Sanity Returns to Renal Transplant Ethics Discussions

[stauffenberg]

Your decision should be explained and justified, don't you agree?

[Zach]

Your decision should be explained and justified, don't you agree?

No explanation should be necessary.  IHD is not a democracy.

[pelagia]

not being too smart myself- I read this

Second, there have been studies done as I listed in my post on Bill Peckham's page showing the adverse health effects of renal donation to the majority of those that donated and much evidence that shows that it does not in the least change the status of their poverty.  In fact, with the adverse health consequences well documented in several studies, many donors find themselves in a worse situation since they are no longer able to work at their prior level.

not being concerned with the poverty aspect- but the donating is harmful aspect....Is this just because of the donation happening in a third world country- or does that apply to everyone who donates everywhere? I thought it was not harmful in any way to the donor?

This should be clarified.  When I was considering being a donor for my husband, I gathered as much information as I could, discussed it with the medical professionals and then weighed the risks for myself.  Maybe I felt more comfortable doing this than the average person because I spend most of my time engaged in research for my job.  As far as I could assess from the available information/research, the highest risk of donation is associated with the actual surgery.  In developed countries, many of us do not dwell much on the possible complications of surgery when we are faced with the need for a surgery that we know is going to be clearly beneficial.  Think here in terms of emergency caesareans for childbirth (I had one), knee surgery, even open heart surgery (something my father went through last year).  This is because the risks are relatively low as judged by the perceived and measured benefits.  When thinking about donation, the perspective changes.  The risks remain relatively low, but must be more closely considered because a donor will face no surgery-related risks if they do not donate. 

I presume that the original quote relates to conditions other than those we typically encounter in the developed countries.

[xtrememoosetrax]

 

Glitter: The health effects on live kidney donors of donating an organ have been measured over thousands of patients for over a thirty-year period post-transplant, and no net negative effects of any statitstical significance have been observed, other than a slight, clinically insignificant increase in blood pressure. In fact, one Swedish study even found that kidney donors typically live a LONGER than normal lifespan. (See I. Fehrman-Eckholm, et al, "Kidney Donors Live Longer," Transplantation, vol. 64, no. 7 (1997) pp. 976-978. Occasionally you hear rhetoric from opponents of organ purchasing about all the physical harm this is doing to the donors, but the science simply does not support this.

Another point of view: Here is an interesting article that discusses the limitations of the studies of living donation that have been done to date. Please note that I have included only the abstract and discussion here; to read the full article, use the link(s) below.

Clin J Am Soc Nephrol 1: 885-895, 2006
© 2006 American Society of Nephrology
doi: 10.2215/CJN.00840306

Medical Risks in Living Kidney Donors: Absence of Proof Is Not Proof of Absence
Elizabeth S. Ommen, Jonathan A. Winston, and Barbara Murphy
Mount Sinai Medical Center, Division of Nephrology, New York, New York

Abstract
Living-kidney donation has become increasingly widespread, yet there has been little critical analysis of existing studies of long-term medical outcomes in living donors. This review analyzes issues in study design that affect the quality of the evidence and summarizes possible risk factors in living donors. Virtually all studies of long-term outcomes in donors are retrospective, many with large losses to follow-up, and therefore are subject to selection bias. Most studies have small sample sizes and are underpowered to detect clinically meaningful differences between donors and comparison groups. Many studies compare donors with the general population, but donors are screened to be healthier than the general population and this may not be a valid comparison group. Difficulties in measurement of BP and renal function may underestimate the impact of donation on these outcomes. Several studies have identified possible risk factors for development of hypertension, proteinuria, and ESRD, but potential vulnerability factors in donors have not been well explored and there is a paucity of data on cardiovascular risk factors in donors. Prospective registration of living kidney donors and prospective studies of diverse populations of donors are essential to protect living donors and preserve living-kidney donation.

