J Med Humanit (2008) 29:173–188

DOI 10.1007/s10912-008-9059-z

Live Kidney Donations and the Ethic of Care

Francis Kane & Grace Clement & Mary Kane

Published online: 19 July 2008

# Springer Science + Business Media, LLC 2008

Abstract In this paper, we seek to re-conceptualize the ethical framework through which
ethicists and medical professionals view the practice of live kidney donations. The ethics of
organ donation has been understood primarily within the framework of individual rights
and impartiality, but we show that the ethic of care captures the moral situation of live
kidney donations in a more coherent and comprehensive way, and offers guidance for
practitioners that is more attentive to the actual moral transactions among donors and
recipients. A final section offers guidelines for the practice of live kidney transplants that
emerge from an ethic of care.

Keywords Live kidney donations . Ethic of care . Transplant guidelines

Introduction: Two paradigms

In the summer of 2003, an eccentric millionaire named Zell Kravinsky created a media
splash when he donated his kidney to a woman he had never met.1 Citing the principle of
“maximum human utility,” he argued that “his life is not worth more than anyone else’s,”
and therefore, “no one should have two kidneys until everyone has one.” Ignoring the
threats of his wife to divorce him, parents who no longer speak to him and, arguably, the
interests of his four young children, Zell Kravinsky’s act and motivation stand in stark
contrast to an earlier donation by Oscar Robertson to his daughter, Tia. When queried about

F. Kane (*) : G. Clement

Philosophy Department, Salisbury University, Salisbury, MD 21801, USA
e-mail: fikane@salisbury.edu
G. Clement
e-mail: gaclement@salisbury.edu

M. Kane
Nursing Department, Salisbury University, Salisbury, MD 21801, USA
e-mail: mkkane@salisbury.edu
174 J Med Humanit (2008) 29:173–188

it, the great basketball player replied: “Of course I was going to do it. What father
wouldn’t?”2 These two scenarios serve as paradigms that frame the following discussion
about live kidney donations.3
What initially drew the authors to this issue was the disjunction between the moral
language used by both ethicists and practitioners to frame the discussion about live kidney
donations and the ways in which close relatives and friends most often involved in those
donations expressed themselves. The cases of Zell Kravinsky and Oscar Robertson
express that difference most dramatically. While Mr. Kravinsky’s act seemed bizarre to
many, the rationale that he used to justify it was in keeping with the ethical framework
that has most commonly surrounded discussions of organ transplants. Appeals to
individual rights and an impartial universality are stock in trade language when it comes
to medical ethics. By contrast, Oscar Robertson’s straightforward appeal to parental love
and responsibility, however commonplace in such donations, rests uneasily with the
language of impartiality and individual rights. The disconnection between these two
ethical accounts has not gone unnoticed in theoretical ethical discussions; however, little
has been written about the practical impact of these competing frameworks on the actual
practice of transplantations. It is on that more practical concern that our attention is
focused.
For purposes of contrast, we will call the commonly used framework “the ethics of
individuality/impartiality” and the framework we will argue for “the ethic of care.” The
ethics of individuality/impartiality, admittedly, conflates a number of different ethical
frameworks—most notably, deontological and utilitarian—that theoreticians would ordi-
narily want to distinguish. Our purpose, however, is not to offer a meta-ethical account but
to re-conceptualize the ethical framework out of which ethicists and the medical profession
view the practice of live kidney donations. Our methodology is, broadly speaking,
phenomenological; that is, we try to render an account of the moral transactions found
embedded in the practice of live donations. Though our purpose is, in part, practical, we are
not simply substituting one ethical framework (i.e. care) for another (i.e. individuality/
impartiality) because it works better. Rather, in paying close attention to what donors and
recipients say, we have been led to the conclusion that the care framework captures, in a
more coherent and comprehensive way, the moral situation of live kidney donations in
addition to offering guidance for practitioners that is more attentive to the actual moral
transactions embedded in them. On another level, one could argue that the purposes and
motivations that are ordinarily offered for organ donations are misguided, illusory or ought
to be changed. That argument, however, could only proceed once an account of the donor-
recipient transaction has been adequately clarified.
Our discussion proceeds in the following manner. First, we argue that the standard
ethical accounts are inadequate when dealing with the moral transactions involved in live
kidney donations. Second, we try to show why an ethic of care offers a richer, more
nuanced account, and, finally, we offer some guidelines and recommendations for the
practice of live kidney transplants that emerge from an ethic of care.
However, before beginning the ethical analysis, it is important to provide a context by
citing briefly some salient facts about live kidney transplants.4 Initially, cadavers were the
primary source for kidneys transplants, but the hope that they would be sufficient to meet
transplant needs has never materialized, and the list for transplant candidates far outstrips
the supply of organs. By March 2007, there were 70,678 people awaiting kidney
transplants.5 While kidney dialysis continues to save many lives and offers reasonable
function for most patients, using live donors has become the preferred option. The trend
towards using live donor organs has continued to increase as the number of people on the
J Med Humanit (2008) 29:173–188 175

waiting list has grown, and the success rate and improved surgical techniques have made
the surgery easier and more attractive for the donor.
In the early decades of transplants, there was considerable debate about whether or not
live donors ought to be used at all, but such discussions have been swept aside by the
success rate and low number of reported risks. Although live kidney transplants are viewed
as morally acceptable today, that does not erase the significant moral issues still embedded
in the practice.

