Spring 2002

Dr. Maxwell Firman was medical director of the Scheller Kidney center, one of the most distinguished kidney research centers in the country. For some time he had been seeing Audrey Poland, a middle-aged woman, for chronic renal disease. She was almost to the point where some medical action would have been taken. He had discussed both transplantation and dialysis with her many times. Mrs. Poland, like many patients in kidney failure, strongly preferred a transplant, not wanting to spend the rest of her life attached to a dialysis machine six hours a day, three days a week.

At the most recent visit, Mrs. Poland seemed happy and said that her sister, Ruth Hamill, had volunteered to donate a kidney to her. Dr. Firman explained to her again the importance of tissue-typing in a sibling-to-sibling transplant; that is if the typing is identical, the chance of a successful transplant is about 90 percent, but if the match was less close, the chance of success is less. Poor matches will have no greater chance than with a cadaver graft, or about 50 percent. In that case Dr. Firman would not recommend such a procedure. Mrs. Poland said she would arrange for her sister to accompany her on her next visit and have the requisite tests performed.

The following day, Dr. Firman received a telephone call from the potential donor’s husband, who wanted to urgently see him that day. He arranged for an appointment. Mr. Hamill said that he understood that his sister-in-law had spoken to the doctor about Ruth being a kidney donor. Dr. Firman indicated that Mrs. Poland had said Mrs. Hamill was considering such a donation. Mr. Hamill replied that he was glad she has said “considering”, because she certainly was nowhere close to making such a decision. Mr. Hamill thought that it would be the completely wrong decision to make. He explained to Dr. Firman the active life that his wife led, with several young children at home to take care of and a deep involvement in other activities, some of which were reaching a professional culmination for her. He described some medical problems that he thought might rule her out as a donor in any case. He vividly contrasted his wife’s lifestyle with that of the patient, who was sedentary owing to her chronic disease; and he saw no reason why his sister-in-law would not do well on chronic dialysis. Mr. Hamill said that his wife was deeply disturbed at the prospect of having to confront her sister with a decision not to donate a kidney for her.

Dr. Firman reassured the potential donor’s husband that the medical team would do nothing against his wife’s wishes in terms of her decision to donate or not to donate, and that if her decision was not to donate, they would make every effort to explain the situation to Mrs. Poland in such a way that it would not jeopardize their relationship.

During the next appointment, Dr. Firman had an opportunity to discuss the donation privately with Mrs. Hamill, the potential donor. She expressed great concern about her sister’s health and indicated she wanted to do what she could to help. She asked repeatedly about the risks involved in donation. She seemed tense during the long conversation. She brought up the subject of the suitability of cadaver kidneys for transplant and at one time said, “Would the kidney machine really be that bad for her?” Later consultation with the psychiatrist indicated that Mrs. Hamill seemed anxious, but there was not evidence of present or past mental disturbances. Still Dr. Firman had real doubts about her willingness to give the kidney freely.

Dr. Firman considered four alternatives when he got back the tissue-typing, which indicated an ideal match: tell Mrs. Hamill of the good match; tell Mrs. Hamill of the good match but express a willingness to suggest to her sister that the match was not acceptable; tell Mrs. Hamill that the tissue match was unacceptable; or tell Mrs. Hamill that the match was good but that he refused to perform the transplant at this time because he was not convinced of her willingness to give the organ freely.

Endnote: In addition to the dramatic problems of deciding who is acceptable as an organ donor, there are equally serious moral dilemmas faced in receiving organs or dialysis treatment alternatives. One problem faced by the potential recipient is whether he/she is demanding too much of his/her fellow human beings—demanding not only the organs of life themselves but the resources—monetary, material, and human—which might otherwise be used for the benefit of other sick and suffering humanity. Even if there are not others competing for the scarce resources consumed, the psychological and moral dilemmas for the potential organ recipient can be excruciating. Key problems are whether an organ can be so much a part of a person as to make its transplant a moral offense, and whether a medical procedure can inflict so much pain and suffering, mental and physical, as to make it morally expendable even though it may well save the patient’s life.

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