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Although rules and practices governing living donation have generallybecome much more permissive, they have become stricter in the case ofincompetent donors (Price 2000). In fact, live children have neverbeen used as a source of organs in the U.K. (Brazier and Cave 2011) and there have been only 60cases in the U.S. between 1987 and 2000 (out of approximately 40,000live kidney donations) (Ross et al. 2008). As the discussion above ofpsychosocial screening implies, competence is not always easilydetermined, but let us assume in this section that we are consideringclearly incompetent donors, namely relatively young children andpeople with severe mental disabilities or illnesses.
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With organs being limited and with so many factors that cause a negative outcomes with kidney transplants; should there be limits to whom transplants should be given to or should every patient have a chance without regarding of age or ou...
What about organ donation that goes beyond what is currentlypermitted, such as the donation of the second kidney or donation of anorgan necessary for life? Liberal democracies do not generally allowconsent to be a defense to bodily harm at or well below the level ofdeath (Price 2000), but should they? The answer turns in part on howfar third parties—transplant teams in this case—mayinflict harms on those who genuinely give autonomous consent or, toput it another way, the extent to which autonomous people can waivetheir rights of bodily integrity. But policy considerations are alsorelevant. Can one be sure that consent is genuine? Would some peoplebe forced into consenting in a way that a screening process would failto detect? If so, how much weight should be attached to cases whereorgans are taken without genuine consent? These questions arise forliving donation in general, but the errors are worse in cases wheresevere harm or death is the certain consequence of donation. (Thequestions also arise in the debates about whether voluntary slavery oreuthanasia should be permitted (Feinberg 1986)).
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The committee further observes that many of the available studies of the decision-making process about living donation by potential donors were conducted years ago with living kidney donors (see, for example, the work of Simmons et al., 1977; Sanner, 2005). In addition to continuous quality improvement in the process of selecting, informing, and ensuring the voluntariness of the decisions of prospective donors, transplantation and donor advocacy teams need information from rigorous studies of their processes and of donor and nondonor decision making.
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Establishing registries of living donors would be a first step in developing the infrastructure needed for follow-up studies. Registries are particularly important for nonrenal transplants, and they could be developed without excessive cost because the numbers are small: there are just over 300 living liver donors and about 30 living lung donors (for about 15 lung transplants) each year (HRSA and SRTR, 2006). It could be argued that such a registry is not needed for living kidney donors because this procedure has been used for decades and many thousands of living donors have provided a kidney. However, it is important to start the process of registering all living donors and then to determine, through an appropriate mechanism, what data should be collected after the first year, at what intervals, and for how long, balancing the costs and probable benefits of the data collection.
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The scarcity of organs creates an allocation problem. A great deal hasbeen written in philosophy on the principles of the allocation ofscarce resources, although not much on the allocation of organsspecifically (see the entries on ; ; ). Unsurprisingly, many of the principles cited in officialtransplantation allocation documents are familiar (see : TSANZ 2014; NHSBT 2013). These principles include allocating to those whowould benefit the most (a proxy for utility), to those who are thesickest (a proxy for helping the worst off), to those whose medicalcondition will deteriorate the soonest (urgency), and to those whohave been waiting the longest (often linked to equity). Officialdocuments also stress principles of non-discrimination, which aretaken to exclude allocating according to judgments of social worth, aswell as race, sex, religion etc. In practice, the principles conflict;the person waiting the longest may not be the one who would gain themost from a transplant, for example. So official allocation protocolsalso have to say how the conflict between principles should beresolved. (For a philosophical discussion of the principles and theirapplication to organ allocation see Kamm 1993.)
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As this chapter has stressed repeatedly, more information is needed about the short-term and long-term health and other effects of living organ donation, particularly the donation of nonrenal organs. For the most part, living donation developed on an ad hoc basis in various transplant centers and has never had the central oversight and supervision that has marked practices of donation by deceased individuals. As a result there is no national infrastructure for gathering information and for ensuring accountability as there is for donation by deceased individuals.