Part I: The limitations of the standard accounts

Early discussions of the ethics of organ transplants were focused on cadaver donations
where donors and recipients were, most often, unrelated. In this same context, the literature
also focused on the now familiar “organ shortage”; namely, that many people die each year
who could have been saved had there been sufficient cadaver donors. The participants in
this discussion have suggested different ways of getting people to consent to donate their
own organs when they die or to consent to donate the organs of their newly dead family
members. Because organ donation is presumed to take place between strangers, an ethic of
impartiality that presumes no favorites in the distribution of organs—coupled with the
language of the right to consent or not to such donations—seemed the appropriate moral
framework. To avoid bias, for example, the United Organ Sharing Network (UNOS) set the
standard for cadaver transplants by ensuring that all donations would be non-directed.
While such an ethical framework may be appropriate for cadaver donations, it tends to be
carried uncritically into discussions of live organ donations.6 Zell Kravinsky’s argument is a
case in point. He gave no special considerations to his family’s interests and did not want to
know ahead of time who the recipient of his kidney would be. His impartiality was steadfast
and consistent with his intent; had he been explaining why he was going to fill out a donor
card on his license, his decision would hardly have been problematic. Live kidney
donations, however, raise a whole different set of issues.
First of all, live kidney donations, with rare exceptions, involve close relationships in
which the donor donates precisely because he or she knows and cares about the one in
need. The ethic of impartiality, as the Zell Kravinsky case demonstrates, fails to take into
account that obvious partiality. By the strict standard of impartiality, Oscar Robertson’s
donation has to be morally suspect. Even a more subtle ethic of impartiality that would
make room for the particular preference for one’s child still fails to capture the effortless
judgment that a parent like Oscar Robertson makes. “I’ve done my duty” or “I calculated
benefits versus risks” hardly begins to touch the immediate and realistic response of a
parent: “What else could I do?” A parent who donates a kidney to his child attends and
responds to his specific daughter’s needs. One could argue that such partiality is morally
wrong, but at the very least, such a counter-intuitive claim cuts against the grain of our
common moral experience. More relevant to our purposes, it makes a good deal more
practical sense for the transplant team to work with the caring donor’s own rationale for
donation and to make explicit the ethical context in which such partiality is both
understandable and defensible. In such a reformulated context, “bias” would be both
expected and appropriate: what counts is a parent’s responsibility for his own child rather
than some impartial duty to any child. That, at least, will be the burden of our argument
throughout the rest of the paper.
Inconsistencies arise, secondly, when we look at the critical consideration in any medical
procedure: consent. The ethical concerns that have traditionally surrounded the issue of
176 J Med Humanit (2008) 29:173–188

consent to kidney donations have focused on how one autonomous individual can give
consent that is rational and non-coerced.7 Again, this framework makes most sense (though
the practice is hardly unproblematic) in cadaver donations where one has consented ahead
of time–for example, with a donor card. In live donations, however, a whole different set of
issues arises. Some concerns, for example, about informed consent are actually alleviated in
live related donations because the reasons for consent are so obvious. But that patent
motivation could lull us into an ethical minimalism. The conventional ethic of consent, at
least as usually practiced, is often silent about the harm that can come to a competent adult
who willingly enters into a harmful procedure.8 The standard individualistic and
rationalistic principle could be formulated in such a straightforward way: “If you know
what you are getting into, then it’s your decision.” However, in the emotionally charged
situation of a child’s need, the parent may well offer to donate without considering the risks
to his or her own health or even to the needs of the rest of the family. In fact, most live
donors make an immediate decision upon hearing of the need without much thinking or
further investigation, well before the transplant team has had time to initiate the process of
informed consent.9 Convincing possibly unwilling people to donate cadaver organs is not at
all the same as ensuring that willing live donors understand all the ramifications of their
decision.
Ironically, that same concern about the minimalist requirements for individual consent
could result in an ethical maximalism that overstates the burden of consent and unduly
restricts live donations. One could claim, in an impartial ethic, that the very partiality of
parents’ concern for their child’s condition could compromise a truly informed consent
because the parents are manipulated by the very devotion that led them to offer their kidney
in the first place. The conclusion that would follow (certainly counter-intuitive) is that
strangers, because they are less motivated by partiality, are to be preferred to parents. The
standard language of consent, because it both underestimates and overestimates the burden
of consent, seems ill suited to capture the realities of the accepted practice of actually
preferring related to unrelated donors.
When we explore the motivations for live kidney donations, we come across a third set
of inconsistencies. One often hears, in public promotions, live kidney donors being praised
for their altruistic motivation. The concept of altruism resides most comfortably in an
individualistic framework where there is a clearly separable self and other, each with their
clearly distinct self-interest. Then the task becomes one of balancing altruism and self
interest.10 Zell Kravinsky’s motivation is more unusual; he thought it his duty to give one of
his kidneys to someone who had none. However, neither of these ethical concepts—
altruism or duty—capture the real motivation or purpose behind nearly all live kidney
donations.11 A parent like Oscar Robertson does not think of himself as altruistically
sacrificing his own well-being to promote the independent well-being of another. His and
his child's well-being are connected. Nor does the language of impartial duty accurately
capture the motivation. Donors most often describe it simply as an act of love and care.12
We argue, then, that the language of individualism and impartiality, which has so
dominated the discussions of kidney donations is simply inadequate. However useful such
categories are in cadaver donations, they produce a Procrustean bed when applied to the
now more common live donations. Rather than beginning with an impartial individual who
decides whether or not to donate a kidney, we propose to start with the recognition that the
offer of a live kidney nearly always comes from within a relationship already established.
This simple fact suggests to us that we need to find a better ethical framework to make
sense of that relationship.13
J Med Humanit (2008) 29:173–188 177