Discussion 
The Council on Ethical and Judicial Affairs of the American Medical Association issued a report on the transplantation of organs from living donors that stated, "The risks to a kidney donor... are fairly well understood, have a relatively low incidence, and are considered minimal beyond the regular risks of surgery" (79). This sense of understanding, at first glance, may seem justifiable given the number of studies on living donor outcomes and the long duration of follow-up of several of these studies. When we examine many studies closely, however, we find limitations that weaken our confidence. Early in the history of living donation, it was necessary and appropriate to obtain fairly quickly data that would provide us with preliminary reassurance that donation posed no great harm. Retrospective study designs that included small numbers of subjects and comparisons with the general population were reasonable approaches at that time and have advanced the field. We should be reassured that there have been no consistent increases in BP or large decreases in GFR. However, we have not considered adequately small changes in GFR, proteinuria, and hypertension and the evidence that risk in certain donors may be enhanced by nephrectomy. We also must consider the potential long-term CV risk that is associated with such changes. Moreover, we have not evaluated these issues in donors from minority populations. The history of clinical research has taught us that extrapolation of results in white individuals to other racial and ethnic groups may underestimate the risks in a more diverse group of donors.

Moving forward, it no longer seems sufficient to base practices and consensus statements on the existing studies and the existing methods. It is time for the transplant community to call for prospective registration of living kidney donors and prospective studies of diverse populations of donors that may be compared with groups with similar compositions of race, ethnicity, and family history.

The United Network for Organ Sharing maintains a database on outcomes of living kidney donors. However, an analysis of the completeness of these data found that only 60% of 6-mo follow-up forms were returned to the United Network for Organ Sharing from transplant centers, and those forms that were returned revealed that 36% of donors already were lost to follow-up (51). It is understandably difficult to maintain a relationship with donors who wish to think of themselves as healthy individuals. However, the South-Eastern Organ Procurement Foundation reported on efforts to follow living donors with questionnaires and found an overall response rate of 90% (80). The authors attributed the maintenance of a high response rate to the fact that donors were enrolled prospectively and knew that participation was a part of their follow-up care. It is likely that registries or programs that involve hospital visits and blood tests, which are necessary to ensure adequate and accurate data, would have a lower rate of donor participation than seen in this study. However, it also is likely that if donors understand that the risks of donation are not completely clear and understand from the outset that follow-up of their health is part of the donation process, then we will be able to obtain sufficient information to gain a better understanding of risks of living donation.

How, then, in the era before the creation of a national donor registry and before the development of long-term prospective studies in diverse donor populations should we evaluate and counsel potential living kidney donors? The transplant community continues to revisit this question, most recently at the international Amsterdam Forum in 2004. The report that was generated from this meeting was published in 2005, and we direct the readers to this article for a comprehensive discussion of the currently accepted guidelines for living donation (81). As discussed in this article, however, the data on which these guidelines are based are not complete. Given these circumstances, prudence suggests the exclusion of "marginal living donors"—prospective donors with medical abnormalities that have been shown to increase overall medical risk in the general population. We should recognize that the use of marginal living donors as a response to the growing number of patients who have ESRD and are dying while awaiting renal transplantation may be in direct conflict with our responsibility to potential donors to "do no harm." A recent multicenter study of potential living donors in Canada found that acceptance of potential donors who were excluded for mild hypertension or proteinuria would have resulted in only a 3% increase in the number of patients who receive a transplant (82). Liberalization of these exclusion criteria would have a minimal impact on the waiting list and would not offset its steady growth. However, the impact would be great for the potential donor who has hypertension and is eager to donate to his or her child. The evaluation of potential donors therefore must balance our respect for donor autonomy with our level of comfort with the risk involved. It is not paternalism but protection of our own core beliefs that prevents us from facilitating a donation that we have reason to believe may cause substantial harm to the donor. Perhaps the most compelling argument for maintenance of cautious donor acceptance criteria and for proceeding with registries and research studies is our dependence on public trust and goodwill for continuation of living-donor transplantation. If certain donor characteristics, including medical abnormalities, confer greater medical risks, then it likely will be discovered many years in the future. If the transplant community has not made appropriate efforts, through registries and research, to understand potential risks, then living-donor transplantation and the health care system will be irreparably damaged.

As Henry David Thoreau said, "To know that we know what we know, and that we do not know what we do not know, that is true knowledge." We must acknowledge to ourselves and to potential donors the limits of our knowledge and request of our donors another gift: That of continued participation in research and in registries. It is only by further study that we may truly protect our living donors and preserve the practice of living donation.

Full text version: http://cjasn.asnjournals.org/cgi/content/full/1/4/885?ck=nck

PDF:  http://cjasn.asnjournals.org/cgi/reprint/1/4/885?ck=nck

[Zach]

Excellent article, xtrememoosetrax!  Additional points of view are always welcome.

