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Allowing autonomous agents freedom
  1. A J Cronin
  1. Dr Antonia J Cronin, Institute of Medicine Law and Bioethics and Institute of Science Ethics and Innovation, School of Law, University of Manchester, Oxford Road, Manchester M13 9PL, UK; Antonia.Cronin{at}


Living-donor kidney transplantation is the “gold standard” treatment for many individuals with end-stage renal failure. Superior outcomes for the graft and the transplant recipient have prompted the implementation of new strategies promoting living-donor kidney transplantation, and the number of such transplants has increased considerably over recent years. Living donors are undoubtedly exposed to risk. In his editorial “underestimating the risk in living kidney donation”, Walter Glannon suggests that more data on long-term outcomes for living donors are needed to determine whether this risk is permissible and the extent to which physicians and transplant surgeons should promote living-donor kidney transplantation.1 In this paper I argue that it is not clear that medical professionals have underestimated this risk, nor is it clear that more data on long-term outcomes are needed in order to determine whether it is permissible for individual autonomous agents to expose themselves to this or, indeed, any risk. The global shortage of organs available for transplantation ultimately means that every year thousands of individuals who value their life die needlessly. This is an unacceptable loss of human life. Saving life is one of the most wonderful things an individual can do for another. Promoting any strategy that will assist in saving life and preventing human suffering within acceptable moral limits is legitimate.

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  • Funding: AJC is funded by The Wellcome Trust.

  • Competing interests: None declared.

  • i Statistics are available from UK Transplant (UKT) ( and the United Network for Organ Sharing (UNOS) ( For example, a summary of transplant activity 2005–2006 produced by UK Transplant Statistics and Audit Directorate documents that in that year in the UK the number of living kidney donors rose from 475 (in 2004–2005) to 590, an increase of 24% (

  • ii The Human Tissue Act 2004 came into effect in England, Wales and Northern Ireland on 1 September 2006. The Act is now the primary legislation regulating transplantation in those countries. It will not apply in Scotland (save for section 45, prohibiting the taking and analysis of DNA samples without consent). Separate legislation will apply in Scotland; see the Human Tissue (Scotland) Act 2006.

  • iii An incompatible living-donor and recipient “pair” can swap organs with another pair in the same situation. If more than two donors and two recipients are involved in the swap, it is called pooled donation (

  • iv A living person who has never met the possible recipient may become an organ donor (

  • v A meta-analysis of 48 studies that enrolled 5149 donors, with only six reports being controlled, reviewed the specific risk of increased blood pressure over time after kidney donation. The study documented that kidney donors may have a 5 mm Hg increase in blood pressure within 5 to 10 years after donation over that anticipated due to normal ageing.

  • vi All-cause mortality data are held by the UK Renal Registry (

  • vii There are European data showing that renal transplants performed between 1997 and 1999 have a mean graft half-life of 20 years. In contrast, the mean in 1984 was 7 years.

  • viii One exception to this would be the induction and maintenance of immunological tolerance. Immunological tolerance can be regarded generally as a state of unresponsiveness to self-antigens or foreign antigens in the absence of ongoing therapy. The benchmark for the establishment of clinical tolerance is the ability to completely and successfully withdraw immunosuppressive drugs. Achieving this goal would have an unprecedented revolutionising effect on clinical transplant practice.

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