No Easy Answers in Bioethics Podcast

Why I Donated a Kidney to a Stranger: Fleck and Ward – Episode 14

April 29, 2019 Leonard Fleck photoArthur Ward photo

According to recent data from Donate Life America, more than 110,000 people are waiting for lifesaving organ transplants; 80% of those patients are waiting for a kidney. In this episode, Center Acting Director and Professor Dr. Leonard Fleck is joined by Dr. Arthur Ward of Michigan State University’s Lyman Briggs College. Dr. Ward, a philosopher and bioethicist, shares his recent experience of anonymously donating a kidney to a stranger. He discusses how and why he made the decision to donate, and explains why he thinks more people should consider making the same choice to help others.

Listen now on H-Net

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

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Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. This episode features Center for Ethics Acting Director and Professor Dr. Leonard Fleck, and Dr. Arthur Ward, who is a teaching professor of History, Philosophy, and Sociology of Science in Lyman Briggs College here at MSU. Together they have a conversation about Dr. Ward’s recent experience of being a non-directed kidney donor – that is, anonymously donating a kidney to a stranger. As a philosopher and bioethicist, Dr. Ward shares how and why he made the decision to donate, and explains why he thinks more people should consider making the same choice to help others.

Leonard Fleck: Hello everyone, this is Leonard Fleck. I am a professor of philosophy and medical ethics and the Center for Ethics in the College of Human Medicine at Michigan State University. And our guest today is Dr. Arthur Ward, who is a faculty member in Lyman Briggs and who is teaching bioethics. What we're going to be talking with Dr. Ward about is the fact that he himself decided to donate a kidney to a stranger. This is something very unusual in many respects, most of us I think are probably, would not be terribly comfortable with the idea of donating one of our kidneys to a stranger. But nevertheless this is seen as something quite valuable, and so we're going to talk a little bit about how he made this particular choice, and what some of the consequences may have been, and so on. So, Art, let's start with this question-

Arthur Ward: Sure.

LF: As I've already indicated, most people I think would struggle with the idea of wanting, of donating a kidney to a relative, much less a stranger. And, so, how did you manage to do that?

AW: I think there are a few ways that I could answer the question. Retroactively it's hard to sort of analyze one's own motives after the fact, and so the short answer is that I was convinced by an article that I read. But, I know, and, you know, most people realize that truly being convinced by something that you read is pretty rare. And so I think a more, a more nuanced answer is called for. Really I think what, what I need to be able to, to explain is why I was in a position to be convinced by this article. And there I think the core, as I consider it now, the core element there was that previously—and I think this is probably the case with, with most people—it didn't seem like a realistic thing to do. It seemed like something kind of, you know, pretty unusual, strange, maybe heroic, or maybe irresponsible, but not something that was likely to be a part of my life. And if I could describe the main, the main change that happened. In, you know, in, before when I had read this article, and I've been teaching this article for a while, and after the period of time when I felt persuaded by it, it was that my sense of what was realistic changed. I had a lack of imagination before, in a way. I didn't know anybody that had donated a kidney. Actually, as an aside, it turns out I did know somebody that had donated a kidney, it's just that we never talked about it, and I didn't know that he had donated, he donated to his father. So after a while of reading and teaching this article, something just sort of clicked in me, and what had seemed unrealistic and unimaginable just became imaginable and realistic. And then as soon as that happened I had this deep, deep sense of certainty that it was something that I wanted to do.

LF: So this was something you wanted to do. How carefully did you have to think about this? I mean this is, what we're talking about is something that is major surgery, so I suspect an obvious question that people would ask is what kind of risks did you expose yourself to in undergoing this surgery?

AW: Yeah. And so, I did do quite a bit of research. Although this, this article that I'm referencing, it's a article on Vox dot com written by the journalist Dylan Matthews. So he's not a philosopher per se, but he had a philosophical education and he presents the article in a philosophical way. And he talks about some of the, some of the risks. And the, you know, the short answer there is this is a very safe surgery. And so I did do some research. I wanted to know, you know, naturally how safe the actual surgery is. You know, how many people are dying on the table. And then secondarily, what effects does this have later in one's life.

LF: Mm-hmm.

AW: And what I found, through some of my own research and through some of the education that the transplant center provided, is that the surgery itself is extremely safe. I got the surgery at University of Michigan. They do many of these per week. Not altruistic donations, but kidney donations. So they're doing multiple transplants per week and they've done so for decades, and they've never lost anybody. The numbers are about, the mortality for donor nephrectomy, which is what the surgery is called, is about, the mortality is 3 in 10,000. That's around the same numbers as a cesarean section. So when I'm sort of conceptualizing it in my head, and when I’m also explaining it to other people, I can say something like, you know, you know lots of people that have had a cesarean section, do you know anyone that's died from a cesarean section? And hardly, you know, nobody I know has answered yes to that question, although obviously people do occasionally have risks with c-section. So putting, putting it that way, it seemed like, look this is actually akin to a very common operation that lots of people have had, and not very risky at all. Long term, it does elevate one's lifetime risk of end-stage kidney disease, but the elevation is very, very small. In the general population, and I think it's important to note here that the relevant contrast group for donors is the healthy general population. Because on average, donors are unsurprisingly much healthier than the regular population, but it would be, it would be misleading to say like, oh, donors are healthier than the regular population, this could actually be good for you! Well, not quite, because only healthy people make it through the screening process, right. But among the, the healthy population, I think the risk of develop, for a normal healthy person developing end-stage can in disease is .00-something percent, so it's actually pretty rare. And, I probably elevated my risks by a factor of 5 or maybe even a factor of 10. So instead of .00-something risk it's .0-something risk. So, I felt okay with that. The causes of end-stage renal disease in donors are the same causes in the regular population, which is basically diabetes in most cases. So post-surgery, really the only firm advice I have, the only guidance they gave me is, you know, hey, if you can avoid it don't get obese, don't get diabetes, and then you'll be fine.