[pelagia]

I agree - thanks extrememoosetraxs for that contribution.  I personally have viewed living donation only through the lenses of healthy individuals who are using their heads and their hearts to make a decision. 

Right now the medical community seems to be in a position of playing catch up.  The availability of information on the internet has exploded over the last decade and forums such as IHD speed up information transfer among interested parties.  I certainly want to base decisions on the best available science for any aspects of my healthcare.  More studies and better data will help the medical community make better recommendations for potential donors and may also make it possible at some point in the future for some on dialysis to more willingly accept the idea of related living or altruistic donations.

[monrein]

Interesting article.  Thanks.

[stauffenberg]

As for the risks of the renal transplant surgery for the donor, they are so minimal as to be comparable to the risks of death in an automobile accident while the donor is driving to the hospital where the surgery is to be performed.  They amount to one death per three thousand operations.  This operation was first performed by Dr. Murray and colleagues in Boston in 1954, so it is a very old, well-established, and now routine procedure.  The possibility of now performing a much less invasive laparoscopy surgery on the donor further reduces the risk and the recovery time, although this may increase the damage to the kidney.

The several huge statistical studies published by I. Fehrman-Eckholm, et al, and showing NO negative health effects for the donor from renal transplantation simply blow all the dissenting views out of the water. (I have cited some of these above.) The health impact on donors is so utterly minimal that they actually live LONGER than the general population on average. News stories which need to sensationalize their melodramatic tales of the horrors of the kidney market create a lot of confusion by misrepresenting the medical downside of kidney donation.  The best evidence of the safety of kidney donation is that the ultimate vultures of the healthcare system, the medical insurance companies, which have no interests at heart except their own profit, have conducted massive statistical studies on the health of kidney donors and have decided not to charge them higher premiums because of their donation.

When considering the minimal risks to the donor in a kidney transplant, it is important to look at the net health of the pair of people involved in the procedure -- both the kidney donor and the kidney recipient.  Since the net health and longevity of that pair is enormously increased by distributing the available kidneys between them so that each has one, rather than leaving two in one person and none in the other, the issue comes out 100% in favor of donation.

[Hawkeye]

Ok this is the way I see it.  Selling organs isn't right especially from the people that most of the discussions are about.  Your wanting to "harvest" organs from unhealthy people that from the sounds of it live in squaller.  To me this would be compairable to me going to Chicago, finding a bum and telling him I'll give him money if he sells me his Kidney.  Even if he was a match who in their right mind would want that kidney first off and secondly is that bum going to have a better quality of life because he has one less kidney and some cash in his pocket?  Just because he donated a kidney does not mean that he suddenly will live in clean conditions and be able to take care of himself.  He will spend that money on booze or other things and in no time flat end up back in the same filth he came from.  He will most likely get extremely sick and possibly die because of not taking care of the surgical area causing an infection that wont get treated because he can't afford it.  So now once again you have 1 person with a good kidney and someone else dead or dying not 2 people with good kidneys and all smiles.  All the stats shown in this thread that are in favor of it seem to be from various unrelated parts of the world being lumped together as 1 factual mass involving healthy individuals instead of the target audience.  Until I see more compelling arguments I stand by this belief and my statement.

[angela515]

OK this is the way I see it.  Selling organs isn't right especially from the people that most of the discussions are about.  Your wanting to "harvest" organs from unhealthy people that from the sounds of it live in squaller.  To me this would be compairable to me going to Chicago, finding a bum and telling him I'll give him money if he sells me his Kidney.  Even if he was a match who in their right mind would want that kidney first off and secondly is that bum going to have a better quality of life because he has one less kidney and some cash in his pocket?  Just because he donated a kidney does not mean that he suddenly will live in clean conditions and be able to take care of himself.  He will spend that money on booze or other things and in no time flat end up back in the same filth he came from.  He will most likely get extremely sick and possibly die because of not taking care of the surgical area causing an infection that wont get treated because he can't afford it.  So now once again you have 1 person with a good kidney and someone else dead or dying not 2 people with good kidneys and all smiles.  All the stats shown in this thread that are in favor of it seem to be from various unrelated parts of the world being lumped together as 1 factual mass involving healthy individuals instead of the target audience.  Until I see more compelling arguments I stand by this belief and my statement.

