Where Is the Benefit That Allows One to Inflict Harm during Organ Donation?

It has long been believed that the answer to this question is found in the expected benefit for the recipient, and this must exceed the risk for the donor. For example, almost 40 years ago, Professor Hamburger said, “The doctor must respect the desire of one person to risk his life for another; he must only be sure that the risk to the donor is very much less than the probability of success for the recipient.”⁵

Although the suggestion that donor risk must be outweighed by recipient benefit has intuitive appeal, I believe that calculating this balance is problematic and is not the key that should guide physicians (and other professionals) trying to decide if a potential donor is acceptable. There are several reasons for my view. First, medical predictions of risk and benefit are fallible. Second, even if these variables could be reliably estimated, a simple arithmetic comparison of donor risk and recipient benefit would not be sufficient. If the risk to a volunteer is very high, donation should generally not be permitted even if the predicted benefit for the recipient is greater. On the other hand, when there are no other donors, it may be reasonable to allow a mother at added risk to donate part of her liver to her beloved only child, even if the likelihood of success is very low, because transplantation offers the only hope of saving him. Supporting this suggestion are the results of surveys indicating that most adults would be willing to accept a great deal of risk to donate organs to their loved ones.⁶

A third problem with basing a volunteer's suitability on the relative size of donor risk and recipient benefit is that this criterion suggests that medical factors are the only ones that matter and fails to recognize the importance of personal values, which vary widely.⁷ Finally, this standard asks donor physicians to change their loyalty in a major and, I believe, unacceptable way. Norman Levinsky reminds us that “In caring for an individual patient, the doctor must act solely as that patient's advocate….”⁸ A physician cannot accomplish this goal if, in trying to decide whether to recommend a procedure, she is asked to balance the risks for one patient against the benefits for another. Such an approach would pose a clear conflict of interest, and this realization has led to the widespread recommendation that potential donors and recipients be evaluated by separate teams of professionals.

Justified Living Organ Donation Requires Benefit for the Donor

How then should transplant centers decide if a potential organ donor is acceptable? Remember that, from the viewpoint of the donor physician, a potential donor is her patient.⁹

Therefore, in keeping with Dr. Levinsky's admonition, the evaluating physician must limit her concern solely to the volunteer's welfare; she should not allow him to donate simply because the recipient may benefit. For the physician to recommend her patient as an acceptable organ donor she must believe that there will be benefits for the potential donor that are sufficient to offset the risks for the donor.¹⁰ This approach accommodates and considers individual values, avoids conflicts of interest that arise under the donor risk–recipient benefit balancing plan, is concordant with the clear benefit standard used to determine the acceptability of incompetents as donors, and directs physician loyalty to where it belongs—solely with her patient.

The suggestion that donor benefit is the key to determining donor suitability does not mean that recipient benefit is irrelevant. The probability of a successful transplant is an important consideration, but not as a simple balancer of donor risk; rather because it provides essential information that affects the probability that the potential donor will benefit. For example, if there is no chance for a successful outcome, no one could benefit from forging ahead with transplantation.

How May People Benefit from Donating an Organ?

Other than the occasional discovery during the donor evaluation of a treatable serious medical disorder, no physical benefit accrues to living organ donors. However, many donors experience psychological and emotional benefits, including an improved quality of life and lasting increases in self-esteem as a result of the knowledge that they have helped to save a life. Even when donors do not reap these rewards, they may gain another that may be even more important—that is, seeing a loved one resurrected and then having that cherished person available for sharing the joys of life.¹¹

These psychological and emotional benefits can be very large. This is illustrated by the reflections of a set of parental donors, each of whom had donated a kidney to their daughter several years before: “There is no doubt in our minds that we, as kidney donors, have gained much more than we lost.”¹²

I suspect that the more important the intended recipient is to the potential donor, and the more likely there is to be a successful outcome, the more likely it is that the potential donor will benefit, and the larger the expected benefit will be. The fact that the vast majority of donors are glad they donated and would do it again if they could supports the view that many living donors derive much inner benefit from donating an organ.¹³

May we use psychological benefits to balance medical risk? I believe the answer is yes, because psychological benefits can be at least as important as physical ones. This was emphasized by George Schreiner over 30 years ago:

How Can We Determine If the Amount of Donor Benefit Is Sufficient to Offset the Risk?

When a volunteer is competent to make decisions, fully informed, healthy, eager to donate, and deeply concerned about and connected to the recipient's welfare, and where there is a high probability of success and no other good alternatives, most transplant professionals would agree that the likelihood of donor benefit is much higher than the very small risk involved. At the other end of the spectrum are situations where the risk for the volunteer is so high that no anticipated benefits would be sufficient to offset it (e.g., a parent offers to donate her heart to save her child). In cases that fall between these extremes, however, when the potential donor is less than ideal but where there are no glaring contraindications to donation, how can we determine if the probability of donor benefit is sufficient to offset the added risk?

Because psychological and emotional benefits are subjective, they cannot be quantified precisely. Furthermore, because these are the only benefits that a donor can experience, and because they are not physical, physicians have no special ability to estimate either the probability that a donor will benefit from donating or the size of any donor benefit that may occur. Therefore, perhaps more important than asking how can we estimate how much benefit a donor will experience and is it enough to offset the risk is to ask who is best suited to this task?

I believe the answer is usually the potential donor herself, assuming that she is competent and thinking clearly and that she has been presented with and has understood the medical risks and benefits of organ donation. The probability that a donor will experience psychological benefit (or psychological harm) depends heavily on individual values and life plans, the details of which are available only to the volunteer. Therefore, usually it is the potential donor who can best assess how likely she is to benefit and whether anticipated nonmedical benefits are worth the medical risks, because only she knows and understands what is most important to her. Physicians are the only ones that can delineate the physical risks of donation, but the experts regarding the expected psychological impact of donation on the donors, which is where the possibility of benefit lies, are generally the donors themselves.

Although the potential donor may be the person best able to assess her likelihood of benefiting from donation and best able to balance the expected benefit against the risk, this does not mean that the views of the physician are unimportant. On the contrary, it is essential that the physician also examine the balance of risks and benefits. Because organ donation cannot be effected without the physician's help, she is a moral agent here who must consider the donor's welfare and who bears much responsibility for the outcome. Therefore, she may and she should refuse to participate if she believes that donation would do more harm than good, even if the potential donor disagrees. For the physician to give the green light for organ donation, she must believe in her heart that donation makes sense and ultimately she must rely on her own assessment to tell her if it does.¹⁵

At first glance, my position may seem contradictory. On the one hand, I am recommending potential donors as the best people to assess the relative weights of risks and benefits for themselves while, on the other hand, I am arguing that donor physicians must make their own assessments and act accordingly. The answer to this seeming paradox lies in the recognition that living organ donation involves two moral agents—the potential donor and her physician—and the autonomy of both must be respected. Either one may opt out.¹⁶

But although the physician is not obligated to participate, she is obligated to treat the volunteer with respect. This means that before rejecting a competent individual, she must listen carefully and try to see things from that person's point of view, incorporate that vision into the decisionmaking process, and recognize that in general no one can predict the psychological and emotional impact of organ donation on the donor as well as the donor herself. Thus the volunteer's assessment of the relative size of risks and benefits should be given great weight as the physician makes her own determination.