The Ethicist: I’m a 73-Year-Old Cancer Survivor. Can I Accept a Kidney?

April 29, 2018 by Joshua
in Ethicist

My series answering the New York Times’ Ethicist column with an active, leadership approach instead of an analytical, philosophical perspective continues with “I’m a 73-Year-Old Cancer Survivor. Can I Accept a Kidney?”.

Over the past eight years I underwent two stem-cell transplants, each preceded by intense chemotherapy. My oncologist believes I am probably cured. The chemotherapy damaged my kidneys to the point that I am now on dialysis, and other systems are affected as well. There is also a small but significant risk that other malignancies may occur in the future as a result of the chemotherapy.

Kidney-transplant recipients live longer than those on chronic dialysis and generally feel better. They also have a much better quality of life when freed from the logistical constraints and discomfort that any form of dialysis imposes.

I am on a transplant waiting list but have been told that it could be 10 years before I reach the top of the list. I have no relatives or friends who could donate, but I have become aware of a group of altruistic individuals willing to donate a kidney.

I am 73 and, despite the damage from my treatment, have much that I want to do and am capable of doing. I would certainly love to receive a kidney transplant, with all the advantages for me and a better life for my wife. My concern is whether it is ethical to ask a healthy volunteer to undergo the pain as well as the immediate and long-term risks of kidney donation considering my age and medical history. My family and friends think I should. Am I overthinking it? Name Withheld

My response: Everybody involved seems a consenting, sane, fully informed adult. Anyone who wants to decline can.

The New York Times response:

Let’s examine what you’re thinking: You would be increasing the quantity and quality of your remaining years, but the donor would incur increased health risks, and his or her kidney could be in service longer if it went to a younger and otherwise healthier recipient. The first point should not weigh heavily. Tens of thousands of people have chosen to be living kidney donors — there are now more than 5,000 living donations a year in the United States — which suggests that people have decided that the risks, for anyone judged medically suitable as a donor, are modest.

How modest? One large-scale American study showed little evidence of higher long-term mortality for donors than for similar nondonors. A smaller Norwegian study suggested some increase in mortality among donors (although 80 percent of the donors in that study were close relatives of the recipient, and it’s hard to correct for the confounding effect of familial risk of kidney disease). Each study suggested a significant increase in the risk of end-stage renal disease among donors, but the total numbers affected were very small: 0.04 percent in the American study, 0.06 in the Norwegian. Of course, surgery always carries some risks: You yourself are not assured of a successful outcome. Still, the likeliest outcome is that your donor has a long, healthy life and that the rest of your life will indeed be improved.

What about the question of how a donated kidney should be used? The United States population is aging, and the National Institutes of Health says that nearly 19 percent of those on the kidney-transplant list are over 65. The national transplant system tries to allocate kidneys that are expected to last the longest to patients expected to need them the longest. But the system isn’t designed solely to optimize the expected “net lifetime survival benefit”; otherwise, society might give lower priority to black recipients, say, because on average they don’t survive as long as white ones. (As this suggests, there are many complex ethical issues involved in trying to assign organs fairly.)

Outside the national organ-sharing system, what matters is that you are medically eligible for a kidney transplant and have an informed donor who is capable of making a reasonable assessment of his or her risks and of your benefits. Giving you a kidney is that person’s choice, and you can gratefully accept it.

My family and I recently called Uber to get from Manhattan’s financial district to an apartment in the West Village where we were staying. The driver took a while to arrive and appeared flustered, telling us of the traffic and construction that led to the delay. He spoke little English and his GPS was instructing him in a different language. I was in the front seat while my wife and children were in the back, and I was surprised by the route he was taking.

At a certain point it started to look as if we were going toward the entrance to the Holland Tunnel, and I soon realized we were about to head into it with no chance to turn away. I told the driver to illegally pull over to a restricted area so we could get out before we ended up in New Jersey, which would have led to our getting home up to an hour later. He started to pull over when an N.Y.P.D. officer yelled at him to keep driving. The driver turned to me, and I firmly told him to pull over. With me and the officer giving him contradictory instructions, he pulled into the restricted area.