PART II: The ethic of care and live kidney donations

We do not claim that the ethic of care is the only framework to offer guidance in the issue
of live kidney donations; certain relational ethics and some theological approaches could
support our arguments. We choose the ethic of care because it seems especially appropriate
for the relationships inherent in kidney donations and for the illumination it can provide for
public policy recommendations.14

Defining the ethic of care

The ethic of care is complex; contemporary care theorists themselves define it differently
and argue about its meaning. Still, for our practical purposes, there is enough communality
of discourse to identify its distinct framework, to differentiate it from other traditions, and
to apply it to transplant practices. The origins of the care ethic, broadly construed, can be
found in western philosophical and theological traditions, and it could reasonably be argued
that the medical profession itself has always professed a care ethic at its core.15 While we
draw on that long tradition, we will more directly employ the ethic of care as it has been
formulated in the work of Nel Noddings and developed and critiqued by recent feminist
philosophers, such as Joan Tronto.16
In brief, the ethic of care differs from the ethic of individuality/impartiality in three main
ways. It differs, first, in its method: the ethic of care focuses on the concrete and contextual
as distinct from a more abstract, principled approach. It differs, second, in its priorities: the
ethic of care concentrates on creating and sustaining relationships and meeting the needs of
those to whom one is connected, as distinct from concentrating on establishing and
maintaining equality and rights. The ethic of care, thirdly, has a relational rather than an
individualistic conception of the self: persons are considered, first and foremost, already
established in families, in friendships and in other relationships, rather than individuals who
may or may not choose to participate in such relationships.17 In sum, rather than
articulating universal norms applicable in all situations (for example, the idea of universal
human rights), the ethic of care focuses on close, intimate relationships which, by their
nature, involve particularity and are not amenable to impartial, abstract rules. “Here,” notes
Carl Elliott (one of the few bio-ethicists attuned to the distinction), “talk of rights,
obligations, respect and freedom gives way more naturally to talk of gratitude, grudges,
devotion and kinship.”18 In this care ethic, individual rights do constitute a necessary side
constraint, but the language of rights cannot capture the deep and rich fabric of intimate
relationships which form us as ethical persons.19 Natural bonds of affection incur special
responsibilities which are often overlooked or neglected in a more impartial ethic.

The care paradigm

However, our interest here is not a metaethical contrast of various ethical frameworks but,
rather, a more practical effort to assess a medical practice within the appropriate moral
framework. To accomplish that, we return to the paradigm of Oscar Robertson’s kidney
donation to his child. We can judge that such a donation is the natural response of a caring
parent. Just as a parent might sacrifice a night’s sleep to care for a sick child, a parent might
also be willing to give a kidney to his critically ill child. There is no need for the child to
ask for a kidney; the parent will routinely offer it first. While the question, “Why are you
going to give your kidney to your child?,” seems both awkward and distasteful, the likely
178 J Med Humanit (2008) 29:173–188

response, “Because that is what parents do!,” backs us up against something like a “first
principle” of a parenting relationship that informs our interactions with our children.
While rational justification for the donation might, in certain contexts, be called for,
more revealing in this situation is not the question, “Why give a kidney?” as the question,
“What is the ethical meaning of giving a kidney to your child?” The latter question fits
more appropriately into the context of care because it strikes at the core of what it means to
be a parent. As Joan Tronto argues, the central moral question for an ethic of care is not,
“What, if anything, I…owe to others? But rather—how can I…best meet my…caring
responsibilities?”20 Referring to our topic, the question can be amplified as: “How can we
best meet our particular responsibilities as they emerge in the concrete relationships of those
involved (donors, recipients, medical professionals) in live kidney donations?”

Responsibilities of care

It follows that it would be incongruent to attempt to construct a universal ethical calculus to

apply to all donations. To do so would mean that we ignore the particularities of each
situation and the distinctive relationships in each donation. One thing we can do, however,
is sort out the lines of responsibility that often go understated or even neglected in an
individual, non-relational, impartial ethic.
To begin with, the responsible potential donor who most often knows why he or she is
giving a kidney needs, in addition, to understand what giving a kidney involves. The
donation, appropriately enough, is most often called a “gift,” but it is certainly neither
simple nor without risks to the giver.21 Though it is not stressed nearly enough by medical
teams, kidney donation is an irrevocable, potentially life-altering act. Its ramifications, both
immediate and long term, are considerable. While transplantation is becoming increasingly
“routine,” it is not without danger and risk to donor and recipient and though extremely
rare, deaths can and have occurred.22 Prospective donors, particularly young adults, need to
assess long-term risks; for example, anyone with even a risk for high blood pressure or
diabetes may not be an appropriate donor. Moreover, the psychological ramifications of
donation can be understated in a framework privileging rational consent. Stress, depression
and occasional dissatisfaction with the decision to donate have been reported. Even though
the risks are low, they need to be contrasted with the “no risk” scenario of not donating,
keeping in mind that there are alternatives to live donation–namely, cadaver donation and
dialysis. Only in the rarest of cases, then, would a live transplant be, strictly speaking, a
life-saving procedure. Additionally, the caring responsibilities of the potential donor for
others within the circle of her or his care could be endangered should the donation result in
serious debilitation or death. Finally, the interpersonal impact on the relationship between
the donor and recipient can be, as we show later, profound and not always positive. Even
where the donation has positive results (as it most often does), it can still be a life-altering
event in ways unanticipated by both donor and recipient. In short, the moral weight of a
donation—whatever its benefits and burdens—is often little understood or little appreciated
by the participants and by those who write about it from the standard ethical framework.
Conversely, a care ethic focuses on relational responsibilities; that is, the moral
sensibility, both cognitive and emotive, whereby we accept that the well-being of someone
close to us is entrusted to our care. The moral transaction embedded in live kidney
donations almost always rises out of an already established relationship. It is not an abstract
claim made upon an autonomous individual; rather, the vulnerable child’s need calls for a
response from a caring parent. To talk about a parent’s right not to give a kidney or even
about an obligation to donate rings false here. Responsibility, as emphasized in the ethic of
J Med Humanit (2008) 29:173–188 179

