Letter to the Editor in Response to: Gordon et al., Elective Surgical Patients as Living Organ Donors: A Clinical and Ethical Innovation by Testa et al

Dear Editor:We are pleased that Gordon et al. are intrigued by our pro-posal even though they urge caution before going forward.On the matter of caution, we agree entirely. In fact, our de-cision to publish our concept paper in the AJTbefore oper-ating on the first case was aimed at promoting opennessand transparency and critical scrutiny of our ideas. This ap-proach of inviting public comment before performing thefirst innovative procedure is based on a model we devel-oped at the University of Chicago in 1989, when we beganthe first protocol series of living donor liver transplantation(1). We will move forward on this concept only after con-ducting rigorous qualitative and quantitative research ex-ploring the feasibility of this idea for the key stakeholdersinvolved—patients, general surgeons, transplant surgeonsand payers. This research will study whether public trust ofthe transplantation system will be affected by our proposaland whether payers, public and private, will support an ef-fort to increase kidney transplantation and thus decreasethe overall costs of end stage renal disease care.Dr. Gordon’s letter also raises questions about a number ofethical issues that we discussed in detail in our paper, in-cluding donor risk, the potential vulnerability of surgical pa-tients, and strategies for improving the informed consentprocess. Certain points deserve repeating for emphasis.On the issue of donor risk, Dr. Gordon claims that ‘reduc-ingthenumberofsurgeries...doesnothelpthedonor’.Noone knows if Dr. Gordon’s claim is correct. For the patientwho is scheduled for elective abdominal surgery and whowants to be a kidney donor, there is no data on whetherthe incremental risk of adding the donor nephrectomy tothe elective surgery is more or less than the de novoriskto a healthy person who volunteers to be a kidney donor.As we indicate in the study, this would be one importantissue to study when a protocol series of cases was done.Regarding donor advocates and their ability to protect sur-gical patients-–whom we agree may be subject to distinc-tive, though not necessarily greater, vulnerabilities—ourexperience differs from Gordon’s ‘prior experience’ whenshe questions the independence of advocates. In 1989,the University of Chicago was one of the first programsin the world to implement a vigorous independent livingdonor advocate program, a program which continues tothe present time. Based on our 20 years of experience,we respectfully disagree with Gordon’s views and believethat donor advocates can maintain their independence andintegrity.However, we do agree with Gordon that there are severalpotential consequences of this proposal that require care-fulexploration,includingthepotentialforgenderinequitiesin patients who would be most likely to be asked to do-nate, and the possibility of slowing the evaluation processfor other living donors. Both concerns raise important eth-ical issues that require empirical investigation.Finally, the decision on whether to move forward may turnultimately on patient/donor attitudes, preferences, desiresand public acceptance. If elective surgery patients whowishtoserveasaltruisticdonorsrequestthattheirgeneralsurgeons give them the opportunity to donate, then thereis a strong possibility that our proposal might succeed andhelp to reduce the current shortage of abdominal organsfor transplantation.Sincerely,Giuliano Testa