A viewpoint article published in BMJ Ethics assessed the moral challenges of living donor transplantation per the principles of the Belmont Report, which articulates an ethical framework for human subject research.

Like human subject research, living donor transplantation “exposes one party to clinical risks for the clinical benefit of [another party].” Originally published as guidance for human subject research, the Belmont Report also provides an appropriate framework for living donor transplantation, the authors argue. The Belmont Report, overseen by the National Commission for the Protection of Human Subjects of Biomedical and Behavior Research, enumerates 3 core principles for the ethics of human subject research: respect for persons, beneficence, and justice.

Respect for persons emphasizes the autonomy of subjects; research participants are entitled to informed consent and must be allowed to make decisions without interference. Similarly, the authors say, live organ donors should be afforded the autonomy to make decisions “free from…pressure or influence,” but must also be given the full spectrum of information necessary for consent. The Belmont Report also highlights beneficence and justice as core ethical principles; per the former, healthcare professionals must maximize benefit while minimizing harm, and per the latter, fair opportunities must be afforded each participant. When applying these principles to living organ donors, members of the transplant team must carefully weigh the risks and benefits before deciding if organ donation is “reasonable.” Similarly, organ donors must be fairly selected and approved, without excluding certain subjects based on “social perception of…worth.”

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The Belmont Report also stratified participant groups by vulnerabilities, asserting that more vulnerable groups must be afforded appropriate protections so that they do not bear a disproportionate part of the burden of clinical research risks. Authors of the viewpoint piece identified 8 categoric vulnerabilities of living organ donors: cognitive, juridic, deferential, social, medical, situational, allocational, and infrastructural. According to these vulnerabilities, fundamental requirements for living organ donors include the cognitive capacity to make decisions, independence from external influence or pressures, appropriate accommodations for “socially disvalued” groups, appropriate education of the donor, and certainty that the donor is not selected simply due to “serious health-related condition[s]” or the “[lack] of…important social goods.” The authors emphasized that donors should be considered patients in their own right and afforded the same protections given to clinical research participants or organ donation recipients.

The authors asserted that the moral framework behind human subject research closely approximates that of live organ donation, and as such should be considered in addressing the ethical challenges of live organ donation. In the evolving medical landscape, referencing existing frameworks and precedents may be useful to practitioners in navigating complex ethical situations.  


Ross LF, Thistlethwaite JR. Developing an ethics framework for living donor transplantation [published online July 4, 2018]. BMJ Ethics. doi:10.1136/medethics-2018-104762