Living kidney donation prior to euthanasia: medical, psychological and ethical considerations

Living kidney donation prior to euthanasia has never previously been reported and is not incorporated into current clinical guidelines. This study aims to discuss the unique medical, procedural, psychological and ethical considerations of living donation prior to euthanasia based on 3 Dutch cases. Of the 3 candidates, 2 successfully donated without detrimental effects to physical or mental health; one was declined for medical reasons. In two cases, euthanasia has been performed; in one case donation was transformative and the request for euthanasia was withdrawn after donation. Medically, normal life-expectancy after donor nephrectomy should be presumed as euthanasia remains uncertain. Procedurally, timing can create tension between these two processes as postponing euthanasia could be harmful. Psychologically, potential exacerbation in psychopathology should be weighed against the impact of being declined for donation. Ethically, autonomy, capacity to consent and risk-benefit ratio must be rigorously assessed, especially given the degree of suffering in these cases. We conclude that living donation and euthanasia should be seen as independent processes and a euthanasia request should not be considered an absolute contra-indication for living donation. Our initial experiences underscore the need for international dialogue and policy development.