Ethical Considerations in the kidney allocation for transplantation : a comparative study

Abstract

Renal transplantation has become the treatment of choice for most patients with End-Stage Renal Disease (ESRD), yet a growing number of transplant candidates suffer and even die while waiting for this life-saving organ. Since the demand is much greater than the supply, the process of allocation is very complex and presents immense ethical challenges. Organ allocation should ideally be organized in accordance with transparent policies grounded on sound criteria of equity, justice, solidarity, efficiency and utility. As the demand for kidney transplantation increased over the years, transplant organizations had to review the deceased donor kidney allocation criteria in order to strike ethical balance between medical efficacy and social equity. Nonetheless, these values may often be in conflict and the balance is difficult to achieve since the circumstances may be complex and vary considerably. UNOS from the United States and ET from Europe are established Transplant Networks that allocate deceased donor kidneys using objective criteria. They constantly monitor new trends in an attempt to balance improved outcomes (utility) while providing a reasonable chance to all candidates on the waiting list to receive a transplant (justice). Yet, the new trends are clearly indicating that this balance seems to be shifting towards utility by the inclusion of several utility-based allocation criteria in an effort to increase the graft survival potential of deceased donor kidneys. From an ethical perspective the allocation criteria is shifting from justice to benefit principles. Contrary to UNOS and ET, Malta has an allocation totally centered on justice (waiting time). Utility based criteria need urgently to be introduced in an effort to increase graft survival. Revision of the allocation criteria, together with data collection for scientific analysis is imperative. The Maltese population, are also at a disadvantage due to geographical constraints, thus joining as full member with another Transplant Network may be the only solution.