LF: Now, I guess one reason, one of the things we want to talk about as part of your motivation for wanting to donate a kidney is the need for kidney transplantation. And I can imagine somebody saying to you, look, folks who end up in end-stage, with end-stage renal disease, they have the option of dialysis. So why not just let 'em stick with dialysis and not take that risk for yourself?

AW: Yeah, that's a good question, and I think that was, you know, as you say, the quality of life of people living with end-stage renal disease was a big factor in my decision. This is something that I thought really had a chance of helping not just someone but many people, and I will probably talk about kidney chains later. But it's very difficult to live on dialysis. Yes the service exists, and you can live for many years on dialysis, but the quality of life is typically pretty low. Someone who's getting dialysis is probably having to go into the clinic multiple times per week and being hooked up to a machine for many, many hours at a time, multiple times per week. So there's a, just a pragmatic concern that it's going to be harder to hold down a full-time job when you're getting dialysis regularly. On top of that, they feel bad. On a daily basis for the, you know, most of the time that they're on dialysis they feel sick, and they feel weak. And there's quite a lot of suffering there. And there's quite a lot of people on dialysis, and there's also a time horizon there. You can only really be on dialysis for so long before it's going to stop being effective. And it's amazing from a biological point of view that kidneys are so functionally miraculous that we can't replicate their functionality even with our advanced technology in a big machine. It still does a very poor job. It's not as good as, you know, one lousy kidney. So, there are well-known statistics about people on the waitlist-

LF: Mm-hmm.

AW: -for kidneys. You know, 120,000 people waiting for a kidney. We know that about 5,000 to 7,000 of them are going to die each year because there aren't enough kidneys to go around. And of course, as I tell students, there are enough kidneys, they're just in us. Right? It's, they're scarce, but they're not really scarce. We have lots of kidneys around, they’re just in the wrong place. And considering the very low risks to myself, I thought, oh, this is this is something that I'd really like to do to help people.

LF: Now, you do have a marital partner, and so this is somebody that you had to persuade that this was a okay thing to do? Did you, did she have any concerns about your deciding to do this, and how did you address those concerns?

AW: Yeah, I thought about how to pose this to my family very carefully. I got this idea over the summer, last summer, and I sat on it for quite some time not really telling anybody. And I thought it would be, it would be unfair, maybe bullying, maybe scary, if I just posed this to, you know, my family. Saying, like, I got this great idea, what do you think? So instead what I thought is I would kind of ask for permission to look into it more. I wanted to tread lightly, because it is a big deal, right? You know, I have kids, and, you know, I co-parent, and what happens to my body is really not just my business. It's the business of the people that love me. So I asked for permission to look into it, and it took her a little bit by surprise, but she said okay. And I sent her the article that had persuaded me, right. So I said, here, read this. It comes with a little video, actually, so I'd encourage people to look at this Vox article by Dylan Matthews and watch the video at the beginning. Because it made it very salient, what this experience would be like to actually see it in video form. And so, she thought about it, she read the article, we let some time go by, and then she said, okay I understand your thought process, yes you can look into it. So she didn't quite give me permission immediately either. We both pretended like this was going to be a slower process, when I think she saw that I had kind of made up my mind and I was, I was asking for her consent.

LF: Yeah.

AW: But it, but I knew it would take a little while. I don't think it surprised her. Really in one sense that this is kind of something that people could see me doing.

LF: Mm-hmm.

AW: I'm a philosopher and a bioethicist, and I think people who know me know that there are some ideas that have haunted me for a very long time, as all philosophers should be haunted by ideas. And I had written a, as an undergraduate I'd written a senior thesis on Peter Singer's argument for altruism. And, and I have been haunted by that for decades. Thinking that maybe, maybe I should be doing more to help people. I'm not sure if one is obliged to do something drastic, but I had always felt like if I had the opportunity to, to really do something big and remarkable, that maybe I'd take it. And this was the thing.