care, is localized and particularized. These specific parents accept and take responsibility
for this, their engendered child. Even in a case where a parent, for whatever good reason,
does not donate, that would not lessen the sense of responsibility. Whatever else parenting
means, it surely means that we ought to care for our sick children in the best way we can.
In the standard ethical account, concerned as it is with the interests of the individual
donor, very little is said about the role the recipient plays in this moral transaction. In the
ethic of care, however, taking responsibility calls for a corresponding responsiveness on the
part of the recipient of care.23 An infant’s smile, a child’s thank-you, an adult-child’s
managing her parents’ finances—all bear evidence to the mutual dynamic inherent in caring
relationships. While the nature of a kidney donation is clearly one-sided—there could be no
quid pro quo operative here—the cared-for does have his or her own responsibilities as the
recipient of kidney. In the context of a loving parent-child relationship, a response of
gratitude and warm affection flow rather naturally. The adult recipient’s response is
obviously more conscious and explicit. In fact, out of a legitimate care for and
responsiveness to the potential donor, the potential recipient needs to ponder whether or
not the donor should be put in harm’s way. Should the donation be accepted, the recipient
then has the obvious responsibility, in gratitude, to live a healthy lifestyle.
The dynamics involved in donor-recipient relationships are more complex and more
subtle than one finds in an ethic focused on the traditional canons of informed consent. The
intimate relationship between the potential donor and recipient can create tremendous,
unstated pressure on both. On the one hand, the donor may want to donate out of care for
the recipient, but the recipient may well be reluctant to accept out of concern for the donor’s
health or apprehension over the burdens of receiving the kidney. On the other hand, a
potential donor may be reluctant but afraid to express hesitation because of the pressure,
real or imagined, to donate. Furthermore, the lack of a good relationship may lead both
donor and recipient to place unrealistic expectations on the gift, much like the partners in a
strained marriage who imagine that having a child will bring them closer together. Given
these dynamics, we believe that the caring and responsible response (though admittedly an
ideal) would be for the potential donor to offer, rather than the potential recipient to request,
the kidney; that would at least minimize the opportunity for manipulation. That is but one
example of paying attention to the moral dynamics within live donations. There are other
phenomena to which those who are responsible for live kidney donations need to be
attentive; for example, just as the love of a parent can turn possessive and destructive, the
gift of a kidney can become a weapon, conscious or not, used to manipulate and control the
recipient. Two writers who have been attuned to the psychological dynamics of donations,
Renee Fox and Judith Swazey, have aptly named this phenomenon “the tyranny of the gift.”
They recount the story of one particularly insightful donor who records the breakdown of
her relationship with her sister because of the strains the donation put on both of them. The
difficulties of maintaining “a reasonable amount of psychic distance and independence from
the donor” can easily be overlooked.24

The third party: The transplant team

The natural relationship of donor-recipient is greatly complicated by the introduction of an

“artificial” but indispensable third party: the transplant team. At one and the same time,
they present themselves as the humble facilitators of the donation but also as the high tech
professionals at the cutting edge of medicine–medical caregivers who, nonetheless, are also
in the business of procuring organs. As a third party, they are not completely disinterested
gate-keepers, and hence, their dual roles can and do come into conflict much like those of a
180 J Med Humanit (2008) 29:173–188

research physician. Attuned to the language of individual rights, they want to protect the
potential donor, chiefly by ensuring informed consent. Some counseling may be offered but
very little attention is paid to the dynamics between donor and recipient.25 From the
medical team’s perspective, the anticipation of procuring a kidney might override qualms
about the wisdom of the donation. In an individualistic ethic, it may be morally acceptable
for an autonomous agent to risk harm, provided informed consent is given; in a care ethic,
however, the responsibilities of a third party not to manipulate potential donors who put
themselves in harm’s way would be of overriding concern.26
A brief summary of the current strategies to increase the number of organs reveals how
pressured the demand for kidneys can get. In the face of shortages, clever slogans were first
developed for procuring cadaver organs (“Don’t take your organs to heaven with you,
heaven knows we need them here”); transplant teams, with coordinators, were put in place
at major hospitals; and expanded criteria for accepting donors were established. When all of
these new procedures still did not bring in enough organs, attention turned to live organ
donors. Here again, the push to get them has been intensive with new slogans proclaiming
kidney donors as heroes. All such initiatives have created a “culture of transplantation” with
its high priests (the surgeons), its ministers (the transplant team), its distinct terminology
and media messages—working for the single purpose of procuring and transplanting
organs. However good that goal, it is easy for the private donor-recipient relationship to get
lost in this new, exotic, high-tech culture.
There is, for example, a tendency in the transplant culture both to understate and
overstate what a kidney donation involves, to play down the risks of donation and play up
the status of the donor, sending conflicting messages to both donor and recipient. In
underplaying the risks, transplant teams tend to underestimate what Fox and Swazey have
called “one of the most sociologically intricate and powerfully symbolic events in modern
medicine.” Donor kidneys are often represented as if they were things, “‘just organs,’ rather
than as living parts of a person…that resonate with the symbolic meaning of our relation to
our bodies, ourselves and to each other….”27 This commodification neglects the fact that
the kidney is a vital organ, and hence, the donation is quite different from a gift one buys
for a child at the toy store. Our bodies help constitute our identity and sacrificing parts of
our bodies requires understanding the psychological ramifications of the donation. For
example, the phenomenon of “animism” in which the donor’s qualities are imagined to live
within the recipient has been well documented. Fox tells the story of a kidney donor, a
brother, who commented to his sister upon winning the Miss Pennsylvania contest: “We
looked good up there on stage”28 Such animistic feelings reveal that relationships, however
intimate, also demand a certain space and distance to remain intact.
Equally perturbing is the sometimes overblown response accorded to the donor. The
donor is often treated like a hero, which recognizes, albeit indirectly, that something more is
going on than giving something we have no need for—an extra kidney. One transplant
hospital has a “room of heroes” devoted to the names of all those who have been live
donors. Undoubtedly, courage is required on the part of the donor. In the context of the
caring relationship of parent and child, however, such an act would hardly be deemed
heroic as any parent would recognize that the daily grind of caring for one’s children is far
more wearing and demands more courage than a one-time surgery. The transplant culture,
however, needs kidneys and treating the donor as a hero, if only for the initial contact and
duration of the stay, is clearly in its interest.
It is our contention that health care professionals might significantly assist in the
relational dynamics if they became more attuned to and took some responsibility for the
moral complexities outlined above. Shifting from a moral framework that focuses on
J Med Humanit (2008) 29:173–188 181

