A 1980s cult advertising campaign posed sharing your tube of cheap caramels as an existential crisis. A 21st century version of the dilemma involves higher stakes. Would you offer one of your kidneys to a member of your family? To a friend? To a stranger?
The first successful living donor kidney transplant was performed in 1954. The donor and recipient were identical twins. More than half a century later, you no longer need an exact match. Kidneys are commonly given by unrelated living donors. Transplants from living donors start work faster and last longer than any cadaver kidney. And end-stage renal failure is often predictable, so live donor transplants can be done before the patient needs dialysis, which improves the outcome.
No wonder that transplant units, despairing at seeing patients on the 8000-long UK waiting list die because there aren’t enough cadaver kidneys to meet the need, are keen to encourage living donation. It is something an increasing number of people do – around 1000 in the UK last year. So nearly half of renal transplants were from living donors. From spouses, blood relatives, friends, and some from unknown donors who offered a kidney to whoever needed it most.
In 2008 Annabel Ferriman, the BMJ’s News Editor, described in the BMJ how she had donated a kidney to a friend. What started as a wild offer at a party ended up as a gift beyond price. Probably her experience, and the other personal stories available on donation websites, have encouraged others. Clearly, living donation is moving from a rare altruistic act, humbling to those who hear of it, towards a routine event.
The physical sequelae for the donor are said to be minor: the usual operative risks; pain which in some cases can be long term. But donors are more likely than other people to develop renal failure. In cases where the transplanted organ fails, the emotional cost for both donor and recipient can be devastating. Nevertheless the overwhelming majority of donors are very happy, even exultant, with their decision.
There is no legal obligation to donate an organ. Nor is it a requirement of any religion. And in these days of reduced social capital and fear of legal consequences, people are perhaps less likely to help a stranger in distress than they might have been when our sense of community was stronger. Nevertheless there is a growing social expectation that relatives or friends might donate a kidney. An American website urges ‘End the Wait’.
In this country it is illegal to buy a kidney, and the rules make it clear that there should be no pressure on potential donors. Yet, having someone on dialysis affects the lives of all the household, and a relative or friend may be happy to donate, knowing that a transplant gives not just the patient but the whole family a better quality of life. But not everyone feels able to do so.
Potential donors may be subject to coercion. It is easy enough to weed out the businessman who brings along five employees whom he claims are willing to donate, or the patriarch who produces his teenage granddaughter. But it may be harder to detect that a young person has been encouraged to expect a generous bequest in exchange for a kidney. And it can be difficult to pick up that a potential donor actually isn’t comfortable with the idea.. Social pressure can be very strong. It can be seen as a test of love. Your son whose life is blighted by renal failure, or your spouse, or your father, is so hopeful. The rest of the family, the bridge club, the cronies down at the pub think it is a wonderful idea. How do you get out of that?
Potential donors must be given a graceful way out, one that preserves their relationship, and the team that looks after a potential donor – which must be separate from the patient’s team – should provide suitable ‘alibis’.
Will living people ever become a mainstream source of spare parts? The UK Blood Transfusion Service started in 1946 and around 2 million units are donated each year. The Anthony Nolan Trust has 400,000 potential bone marrow donors on its register. But kidneys? Donating a kidney is a much bigger deal than donating a Rolo. Are we ready to go to a dinner party and find our host eyeing us up over the risotto as a source of a replacement organ?
Ferriman, A. (2008). Becoming a live kidney donor BMJ, 336 (7657), 1374-1376 DOI: 10.1136/bmj.a277