I just want to first off say that I do not believe in selling organs period. I also do not believe in receiving organs from unhealthy people.

Now, the only thing I wanted to say in regards to this post was that comment: "He will spend that money on booze or other things and in no time flat end up back in the same filth he came from."

That is very stereotypical, rude, and the list goes on. To categorize someone who is homeless into one group and that being a group that only spends what money they get on booze, and to imply they choose to live in filth and that's what they will always end up going back to, is disgusting to say. There are PLENTY of people who are homeless by no fault of their own and any money they get is spent on them trying to survive and get out of the situation they are in. There are PLENTY of people who are homeless with children and it is no fault of their own and they would give anything to be off the streets and sure as hell don't spend what help they get on booze. I feel bad for people who are in reality homeless and have ended up in that situation trying their hardest to not end up there and can't get the help they need due to people like you who assume they will spend it on booze. How sad.

Of course there is a group of people who fit into that category, but the way you said it... you put everyone into it.

[stauffenberg]

Also, Hawkeye, why do you presuppose in your reasoning that the bum would sell you his kidney for less than he needs to earn from it to restore his prosperity?  After all, you need the kidney more than he needs to sell it, since you will die (or live a vastly shortened life expectancy) without it, while he will only live a more materially comfortable life by selling it.  Thus he holds all the cards.

Consider the landmark legal case I have mentioned a few times in my comments, Post v. Jones.  In that case, a whaling ship had crashed on the ice near the North Pole, and another ship happened by and offered to rescue the stranded crew, who were starving to death, and take them with the ship to Hawaii.  The captain of the rescue ship insisted, however, that the captain of the stranded sailors pay him the entire value of the stranded ship's cargo for the rescue, which was many times higher than the actual costs of transporting the crew to Hawaii.

Once in Hawaii, the courts refused to enforce this contract, holding that it was immoral exploitation.  The reason why the court said it was immoral exploitation was that the stranded sailors were in danger of losing their lives if they did not accept the terms offered, while the rescue ship only wanted to make money, so they were not under comparable pressure to accept any bargain offered.  The case applies to organ purchasing as well: It is the purchaser, not the donor, who is the desperate person likely to be exploited, since he will die without the contract for sale, while the donor only wants some extra money, and can live without it.

[stauffenberg]

Zach, even in an autocracy, administrative law principles presuppose that decisions which purport to be reasonable carry a moral duty to those affected by them to demonstrate their reasonableness by stating and defending their reasoning.  That principle is not a matter of democracy, but of the basic human right of people affected by another's power not to be treated like dirt.

[stauffenberg]

The reasoning in that article by Ommen, et al, displays all the illogic I have come to expect on this topic.  In saying that potential living donors whose health status makes them only marginally acceptable as donors we violate the principle of 'first, do no harm,' the authors utterly neglect the glaring fact that enormous harm is done by doing nothing, since the dialysis patient who does not receive a transplant has about half the life expectancy (one third if he is also diabetic), or the one who does receive a transplant.  The duty not to do harm should be measured over the pair of people involved in the donation relationship, thus including the recipient as well as the donor, and the net gain in health and longevity in the pair if the kidneys are redistributed from one person having two and the other having none to each having one is unquestionably enormous.  So to rely on the Hippocratic 'first, do no harm' principle as an excuse for excluding marginal living donors is idiotic, since a moral duty to do no harm is owed to both parties, not just to the potential donor.

The authors then note that even if marginal donors were accepted, this would yield 'only' a 3% increase in kidney transplants, which they arrogantly announce is too small to count.  But since this procedure saves the lives of those who receive transplants, and the value even of a single human life saved is infinite, the authors demonstrate their utter idiocy and moral bankruptcy when they characterize this as only a small gain.

They reason with equal foolishness when they try to defend themselves against the charge that they are being paternalistic by denying willing potential donors the the right to donate, because they are just protecting their health.  But it is the universal practice of society in every other context to allow people to make idealistic, altruistic choices to benefit others at their own risk.  There is no legal power in the police to prevent a frantic parent from rushing into a burning building to save his or her child.  The state never intervenes to deny people the right to choose dangerous professions by joining the police, the fire department, the military, or by becoming coal miners.  During World War II, the state itself experimented with untested and potentially dangerous anti-malaria drugs on prisoners in return for giving them favorable parole consideration.  From all these usages, we can see that it is generally accepted in society that people are free to take medical risks for what they perceive are their own interests.  In fact, we award medals to people who risk their health or incur injury to save others, and we build statues to those who die in the attempt to rescue others.  So where is the excuse for this sudden and massively inconsistent paternalism when it comes to stopping people from saving the lives of dialysis patients?