individual rights and impartial duties to one embedded in the notion of care would go a
long way towards accomplishing that end. Recognizing the natural tendency of a related
donor to underestimate the risks, the transplant team could take particular care to help the
donor explore the medical risks and psychological complications. By appreciating that the
offer of a kidney is most commonly done out of care for the loved one needing a transplant,
they would tune into those dynamics and avoid the language of “heroism.” One concrete
implementation would be the assignment of a health care professional to serve as an
impartial but caring third party representing the donor’s health and well being. Actually, the
idea of a “donor advocate” is not new to transplantation but is most often used in unrelated
donations where standard concerns about informed consent come to the forefront. In
donations where the emotional ties are strongest, however, the need for an advocate is just
as pressing since the one who is anxious to donate may not be attuned to the relational
dynamics and may be unable to see the risks that lie down the road. In fact, some
counseling for both donor and recipient is clearly called for when we study the very
complex and sometimes destructive dynamics that can take place in these live donations.

Part III: The circles of care: expanding the paradigm

Within the sheltering and nurturing parent-child relationship, the donation of a kidney
represents the natural and moral optimum instance of a live donation. The opportunities for
exploitation, while real, can be minimized. That is why we choose it for our paradigm.
What happens, however, when we move out from that relationship to other opportunities
for donations? Again, while the ethic of care cannot afford us a simplistic moral calculus
that determines who should and who should not donate, it can offer some moral guidelines
to inform the practice.
In her book, Caring, Noddings speaks of ever-enlarging but less intimate circles of
relationships that envelop our caring responsibilities. The farther out one goes in the rings
of relationships, the less demand can be put on our caring responsibilities.29 For example, a
mother must feed her child, but feeding a starving child a continent away is problematic. A
parent would, out of a sense of responsibility, offer a kidney to his or her child; offering it
to a stranger could well be irresponsible. The ethics of care makes sense of those
differences because it locates our primary ethical responsibilities within relationships that
are already established and responsibilities already accepted. In this context, Zell Kravinsky
could be accused of falling into what Christina Hoff Sommers has called the “Jellyby
fallacy.” Mrs. Jellyby, the infamous character in Charles Dickens Bleak House, suffers from
a moral hyperopia, whose eyes “had the curious habit of seeming to look a long way off.”30
The children at her feet, by contrast, are horribly neglected. Without getting into the details
of the contemporary debate between what we have called impartiality and partiality, it
seems evident that there is a circle of care, which widens out from our most intimate
relationships. As care becomes diffused, it becomes less effective, and our responsibilities
become less urgent. After our own children, our intimate circle might include parents,
spouses, siblings, and close friends. Noddings also speaks of “chains” that are connecting
links to those brought into our circle by our intimates; i.e. in-laws, boyfriends and
girlfriends, perhaps even friends of friends. The same logic is operative here; acceptance
within the circle brings with it certain responsibilities of care. How would this consideration
of ever-widening circles and chains play out in the field of live kidney donations?
Given that we have but one kidney to donate, it makes good moral sense to offer it, if we
do, to those in need who are closest to us. The needs that emerge within the intimate circle
182 J Med Humanit (2008) 29:173–188

