Who shall be allowed to give? Living organ donors and the concept of autonomy

Free and informed consent is generally acknowledged as the legal and ethical basis for living organ donation, but assessments of living donors are not always an easy matter. Sometimes it is necessary to involve psychosomatics or ethics consultation to evaluate a prospective donor to make certain that the requirements for a voluntary and autonomous decision are met. The paper focuses on the conceptual questions underlying this evaluation process. In order to illustrate how different views of autonomy influence the decision if a donor's offer is ethically acceptable, three cases are presented--from Germany, the United States, and India. Each case features a person with questionable decision-making capacity who offered to donate a kidney for a sibling with severe renal insufficiency. Although the normative framework is similar in the three countries, different or sometimes even contrary arguments for and against accepting the offer were brought forward. The subsequent analysis offers two explanations for the differences in argumentation and outcome in spite of the shared reference to autonomy as the guiding principle: (1) Decisions on the acceptability of a living donor cannot simply be deducted from the principle of autonomy but need to integrate contextual information; (2) understandings of the way autonomy should be contextualized have an important influence on the evaluation of individual cases.

Analyzing the conceptual assumptions about autonomy and its relationship to contextual factors can help in working towards more transparent and better justified decisions in the assessment of living organ donors.