[Sluff]

Your decision should be explained and justified, don't you agree?

nope.

[Hemodoc]

The policemen did not stop the woman from running in to the burning building, but the policemen did not likewise go in as well.

Your analogy of a person wishing to donate no matter what the risk is asking the surgeon to run into the burning building with the mother.  They do not have to take such a risk upon themselves, it is a personal decision.

As a physician, the burden of not harming your patient weighs heavily upon decisions made.  The physician does not have to succumb to all the wants and wishes of their patients when it goes outside of the bounds of the fiduciary responsibility to that patient.  The patient is free to find another physician if the initial MD declines requests outside of his practice or outside of his personal ethics.  I suspect that you will advocate otherwise.  Thankfully, we have not taken away professional and personal judgements from physicians yet in this nation, but the utilitarian ethos present will soon I am sure.  So, you need not advocate for the world to come.  It will be filled with many such utilitarian principles.

Utilitarianism advocates for the greater good for the most people.  In such, a concerted discussion on 18th century slavery where the labour of the few benefited the masses of the south is one such utilitarian argument that could be made.  Yet, by justice, we know that the practice of slavery is, was and should always be routed out.  In just the same colonialism of the labour of a few subjugated by the rich is the entire transplant tourism argument.  The rich who can afford to pay are subjugating the poor but they are not compensating them enough for placing their lives at risk. (Mortality in American renal donors is 1/3000.  This is a number for people to take note of.)

Thank you Sluff for setting the standards on IHD.  It will be a pleasure to continue posting with people dedicated to preserving a place for congenial discussions and exchange of information.  It has already been a pleasure and I look forward to many future discussions.  Thank you all.

Peter

[Zach]

Zach, even in an autocracy, administrative law principles presuppose that decisions which purport to be reasonable carry a moral duty to those affected by them to demonstrate their reasonableness by stating and defending their reasoning.  That principle is not a matter of democracy, but of the basic human right of people affected by another's power not to be treated like dirt.

Your premise is quite flawed with regard to IHD.
 

[Hemodoc]

Here is a follow up article on the Declaration of Istanbul.  It is a large document in light of the calls for global colonization of poor organ donors by those that not only support payment for renal donation those that actually approve of the current black market organ donor pools.

http://www.newscientist.com/article/dn14273-transplant-tourists-running-out-of-destinations.html

The WHO and several influential renal care networks stand behind this declaration.

Colonial subjugation of poor people in impoverished nations should not be the ethical choice of how to treat CKD-5 patients.   There are limits to how far we can go.

[Hawkeye]

OK this is the way I see it.  Selling organs isn't right especially from the people that most of the discussions are about.  Your wanting to "harvest" organs from unhealthy people that from the sounds of it live in squaller.  To me this would be compairable to me going to Chicago, finding a bum and telling him I'll give him money if he sells me his Kidney.  Even if he was a match who in their right mind would want that kidney first off and secondly is that bum going to have a better quality of life because he has one less kidney and some cash in his pocket?  Just because he donated a kidney does not mean that he suddenly will live in clean conditions and be able to take care of himself.  He will spend that money on booze or other things and in no time flat end up back in the same filth he came from.  He will most likely get extremely sick and possibly die because of not taking care of the surgical area causing an infection that wont get treated because he can't afford it.  So now once again you have 1 person with a good kidney and someone else dead or dying not 2 people with good kidneys and all smiles.  All the stats shown in this thread that are in favor of it seem to be from various unrelated parts of the world being lumped together as 1 factual mass involving healthy individuals instead of the target audience.  Until I see more compelling arguments I stand by this belief and my statement.

I just want to first off say that I do not believe in selling organs period. I also do not believe in receiving organs from unhealthy people.

Now, the only thing I wanted to say in regards to this post was that comment: "He will spend that money on booze or other things and in no time flat end up back in the same filth he came from."