of care are experienced as most urgent and most obligatory. Thus, it would be both natural
and ethical for those closest to the one in need to offer a kidney: a spouse, a sibling, a
relative or even a friend. A sense of responsibility, similar but not equivalent to that of a
parent, might be in play here, and one might judge, in part, the appropriateness of the offer
in terms of the closeness of the relationship of the donor. For that reason, we do not think it
possible to specify in advance some rigid hierarchical order of preference. The ethic of care,
however, would pay close attention to the dynamics of this circle of relationships,
proceeding even more cautiously than with the parent-child donation.
A few examples illustrate the necessity of prudence. For instance, simple reversal of the
original paradigm, child to parent donation, should be looked at carefully, as a child’s
responsibilities to his or her parent are obviously not under the same requirements as a
parent’s to his or her child. Despite the possibly better tissue match, concern for a child’s
vulnerability and welfare might make an offer from a spouse a more medically appropriate
and a morally better option. Similarly, while a sibling transplant might be judged ethically
acceptable because of the close, interdependent relationship of brothers and sisters, one,
again, has to be cautious. Hans Jonas points out, rightly we think, that the “vertical
responsibility” of a sibling “will always be weaker, less unconditional” than the “horizontal
responsibility” of a parent.31 Parents would be less inclined, then, to put at risk their own
children’s health in a transplant operation rather than themselves. With the consent (or
assent at least) of a sibling, however, a donation can be acceptable, given the severity of the
sick child’s illness and other appropriate conditions.32 Here, again, the appointment of a
donor advocate for the child would help to insure that the family’s concern for their sick
child did not unduly put at risk the sibling child.
As we expand outward to donor-friends, we continue to see similar ties of care and
responsibility. Friendship sometimes requires sacrifice, and a case could be made that, in
some situations, a friend’s donation is more acceptable than that of a spouse or sibling. A
friend, however, may well have his own familial responsibilities to consider and might
render the wish to donate prohibitive. In the ethics of such decisions, there may be no clear-
cut answer. The donor’s practical wisdom—as well as the recipient’s—is critical here;
deciding whether or not, within the context of relationships and future responsibilities, what
is the right decision.
Most problematic of all are unrelated donors, sometimes called “stranger to stranger
donations.” These donations deserve separate consideration, and we can only show how
morally problematic such donations are when viewed from an ethic of care. We do not deny
moral obligations to strangers, but, as we move to the outer circles of our care, we argue,
pace Kravinsky, that there does not exist (at least in ordinary circumstances) a moral
obligation to donate to a stranger; nor do we think unrelated donations should be preferred
to related ones. Of critical importance here is that in related donations a relationship already
exists; indeed, that is why the donation is offered. In unrelated donations, there is no
relationship; if one develops, it will be constituted by the donation. That fact alone does not
render the former ethical and the latter unethical, but very little attention has been paid to
that crucial difference and the consequences that follow from it. If a close relationship of
donor and recipient is not without its problems, surely the relationship of stranger donors
and recipients is likely to be more delicate, more complex, and more fraught with potential
for psychological damage. We do think a case can be made for unrelated donations,
particularly under the different ethical canon of what is often called supererogatory acts.
While it may go against the current of today’s transplant culture, we believe the very real
differences between related and stranger donations call for prudence and caution.33
J Med Humanit (2008) 29:173–188 183

Several recent strategies mixing related and unrelated donations should briefly be
mentioned in this context. There is something to be said for the dramatic and much
publicized practice of “kidney swapping,” whereby a relative or friend of someone who
needs a kidney donates a kidney to a compatible stranger recipient in return for a relative
or friend of that recipient donating to the first kidney patient.34 The possibilities for live
donations are greatly enhanced; in principle, anyone who offers to donate a kidney to a
loved one is then a potential donor because there is the likelihood someone else would be
compatible and a simultaneous transplant could occur. While such donations might be
morally acceptable, there are still some difficulties here, not the least of which is the
confusion between related and unrelated donors. Clearly, the related donor has initially
volunteered precisely because that donor cares about the recipient. The related donor’s
initial intention is not to offer a kidney to a stranger but to a close relative or friend. When
the transplant team offers an option of an unrelated donation, it would be harder to say
no. At the very least, prospective donors should be told by the transplant team at the
outset that swapping may be an option and they should be given a chance to decline up
front.
We are even less sanguine about the recent practices of allowing someone close to the
patient to donate a kidney so that one’s relative or friend can be given priority on the
waiting list. Initially, this practice may seem attractive, even fair, but, on reflection, it raises
serious problems of justice for those already on the list who get bumped because they have
no one willing to do the same for them. Swapping would be preferable to the potentially
unjust distribution of this latter practice.
Much more could be and needs to be said about these practices and the whole field of
unrelated donations. The easy acceptance, even celebration, of them in the transplant
culture should raise some cautionary flags, particularly when looked at through the lens of
the ethic of care.

Part IV: Recommendations

At this point, we offer some concrete recommendations gleaned from an ethic of care that
we believe can better guide live kidney donations. The following proposals do not call for a
radical restructuring of procedures and policies but require a definite shift in perspective, a
corrective vision, which would more adequately attend to the moral dimension in those
donations.

Selection of appropriate donors

& Those closest to the patient needing a kidney, who feel most responsible for them,
should be the most likely candidates for transplant.
Family and friends are to be preferred, where possible, over stranger donations. The
degree of acceptable risks would vary according to the relationship to the recipient.
& The further one moves out of immediate relationships, the more cautious must be
the selection of donors.
In this “sliding scale” approach, more rigorous screening of stranger donors would be
required for their own protection and to ensure that their motivation was not to fulfill
some psychological need.
184 J Med Humanit (2008) 29:173–188

Responsibilities of transplant team

& The focus in organ transplants needs to shift perspective from solving the organ
scarcity problem to caring for both donor and recipient.
The societal problem of how to get more organs needs to be clearly separated from the
process and procedures of individual organ transplants. Likewise, patients should not be
pressured to find donors. The medical profession cannot compromise its primary
responsibility “to do no harm.”
& The organ donation process, which is now streamlined and oriented toward
medical compatibility and suitability, needs to be more attentive to the personal
dynamics between donor and recipient.
The common approach to donation is to screen for medically appropriate donors first
and only later, if at all, worry about the psychological dimensions of giving. While
that may be cost effective, it enhances the possibility of manipulation. What starts
out as an investigation of compatibility inexorably works its way to expected
donation, making withdrawal more difficult. The interpersonal dynamics need to be
dealt with at the outset.

