Balancing non-maleficence and autonomy: Establishing ethical risk thresholds for living kidney donors

Over the last decade, the number of deceased kidney donors has plateaued, while the number of patients in need of a kidney transplant has substantially increased, resulting in longer waiting times and greater mortality. Increasing living donation in a safe and ethical manner can reduce the societal burden of end-stage renal disease. Living kidney donor evaluation entails extensive medical and psychosocial testing to minimize harm to donors, and detailed education about medical/surgical risks to ensure donor autonomy. However, living donors are usually excluded from participation in their own risk assessment and from engaging clinicians in a dialogue about the levels of risk that they will be permitted to undertake. Thresholds for acceptable risk are highly variable between transplant centers but commonly focus on medical risks. 1 However, potential donors also experience non-medical risks and burdens, 2 which may alter their assessment of an acceptable level of risk. Thus, transplant centers and potential donors may encounter ethical tensions surrounding the balance between non-maleficence and respect for donor autonomy. Establishing what donors perceive as relevant risks, how they quantify these risks, and what they deem acceptable tradeoffs for these risks is essential to developing a donor-centered approach to the living donor evaluation process. A donor-centered approach could enhance autonomy by allowing informed individuals to donate, in selected circumstances, when their risk of post-donation complications is higher than would typically be considered permissible by a transplant center. This study has the potential to advance the debate within the transplant community about where to set the threshold of acceptable living donor risk, whether this threshold should be donor-specific, and who should establish it. Our results may provide normative support for the development of a donor/patient-centered model of donor approval based on greater donor involvement in risk assessment. This could significantly affect donor engagement in transplant centers’ decision-making processes and ultimately, the number of living kidney donors.