The ethics of buy-in before transplantation

Purpose of review This paper explores the ethical complexities of surgical buy-in within the context of organ transplantation. Surgical buy-in refers to an implicit agreement in which transplant recipients consent not only to the surgery itself, but also to the necessary postoperative care in the context of scarce donor organs. Ethical tensions arise when patients choose to deviate from suggested care pathways after receiving organ transplantation, challenging the balance between respecting individual autonomy and ensuring just stewardship of finite donor organs. Recent findings Recent literature highlights the experience of transplant teams when patients withdraw from posttransplant care, a phenomenon termed “cashing out.” Approximately 60% of surgeons performing high-risk surgeries expect postoperative compliance as a precondition to surgery. In transplant settings, this expectation is intensified by the communal impact of organ allocation, raising justice-based concerns when organ recipients withdraw from postoperative protocols. Summary This review proposes a modified informed consent process that explicitly delineates a recipient's ethical commitment when receiving an organ transplant. Improving transparency and aligning expectations with patients can help transplant teams better navigate the ethical tension between respecting patient autonomy and responsibly stewarding scarce public resources.