That is very stereotypical, rude, and the list goes on. To categorize someone who is homeless into one group and that being a group that only spends what money they get on booze, and to imply they choose to live in filth and that's what they will always end up going back to, is disgusting to say. There are PLENTY of people who are homeless by no fault of their own and any money they get is spent on them trying to survive and get out of the situation they are in. There are PLENTY of people who are homeless with children and it is no fault of their own and they would give anything to be off the streets and sure as hell don't spend what help they get on booze. I feel bad for people who are in reality homeless and have ended up in that situation trying their hardest to not end up there and can't get the help they need due to people like you who assume they will spend it on booze. How sad.

Of course there is a group of people who fit into that category, but the way you said it... you put everyone into it.

Yes it was a stereotypical remark you are correct and I should have thought about how I stated that before I wrote because I know as well that there are many people out there that are homeless for various reasons.  It was really just meant to make a point that regardless of the money gotten that there is no reasonable amount that could be paid that would lift them out of their current situations permanently especially since in our world it seems that the more vulnerable or dependant you are on others the more likely you will be taken advantage of and not given your due.  Yes I know that sounds stereotypical too, but just look at all the cases where the elderly have all there money stolen or are severely mistreated by their caregivers and nursing homes.

[Hemodoc]

Here is another follow up article on the Declaration of Istanbul that presents some interesting commentary on the issue.

http://health.asiaone.com/Health/News/Story/A1Story20080710-75872.html

[Hawkeye]

Here is another follow up article on the Declaration of Istanbul that presents some interesting commentary on the issue.

http://health.asiaone.com/Health/News/Story/A1Story20080710-75872.html

I found this to be an excellent article with many valid points.

[stauffenberg]

HD: Have you ever asked yourself who is really poorer, the diabetic dialysis patient in his forties who has at the very start of dialysis an eight-year life expectancy, and who in New England faces a seven-year average waiting time for a transplant, or in Canada an eight-year average waiting time, which gives him a very good chance of being dead prior to transplant -- or the perfectly healthy but economically poor person in the Philippines, who is not under any immediate medical pressure to enter into the contract to sell one kidney or die?

I think you are simply being misled by the STEREOTYPICAL IMAGE of the rich, exploitative Westerner and the poor, pitiful third world resident, when in fact the dialysis patient, with his miserable quality of life, typical inability to work, burgeoning co-morbidities, and severely limited life expectancy is in fact INFINITELY poorer.  I would prefer any day to be healthy and poor than to be profoundly unhealthy and on the verge of death and wealthy.

[stauffenberg]

HD: To your other point regarding the fiduciary duty of physicians to frustrate what their patients autonomously deem to be their own, highly personal, real medical interests because the physicians arrogantly assume they have the right to dominate and control their patients access to the medical care they want, I believe that represents an outmoded attitude of the 'Doctor as God' which we are now thankfully getting away from.

Although in theory the patient can go to another doctor, as for example if she desires an abortion and her own physician will not cooperate, for many medical choices this is simply not possible, since the medical profession often operates as a monolithic force, imposing its uniform ethical presupppositions --many times through professional practice guidelines of the governing body -- on patients who have no other options.

An important question to ask in this context is who gave the authority to the medical profession to bar the ability of patients to exercise their autonomy over the most vital expression of personal freedom conceivable, which is to determine how to realize one's own physical health and preserve oneself from death.  The medical profession, in my experience, knows so little about medical ethics -- which I have never observed to be a required course at any medical school -- that they would not be able to get a grade any better than D minus on any standard exam in the field.  So knowledge does not give them the right to determine what should be the moral limits of the patient's autonomy.  There is no connetion between medical skill per se and analytical sophistication regarding medical ethics, for which many years of highly technical philosophical training are required.  You might as well ask an electrician instead of a judge and jury about who in justice deserves to be electrocuted for a crime as to ask a physician to assess a complex problem in medical ethics.

There is also no democratic warrant for the authority of the medical profession to enslave the patient population into service of its own uneducated intuitions about which treatments are proper and which are not.  Ususally the medical profession has been treated by governments as a self-governing profession, meaning that the democratic will of the people manifested in the government does not penetrate to the medical profession and control it in the public interest.  This means that the intuitions of the medical profession about the ethically acceptable limts of patient autonomy are utterly lacking in democratic legitimacy.

The scandalous record of what the medical profession has, in its infinite ethical wisdom, determined to be proper moral practice abundantly illustrates how foolish it is to grant then any authority over medical ethics at all.  From the cooperation of American doctors with the infamous Tuskegee experiment, to the cooperation of German doctors with eye color transformation experiments at Auschwitz, we have evidence enough that a medical education warrants no special license to be the master of patients' medical autonomy.

