Introduction: With a global shortage of organs for transplantation, Reese et al.¹ describe an opportunity to significantly increase the global organ donor pool. The Global Kidney Exchange Program (GKEP) intends to overcome poverty barriers in Low-to-Middle Income Countries (LMIC) and immunological barriers in High-Income Countries (HIC), saving the lives of the LMICs’ patients and enhancing the quality of life and life expectancy of HICs’ patients, while a creating cost-saving initiative for healthcare funders. But not all bioethicists agree that the GKEP, in its current form, is an ethical solution.
Methods: Based on the principles of the 2018 Declaration of Istanbul, arguments regarding ‘coercion’, 'equitable access to transplantation services' and 'self-sufficiency' are developed from the general viewpoint of a LMIC that would contribute “financial incompatible” donor-recipient pairs to the GKEP.
Results and Discussion: The strongest argument supporting the GKEP is that it will save lives of LMICs’ patients that do not have access to transplantation or do not have the financial means to pay for the procedure, while in HICs it will increase the quality of life and life expectancy of “difficult to match” patients with immunological complexities. However, in a setting where renal replacement therapy needs to be rationed, dialysis allocation policies are often aligned with surgical criteria related to transplantation. When the GKEP are the only or the main transplantation strategy in a LMIC, the entry criteria for all renal replacement therapy will be skewed to recipients who meet the GKEP criteria. Therefore a select group of patients (those with living donors) will be more likely to be accepted for dialysis and transplantation. When the only lifesaving option available is dependent on having a living donor, the risk for donor coercion is undeniable. Coupled with environments of extreme income inequality, as in many LMICs, where the availability of poor and desperate people is abundant, fairly little safeguarding mechanisms could be put in place to protect against donor exploitation.
Furthermore, if a situation arises where HICs will (only) perform and fund the transplants of patients meeting the (funding) GKEP criteria, then little incentives may exist for LMICs to transplant the patients who do not meet the GKEP criteria and develop deceased donation programs.
Conclusion: In conclusion, the GKEP in its current form could create circumstances that put undue pressure on ESRD patients to have a living donor, as well as, lead to inequitable access to transplantation for patients in LMICs. Furthermore, the GKEP could create a funding dependency of transplant programs in LMICs on HICs, while undermining self-sufficiency efforts in LMICs. If these ethical issues can be addressed, the GKEP could save many lives globally.