Controversies in organ donation: the altruistic living donor

Renal transplantation is now widely considered the preferred mode of renal replacement therapy. Previous analyses of comparative mortality risks for dialysis and transplant patients have demonstrated that renal transplantation confers a superior long‐term survival benefit compared with similar patients on dialysis [1,2]. Unfortunately, the most important obstacle facing transplantation today is the great shortage of organs throughout the world. Currently, approximately 35 000 patients are waiting for kidneys in the United States, which represents a 2.5‐fold increase from 1988 to 1997 [3]. The shortage of cadaver organs imposes a severe limit to the number of patients who could potentially benefit from transplantation. In an attempt to address this problem, the majority of transplant centres continue to rely on living donors as an important kidney source. Thus far, the majority of kidneys from living donors have been from relatives, because of the excellent long‐term results attributed to the varying degrees of matching of haplotypes of the major histocompatibility complex in consanguineous donor–recipient pairs. However, more recently, many transplant centres have started programs utilizing living‐unrelated donors, persons who are related to the recipients emotionally rather than by blood, because of mounting evidence of unexpectedly high survival rates, despite high degrees of HLA‐mismatch [4]. Nevertheless, widespread acceptance of such unconventional donors has not occurred because of the difficult ethical issues raised by this practice. An even more difficult ethical dilemma arises if the donor happens to be a stranger. Thus far, the use of altruistic strangers has been considered to be an impenetrable taboo. The following describes one such case with unique aspects and offers a strategy as to how such volunteers should be handled.