In any case, all of this is irrelevant to the topic at hand, which is the legitmacy of payment for organ donation from living donors.

[Hemodoc]

Dear Staufenberg,

In response to your first post.  I do not concur with your assessment that my views are stereotypical of a misled image of the rich expolitive westerner and the pitiful third world resident, nor do I deny the health consequences of a rich 40 year old with diabetes and CKD-5.  I have devoted a large part of my life in taking care of these patients and expending much energy to do so effectively.  The health consequences of being poor include many health related issues such as food insecurity, lack of sanitary water and exposure to poor sanitation which kills more people than any organ specific disease.  I wish that I had an answer to their issues of poverty, but I do know that selling a kidney to secure a future for their family as so many have done does not accomplish that goal.

Now, back to the article, this issue is not about me specifically and my views as you wish to turn this debate, it is about the article that I have posted and the views of the WHO and other large renal related organizations that stand in opposition to transplant tourism. Simply because I am in agreement with this view does not in the least diminish the impact that the WHO has to say in taking its own stand on this issue.

Please list the supporting organizations that you are aware of that condone transplant tourism and perhaps we may have an interesting exchange.

Once again, I sincerely doubt that there are many people that will even take note of my own personal views, this issue is much larger than you or me.  I continue to stand in support of the courageous stand that the members of the Declaration of Istanbul have taken.

Peter

[Hemodoc]

The patient that comes to a surgeon to donate a kidney is not in a relationship at which his condition warrents "therapy" that would then be the fiduciary responsibility of the doctor to ethically treat to the best of his ability.  If the surgeon believes that the operation will harm this patient, then that surgeon is under NO obligation whatsoever to proceed against his better judgement.  Let him seek another in my profession that reguards money higher than personal responsibility to first do no harm.

Secondly, please tell me which planet you are considering having a monolithic medical ethics?  I have been in this profession and I must confess that the ethical posture of my colleagues runs the same range as it does in the general population.  There are conservative, liberal, theological, atheistic views just as in the general population.

Now, the examples of out of control experimentation is precisely the background to the Declaration of Istanbul in recognizling that physicians can be motivated by actions and rewards other than a direct fiduciary responsibility.  Contrary to your slanted implied definition of fiduciary, it is instead a real world daily reality in caring for patients that place their trust in you to perform to the best of your abilities what is right and just for them individually.  It is not a God complex at all as you imply but instead a heavy burden of responsibility that has interupted the sleep of many doctors including myself worrying about whether we have forgotten to do anything that we were supposed to do for our patients that day.  At times this review in the late hours of night has the purpose of reminding us of important parts of a patient's care that we should attend to immediately and phone calls to nurses in the middle of the night with new orders is a routine that every doctor that I know can relate to.

Further, I have spent the majority of my adult life conversing and consoling and learning from my colleagues.  Indeed, my honest appraisal of the majority of my colleagues is a deep paranoia of missing the diagnosis, missing the right treatment and in any manner harming those that they are dedicated to serve.  Sorry, but I have not met any gods in my many years of practice. 

What you find instead is that medicine is a very humbling profession in that we are always in a state of searching for answers that often are difficult to find.  No, my dear friend, your version of medical practice has no bearing whatsoever to that in which I have dedicated over half of my life to learn and to serve.

Back to the issue, a physician is not under any ethical obligation to adhere to patient requests when they may harm that patient.

Further, I would ask what profession deals DAILY with medical ethics?  THe professor in the ivory tower?  The high paid lawyer?  No, my friend, it is the medical doctor that needs to be highly knowlegeable on the daily practice manifestations of ethical behavior and legal ramifications.  As in any profession, some are better at it than others, but I know of no doctor that can get a D- in medical ethics on a day to day basis that will stay in practice for long.  Once again, your views are quite apart from the reality of modern medicine.

[Hemodoc]

The medical profession, in my experience, knows so little about medical ethics -- which I have never observed to be a required course at any medical school

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http://medcatalog.harvard.edu/coursedetails.aspx?cl=preclinical1&id=14946

Well, I didn't have to go very far to find a rebuttal to your false statement.

Peter

Fixed quote from Stauffenberg-Boxman,Moderator