Protection and responsibilities of the donor

& Donor Advocates need to be designated in all live kidney transplants.

While committed to transplants, the advocate must give priority to the potential donor
and even veto the transplant when there is sufficient reason not to proceed.
& Informed consent needs to be adapted to the particular circumstances of
emotionally related donations.
While the traditional emphasis on informed consent should continue, special care needs
to taken with respect to the natural response to give a kidney to a loved one. Not just the
cognitive but also the emotive dimension of informed consent becomes particularly
important.
& Potential donors need to balance their responsibilities not just to the recipient but
also to others in their circle of care and to their own health.
In this life-altering decision, the potential donor’s generosity needs to be tempered with
an understanding of the current and future risks. The donor advocate can help to sort
through these various issues.

Responsibilities and protection of the recipient

& Potential kidney recipients need to be particularly sensitive to the possibility of

manipulation of potential donors.
Recipients cannot allow the debilitating condition to overwhelm them into forgetting
that donation is a gift and not a right. The preferred course of action would be for the
recipient not to ask but for the donor to offer, diminishing the chance for manipulation.
Public appeals by patients needing kidneys can easily exploit naive, vulnerable people.
& Recipients need to balance gratitude toward donors with protection of their own
independence.
The inestimable gift does call out for a grateful response. Given the possibility for the gift
becoming a tyranny, however, the recipient also deserves protection from victimization.
J Med Humanit (2008) 29:173–188 185

& The ethic of care should not be a replacement for issues of justice or a substitute
for fairness.
This recommendation serves as a caveat. We recognize that the emphasis on the
particular relationships of care could create some unfairness in the allocation of organs.
We need to insure those who are not fortunate enough to have related donors still have
reasonable opportunities to receive kidneys.
The above recommendations should not be viewed as exhaustive but as a summary of
some of the specific differences we think an ethic of care brings to the discussion. One final
caveat: no list of policy recommendations can substitute for practical wisdom. In this
delicate, highly complex process, all those involved would be well served by the old
Aristotelian advice: the right thing is to be done in the right way by the right persons for the
right motive.

Conclusion

The moral world “will look different,” argues Joan Tronto, if we “move care from its
current peripheral location to a place near the center of life.”35 This article has been a
sustained effort to demonstrate how different the world of Oscar Robertson looks from that
of Zell Kravinsky. In so doing, we have resolutely steered a middle path between the
unrestrained exuberance of the transplant culture and an ungenerous negativism that would
forestall any transplant, between an overestimation of the gift of one’s kidney and an
underestimation of the risks such a gift involves. In the end, it is, at best, an act done out of
care and responsibility for those we love.

This article is dedicated to the memory of Kevin Sullivan (1952–2000), a victim of

kidney disease, but, even more, a loving husband, devoted father and loyal friend.

Endnotes

1 See S. Strom, “Kidney donor pushes his altruism to the extreme,” Seattletimes.com (17 August 2003); O.
Pritchard, “No more to give, so much left to lose,” Philly.com (24 August 2003); “Philanthropist donates
kidney to stranger,” CNN.com (22 July 2003).
2 Sports Illustrated (15 July 2002), p. 79.
3 Though the ethical literature often speaks of organ donations in general, we will limit our considerations
to kidney donations. We do believe, however, that the thrust of our arguments can be applied, mutatis
mutandis, to other live donations.
4 R. Baker and V. Hargraves, “Organ Donation and Transplantation: A Brief History of Technological and
Ethical Developments,” in The Ethics of Organ Transplantation, Volume 7 of Advances in Bioethics, eds.
W. Shelton and J. Balient (Amsterdam: Elsevier Science, 2001), pp 1–42.
5 Organ Procurement and Transplant Network 2007. http://www.optn.org.
6 See D. Vawter, "Ethical Frameworks for Live and Cadaver Organ Donation," in Organ and Tissue
Donation: Ethical, Legal and Policy Issues, ed. B. Speilman (Carbondale: Southern Illinois University
Press, 1996.
7 See A. Spital, “Ethical and Policy Issues in Altruistic Living and Cadavaric Organ Donation,” Clinical
Transplantation, 1997.
8 See C. Elliott, “Doing Harm: Living Organ Donors, Clinical Research and The Tenth Man,” Journal of
Medical Ethics 21 (1995): 91–96.
9 See R.C. Fox and J.P. Swazey, Spare Parts: Organ Replacement in American Society (Oxford UK:
Oxford University Press, 1992).
10 See Spital, “The Ethics of Unconventional Living Organ Donation.”
186 J Med Humanit (2008) 29:173–188

