I would like to share comments made during a lively debate at the first international medical sociology conference in Chennai on May 25-26, 2002.

The debate revolved around issues of informed consent and the ethics of live unrelated donation. What should the transplant surgeon do when recipient and donor are unrelated but produce papers to legally establish their biological relationship? What if donor and recipient admit they are unrelated but the donor claims that he is willing to donate a kidney on altruistic grounds? Transplant surgeons participating in the debate said that very often the donor is an employee of the recipient, who has voluntarily consented to be part of the operation, fully knowing the possible risks involved. Surgeons confessed that they were helpless when they were sure that their patient is biologically unrelated to the donor, but the patients possessed the required legal documents in support of their claim; one knows how easy it is to get forged affidavits from the concerned authorities in India.

The broader predicament for surgeons is: should they be judgmental in such situations when there are no legal impediments to the transplant? When unsure, surgeons are required to refer the issue to the ethical clearance committee concerned with the kidney transplantation. Mr N Ram, editor of Frontline, mentioned that in Karnataka the committee had received more than 1,000 cases for clearance — and only 22 cases were rejected, because the papers were not in order. Some of them subsequently brought ‘appropriate’ papers and got clearance.

Two transplant surgeons felt that they need not be judgemental when donor and recipients are medically eligible and fit for the transplantation, their legal documents are in order (genuine or otherwise), and the donor has given voluntary informed consent. They also said the HLA typing test carried out to verify the relationship claim is not 100 per cent reliable. In this context, surgeons have no option but to undertake the operation. Moreover, they say it is especially warranted, since the demand for kidneys far exceeds the availability from cadaver (brain stem death) organs.

This view was strongly contested by those who felt surgeons could always take a moral stand and refuse to be part of a operation when they suspected the donor of participating for an incentive.

On the question of gender bias in organ transplants (there are more live unrelated female donors than male donors), a participant questioned the ethics of denying a woman’s freedom to make an independent and informed decision, when she is desperately in need of money and wishes to donate her kidney to repay a debt. Failing this option, she may see prostitution as an option.

Transplant surgeons also questioned the integrity of kidney transplants among related donors. They cited examples of sons donating a kidney to the father in exchange for educational sponsorship or other financial incentives. Should such transplants be allowed just because they are biologically related, even though it is clear that compensation is involved? How does one verify the integrity of the relationship in related kidney donation?

Others feared that if unrelated donation were not regulated, people would prefer (buying) kidneys from unrelated donors — cheap for Rs 40,000-60,000 and without risk to their relatives.