A new program of advanced donation is being piloted in the US to address a barrier to living kidney donation in the form of “chronological incompatibility” between potential donors and their intended beneficiaries. In this program, a person whose kidney is not currently required for transplantation in a specific recipient may instead donate to the paired exchange program: in return, a commitment is made to the specified recipient that priority access for a living donor transplant in a paired exchange program will be offered when or if the need arises in the future. This commitment has been symbolically described as a “voucher”.
We evaluated the current model of advanced donation to identify ethical risks and potential benefits of the program.
The program enables advanced donors to help their intended beneficiaries obtain a transplant in the future, while helping to meet public needs for transplantation in the present. However, conditions imposed in the current program unduly limit the potential benefits of the program, particularly the prohibition of transfer of “vouchers” during the lifetime of the donor. If a person close to the donor unexpectedly develops the need for transplantation but is unable to take advantage of the voucher, the donor may experience significant decisional regret, especially if they would have been eligible to donate at this time in the absence of advanced donation.
Advanced donation enables a form of public virtual banking of kidneys obtained through living donation by providing opportunities for donation to the common pool of organs for public allocation, while preserving the future opportunity for donors to benefit a designated individual. If advanced donation vouchers were transferable, this program might greatly increase non-directed donation by those who are chronologically incompatible with their intended transplant recipient, and those who are willing to make an altruistic donation but concerned about potential future transplant needs of loved ones.