11 See W. Gannon and L.F. Friedman, “Do Genetic Relationships Create Moral Obligations in Organ
Transplantation?” Cambridge Quarterly of Health Care Ethics 11 (2002): 153–159 and A. Spital,
“Response: Do Genetic Relationships Create Moral Obligations in Organ Transplantation?” Cambridge
Quarterly of Health Care Ethics 12 (2003): 116–118.
12 Though we cannot, in the limited space here, offer a detailed analysis of the literature, a recent debate that
occurred in the Cambridge Quarterly of Health Care Ethics is instructive. Operating out of an
individualistic framework, Gannon and Friedman (2002) argue that unrelated donations are more morally
praiseworthy than parental ones because the former are altruistic while the latter obligatory. Spital’s
response (2003), namely, that parents donate out of love not duty, begins to break out of the
individualistic framework but even he still employs the language of altruism. It is precisely this impasse
our own effort is an attempt to overcome.
13 Though it is beyond the scope of this article, it should be obvious that the market based approach to organ
donations also provides a sharp contrast between our two paradigms. Such economic considerations could
be more easily entertained within an individualistic, impartial framework. An individual acting out of self
interest (mixed, perhaps, with some altruism) might argue that he “owns” his body and, therefore, has a
right to sell his organs. Whatever the worth of that argument, it simply makes no sense when applied to
parental-child donations. To introduce such a financial incentive into a familial relationship surely would
be deemed inconsistent with the very nature of the caring relationship, which gave rise to the offer of a
donation in the first place.
14 Any philosophical or theological tradition that begins within a relational context could come to similar
conclusions. The new emphasis on family ethics, as developed by John Hardwig would resonate with our
own ethic of care although we do not rely on the notion of interests as he does (Hardwig, 1989). We
should also point out no meta-ethical claims are being urged in this article; that is, we do not claim the
ethical superiority of care ethics to any other ethic except in the case of morally assessing live kidney
donations. We think it probable that our argument could be extended to other areas, both in medicine and
ethics, but those claims lie well beyond the scope of this essay.
15 From Plato’s emphasis on care (melein) in the Apology to Heidegger’s construction of Sorge (Care) in
Being and Time, there has been much written (albeit not explicit) in the philosophical tradition on care. In
the theological tradition, the Jewish call to care for the widow and stranger and the Christian appeal to the
Good Samaritan could also be cited in this context.
16 See N. Noddings, Caring: A Feminine Approach to Ethics and Moral Education (Berkeley: University of
California Press, 1984); J.C. Tronto, Moral Boundaries: A Political Argument for an Ethic of Care (New
York: Routledge, 1994); and H.M. Nathan et al., “Organ Donation in the United States,” American
Journal of Transplantation. 3 Supplement 4: 34. In keeping with the ethics of care, we do not equate
“feminine” with solely women nor “masculine” with solely men. The gendered distinction can be
understood and adopted by both women and men. We do find it suggestive that 59% of cadaver donors
are male and 57% of live donors are women, perhaps indicating a gender difference between an
individualistic and relational ethic. (Organ Procurement and Transplant Network. http://www.optn.org/
latestData/rptData.asp. Retrieved 8/04/06.)
17 G. Clement, Care, Autonomy and Justice: Feminism and the Ethic of Care (Boulder, CO: Westview Press,
1996).
18 Elliott, 95. For a fascinating cross cultural study that reinforces our own approach but also points out how
family dynamics can differ considerably, one can consult the work of Yi (Yi, 2003).
19 See R.C. Fox, “Afterthoughts: Continuing Reflections on Organ Transplantation,” in Organ
Transplantation: Meanings and Realities, eds. S.J. Younger, R.C. Fox, and L.J. O’Connell (Madison:
University of Wisconsin Press, 1996), pp. 253–257.
20 Tronto, 137.
21 Though not an ethical treatment as such, the work of Marcel Mauss is very instructive here. See
especially, The Gift: The Form and Reason for Exchange in Archaic Societies.
22 See A.J. Matas et al., “Nondirected Donation of Kidneys from Living Donation,” New England Journal of
Medicine 343, no. 6 (2000): 433–436; E.M. Johnson et al., “Long-term Follow-up of Living Kidney
Donors: Quality of Life After Donation,” American Journal of Transplantation 67 (1999): 712–717; P.M.
Franklin and A.K. Crombie, “Live Related Renal Transplantation: Psychological, Social, and Cultural
Issues,” Transplantation 76, no. 8 (2003): 1247–52; and C. Vastag, “Living-Donor Transplants
Reexamined,” Journal of American Medical Association 290, no. 2 (2003): 181–182.
23 See Tronto.
J Med Humanit (2008) 29:173–188 187

24 Fox and Swazey, 39–40.

25 See Chapter Two in Fox and Swazey.
26 See M.F. Woodruff, “Ethical Problems in Organ Transplantation,” British Medical Journal I (1964):
1457–1460; and Elliott.
27 Fox and Swazey, 31 and 207.
28 Ibid, 36.
29 See Noddings and Elliott.
30 See C. Sommers and F. Sommers, Vice and Virtue in Everyday Life (Fort Worth: Harcourt College
Publishers, 2001), p. 720.
31 H. Jonas, Philosophical Essays: From Current Creed to Technological Man (Chicago: Chicago University
Press, 1980), p. 94.
32 See A. Spital, “Ethical and Policy Issues in Altruistic Living and Cadaveric Organ Donation,” Clinical
Transplantation 11 (1997): 80; and Crouch and Elliott.
33 A. S Levey, S. Hou, and H.L. Bush, “Kidney Transplantation From Unrelated Living Donors: Time to
Reclaim a Discarded Opportunity,” in The Ethics of Organ Transplants: The Current Debate, eds. A.L.
Caplan and D.H. Coelho (New York: Prometheus Books, 1998), 48–53.
34 See L.F. Ross et al., “Ethics of a Paired-Kidney-Exchange Program,” The New England Journal of
Medicine 336 (1997): 1752–1756; K. Park et al., “Exchange-Donor Program in Kidney Transplantation,”
Transplantation Proceedings 31, nos. 1–2 (1999): 356–357; and S. Levine, “We Each Have a Piece of
Each Other,” The Washington Post (2 August 2003): A:1.
35 Tronto, 101.

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