Starting a Crossover Kidney Transplantation Program in The Netherlands: Ethical and Psychological Considerations

On April 15th, 2003, the first crossover kidney transplantation took place in The Netherlands. In September of the same year, a national database was established to facilitate kidney exchange between two donor-recipient couples. During 2004, kidneys from living donors will be exchanged between the seven university medical centers in The Netherlands. One of the conditions for successfully implementing this program was the need to address the ethical and psychologic implications involved. In this article we will discuss the ethical and psychologic considerations that are accompanying the practical preparations for the first Dutch crossover transplantation program. We identified five topics of interest: the influence of "donation by strangers" on the motivation and willingness of donor-patient couples, the issue of anonymity, the loss of the possibility of "medical excuses" for unwilling donors, the view that crossover is a first step to commercial organ trade, and the interference with existing organ donation programs. We concluded that whether viewed separately or in combination, these issues do not impede the efficient organization of a crossover program or raise worrying ethical issues. Key Words: Ethics, psychology, crossover transplantation, kidney exchange program. 2004;78: 194 -197) T he Netherlands has a population of 16 million. Approximately 375 to 425 kidneys per year are transplanted from cadaver donors. In addition to cadaver transplants, approximately 200 kidneys from living donors were transplanted during 2003. Although the growing number of available living donors helps prevent the waiting lists from growing further, there are not enough kidneys available to help the 1,300 patients already on the waiting list. After starting dialysis, kidney patients have an average waiting time of 4 years before a kidney becomes available. In the meantime, their health status declines. Currently, the mortality rate of patients on dialysis is approximately 20% per year (1). (Transplantation Living organ donation by family or friends offers an opportunity to reduce the long waiting lists. However, in a third of these cases, the transplantation cannot take place because of ABO incompatibility or donor-specific sensitization (2). A crossover transplantation program offers new hope. The program provides a lifesaving opportunity when a donor cannot give his or her kidney to his or her recipient. If another donor-recipient couple experiences the same problem, the kidneys can be exchanged. In South Korea, such a crossover kidney exchange program has been operating successfully for more than 10 years (3). The United States also has experience with "kidney swapping" (4). In Europe, however, crossover transplantations have been attempted only once in Switzerland, in Romania, and in Rotterdam. This conservative European attitude is in part explained by concerns surrounding the ethical and psychologic implications of crossover transplantation. When a crossover program was initiated in The Netherlands, it was agreed that these concerns should be addressed. A multidisciplinary research effort was conducted to determine the most prominent psychologic and ethical issues that surround crossover kidney exchange and to propose practical solutions. We identified five topics of interest: (1) the influence of "donation by strangers" on the motivation and willingness of donor-patient couples; (2) the issue of anonymity; (3) the loss of the possibility of "medical excuses" for unwilling donors; (4) the view that crossover might be the first step to commercial organ trade; and (5) the interference with existing organ donation programs. Next we describe these five topics in detail and suggest practical solutions. Living Organ Donation by Strangers When discussing the ethical and psychologic issues of a crossover transplantation program, a prominent issue is the possibility of a difference in motivation and willingness of kidney donors and recipients compared with the attitudes of those involved in a direct living donation program. At first glance, crossover donation between two couples is not significantly different from direct living kidney donation. The motivation of the donor is the same: helping a friend or a family member by giving a kidney. The result for the patient is equivalent as well: He or she receives the much needed organ. Furthermore, the medical impact for the four people involved is the same as for the two direct living kidney donors. Psychologically, however, it might matter for those involved whethe

The Applicability of the Self-Fulfillment Account of Welfare to Nonhuman Animals, Babies, and Mentally Disabled Humans

In this paper we will argue that generality is a virtue of Haybron’s account of welfare. Indeed, reflecting on the applicability of his theory to nonhuman animals will give us a better understanding of its applicability to humans. We will first focus on self-fulfillment and suggest an interpretation of Haybron’s account according to which the self-fulfillment of an individual consists in the fulfillment of the aspects of the self that are applicable to that particular individual. This makes Haybron’s account of welfare applicable to all sentient beings. Then we will focus on sub-personal nature-fulfillment and argue that the same interpretation leads to the conclusion that Haybron’s account of welfare recognizes even nonsentient beings as welfare subjects. We suggest a way of avoiding this latter conclusion

The Applicability of the Self-Fulfillment Account of Welfare to Nonhuman Animals, Babies, and Mentally Disabled Humans

In this paper we will argue that generality is a virtue of Haybron’s account of welfare. Indeed, reflecting on the applicability of his theory to nonhuman animals will give us a better understanding of its applicability to humans. We will first focus on self-fulfillment and suggest an interpretation of Haybron’s account according to which the self-fulfillment of an individual consists in the fulfillment of the aspects of the self that are applicable to that particular individual. This makes Haybron’s account of welfare applicable to all sentient beings. Then we will focus on sub-personal nature-fulfillment and argue that the same interpretation leads to the conclusion that Haybron’s account of welfare recognizes even nonsentient beings as welfare subjects. We suggest a way of avoiding this latter conclusion