbalance exists in living renal transplantation: women donate kidneys at a significantly higher rate than men. For example, in 2005, 59.2 percent of living kidney donors were women, continuing a long-term trend in which women constitute 56

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