Two cops approached and demanded his license. While one cop was running his license, we explained to the other what had happened. The cop asked, “Are you going to pay the ticket for him?” Luckily, the N.Y.P.D. officers let the driver off with only a warning, but I wondered whether I would have been ethically responsible for paying his fine? I did instruct him to commit an illegal act, but it was because of his mistake and of almost taking me far out of my way. Further, he did not have to commit the illegal maneuver simply because I told him to. Had he gotten a ticket, I would have paid it because I have the means, but would it have been my ethical responsibility? Alex Ruttenberg, New Jersey

My response: Though I’m generally moving toward using standard responses to show that most issues people call ethical can be handled with a few approaches—if only we taught such subjects practically in school instead of abstractly and academically—I’ll indulge in responding that the problem as you described it seems based in the Department of Motor Vehicles giving a license to someone who didn’t deserve it. I only know what you wrote.

You ask what’s ethical. Since everyone has different values, you’ll just get a label that not everyone agrees on. I suggest you want not a label but a practical plan to resolve your situation as best you can by your values and the values of others affected as best you can tell using empathy and projecting possible outcomes.

There is no book in the sky or other measure of absolute right, wrong, good, bad, or evil that 7.6 billion people will agree to. If there were, you would have consulted it, gotten your answer and wouldn’t have had to write here. There isn’t, so you did.

The New York Times response:

It was the driver’s responsibility to understand the GPS; he shouldn’t have offered to drive people if he didn’t. Had you not known about the risks of being sucked into the maw of the Holland Tunnel, he would have been taking you for a long ride through New Jersey. Nevertheless, you might think commanding an immigrant driver into an altercation with a New York police officer risked a situation that could have escalated badly out of control. I would probably have sucked up the unnecessary hour in New Jersey. In the end, though, the decision was his and had he been fined, I don’t believe you would have had a moral obligation to cover his costs.

Still, you could afford a fine far better than he, no doubt, and, for this reason, you say, you would have offered to pay. The fact that you cowed him into a risky situation lends further support, I think, to that decision. Your main duty, though, was to indicate on the app that you had a bad experience or, at the very least, not to pretend that you had a good one. Your driver sounds as though he wasn’t up to the job. It’s a public service to let others know that.

Should you ever warn a friend about someone’s possible actions based on the reports of several trustworthy people?

A person I know (Woman X) is said to befriend people, only to sabotage them later through their professional and social circles or otherwise turn on them. This was reported to me by four different people who had contact with her.

Woman X took an interest in my friend. My friend is a lovely person, who seems overly trusting and is struggling financially. Given that Woman X is said to be drawn to people who seem vulnerable, I’m concerned.

On the other hand, even if what people say about Woman X is true, it doesn’t mean she’s not entitled to friendship. But I know from experience that there are just certain people who wreak havoc on our lives. When I was warned about Woman X, I felt that I’d dodged a bullet. Had I liked her, though, I might feel differently. My instinct says to let adults be adults, but I would feel bad if something happened. Name Withheld

My response: “What should I do?” … Asking what you should do makes sense for children asking their parents. For an adult, it looks like asking someone else to take responsibility, which I call juvenile. Asking for options or views you might have missed makes sense, but you didn’t ask that.

You’re assuming many things about Woman X and your friend without talking to them about it. I would involve them in the process. Why not talk to Woman X about her reputation? If you don’t know how, you’re asking how to lead people, meaning you want to improve your leadership.

Nearly every resource I’ve seen on leadership is leadership appreciation—that is, books on principles and such that help you appreciate others’ leadership but not to lead. To learn to lead you have to practice, starting with basics.

To answer your question on how to lead people, I recommend my book, Leadership Step by Step, which gives you exercises to practice the skills of leadership, not just to appreciate others’ practice. You have to do the work of the exercises, not just passively read it, but what expressive or performance-based practice can you learn without work?

I’m not just plugging my book. I wrote it because nothing existed to give you experience and skills, not just appreciation.

Unit 4 covers what you want, though I’d start at the beginning and do the exercises in order.

The New York Times response:

Protecting vulnerable people is an honorable aim, and telling your friend what you know might help do that. (You don’t sound vulnerable; even you profited, you suggest, from such a warning.) It’s true that if you were wrong you might have deprived Woman X of a relationship. But given the evidence you have, you have reason to suspect that it might turn out badly for your friend. So tell her. Because she is your friend, she’s the one to whom your loyalty is owed. Suppose that she was later victimized and came to know that you had contemplated warning her but didn’t. How persuasive would she find your rationale?

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