Dutch television aired a show on Friday night that purported to be “a reality show featuring three patients competing for a kidney from a terminally ill woman”. Co-blogger Ed Lopez noted the pre-show publicity. Turns out it was an unreality show, a stunt designed to raise awareness of the shortage of kidney donors, with the “donor” being played by an actress (while the “contestants” were played by people who actually do need kidney transplants).

Televising a contest among hard-luck contestants is tacky, of course. (Anybody out there old enough to remember the NBC daytime TV show Queen for a Day?) But the Dutch televisers did have a point: there are indeed three or four people like me, seeking a kidney transplant, for every available cadaveric kidney. Anything that increases in the number of people who sign up to donate at death, or the number of living donors, would help. Barring the elimination of the zero price ceiling on kidneys (payment for organs is illegal in the US), the shortage will continue to be severe. A little publicity, even if tacky, couldn’t hurt and might help bring forth more donors.

Many would-be arbiters of kidney donation, however, are adamantly concerned with "equitably" allocating the supply, even where that would mean a smaller supply. The New York Times reports a comment on the Dutch TV show from an American bioethicist:

It’s not all that different from what’s happening on the Internet, on sites like MatchingDonors.com, where people looking for organs post their pictures and their stories, hoping a potential donor will choose them,” said Jeffrey Kahn, director of the University of Minnesota’s Center for Bioethics. … “I think we’d reject as a matter of morality and equity that the prettiest people, the people with the best story, or the ones who can pay the most, should get access to this very scarce resource,” Mr. Kahn said.

Actually, Mr. Kahn, with all due respect (as Ricky Bobby would say), some of us in need of a kidney would disagree. Allocating kidneys by “morality and equity” criteria presumably means that those in need of a kidney should wait their turn for an organ from a single common pool. This makes sense insofar as transplantable kidneys are supplied to such a pool without restriction by recently deceased donors. But transplantable kidneys may also come from living donors. If we recognize the living donor’s right to his own kidney -- and we should -- then we have to accept the donor’s choice of a recipient even if we don’t like the donor’s criteria.

Consider the case of Lisa Cunningham, who contacted the local newspaper in her search for a kidney donor.

Cunningham's decision to go public triggered a national story when Beth Israel Deaconness Medical Center's transplant director said he would refuse to give Cunningham the potentially life-saving transplant if she found her donor through the media. Citing ethical concerns over donor or patient exploitation and fairness, Dr. Douglas Hanto said he thought it would be best that if an altruistic donor came forward, for that kidney to go to the next person most in need on the waiting list - not Cunningham.

Cunningham died of kidney failure last month after failing to find a donor. Hanto has since reversed his hospital’s policy against directed donations from strangers.

If “equity” criteria were always to trump the donor’s wishes, a donor would not be allowed to direct his donation even to a blood relative. Surely Kahn, Hanto, et al. realize that most donors who come forward to donate do so to donate to a relative. They would not donate if their kidneys would instead go to anonymous recipients on the waiting list. Surely the same applies to potential donors who may have been moved by Lisa Cunningham’s story: some who would donate to her would not come forward to donate to an anonymous recipient.

This is why there is, in fact, no waiting list for live donations, only for cadaveric organs, as Sally Satel noted while rebutting Hanto in an op-ed.

For the sake of those who need a kidney, the decision on who should get access to the “very scarce resource” of a living-donor kidney should therefore be entirely up to the donor, even if the donor wants to choose on the basis of the recipient’s prettiness, narrative excellence, or willingness to pay. If we leave it up to a committee of well-meaning bioethicists we will have fewer donors and we will therefore lose lives that could have been saved.