LF: Now, Peter Singer, if I'm recalling correctly. Correct me if I got this wrong. He, the sort of example he gives of a kind of altruism I guess, is you're walking along the beach, and you see the little kid out in the water, and he's obviously having trouble swimming, and he could drowned. And you're in your Sunday’s best, and the and the thought occurs to you, I don't know that I should try to save that kid, I'm in my Sunday's best. And Singer's argument is, no, you have to do that. There's no danger to you as a practical matter. The water might be only 4 or 5 feet deep, so even if you weren't a great swimmer you wouldn't really have to swim. But the point, at least as I take it, the point of saving a drowning child is that this is an obligation you would have as somebody who just happened to be on the beach at that time, and it's low risk to you and so on. Is it an obligation that anybody has to donate a kidney if they're healthy, and it's low risk, and so on?

AW: I wrestle with that, and I think very clearly that was, that question posed internally to myself was something that I wrestled with. I don't want to tell people that it's an obligation to them. Partly for strategic reasons. That puts people off. And, so, in so far as I, you know, think of myself now partly as a communicator who, you know, would like to see some other people donate. It doesn't seem like the right strategy to tell people, like, you're a moral monster if you don't do this. And I think that is certainly too strong. You know, you're entitled to your bodily autonomy, you don't have to give up one of your organs for somebody else. You know, it might be nice if you do, but you certainly, you don't have to. You're not, you're not a moral monster if you fail to do so. Nevertheless, Singer's argument and his logic, as I said before, haunts me. And I like it to haunt others as well, because when you juxtapose this, this scenario that he gives with a child drowning in the pond, and as he says in this very famous article of his, "Fame and Affluence and Morality," he says, look this is kind of a simple argument. You know, premise one is that, you know, certain qualities of life that involve a lot of suffering are bad, whether it's famine, or drowning in a pond, or living on dialysis and dying from end-stage kidney disease. These things are bad, that's premise one. And premise two is if you have the power to prevent something really bad from happening, without sacrificing much yourself, you should do it. And then the conclusion is sort of put to the reader, and the thinker, like, shouldn't you be doing something more than you're doing to help people who are in a really bad condition? And when people are confronted with the pond scenario, almost everybody is willing to say, yeah, you ought to help that kid, Why? You don't have to sacrifice much. But what if you really like those shoes? Well still, you should help them. And Singer's agenda in that article is to juxtapose that with, you know, a child suffering in Africa from, from famine, from malnutrition. And he thinks, his argument in that article is your obligation to the distant child is equally strong as your obligation to the nearby child. There's a whole lot of philosophy that, you know, one can get into with that, and I'm not, you know, right now going to say that that's necessarily the right answer. But, when people see that contrast, and then you, you consider, like, well could it be that distance alone is what's lessening my moral obligation? Like that would be weird, is morality like magnetism, like the further away you get from somebody the, you know, the less your obligations are? That, that can't be right. And when you try and reason through, like what is the difference between this child or this, you know, this suffering person that's right front of me who I know, and somebody who I don't know as well or who might be more distant, that ought to haunt us. And in certain circumstances if somebody feels like, well, you know, this really wouldn't be a big sacrifice, I think people ought to consider doing it. And in my particular case, and I try and express this to people too, I'm very privileged. I have a job that would allow me to take a few weeks off without it being a big deal. I have support structure at home. I'm in very excellent physical health. And I happen to not really have any big phobias about doctors or hospitals. So it wasn't as big of a sacrifice for me as it would be for some people, right.

LF: Mm-hmm.

AW: If you're petrified of doctors, well this is going to be a bigger deal. If you're going to lose your job, then that's a really big deal. If you're not in great health then fine, don't do it. But I was kind of in the perfect nexus of somebody, like if, if anybody is going to be in a really good position to donate, it was me. And I thought that this is a really good opportunity for me to fulfill something that I've always wondered whether it was an obligation, but it certainly was something that, it made me happy to think that I'd be able to do this for somebody.

LF: Now of course, like you I'm a philosopher, which means that every now and then I have to play the role of the devil's advocate.

AW: Perfect.

LF: And so in this case, what I can imagine somebody saying to you is, if I were walking along that beach and there was that little kid out there, you know 5 years old, 6 years old, very immature and kind of silly and stupid for getting out in the water where he can't swim, I would still feel obligated to save him, no question about it. But the people you're talking about, as you yourself said, they have their kidney failure because of diabetes. That means that they weren't eating the right kind of food, and they weren't exercising, and they weren't paying attention to their own health. They didn't take responsibility for their health, so why should I have to take responsibility for them?

AW: Yeah, and I think that's a totally appropriate sort of consideration to look into. So the first thing to say is that, you know, while most people who are suffering from kidney disease and waiting for a kidney do have diabetes, there are other conditions that people are not responsible for—Lupus is one, and there a variety of others. So it's not always the case that someone has diabetes. And of course if somebody has diabetes, it's not always the case that they've been responsible for being in that condition. And as someone who, you know, thinks about bioethics and teaches about bioethics a lot, I think, you know, really the right approach to take when considering policy, when considering giving care to people, is to shield oneself or to mask off the sense that somebody might be responsible for their bad health. Ideally we want to just deliver health care. Now think about a doctor, right. We don't want doctors second-guessing the, the motivation of their patients or the responsibility of their patients for how they got there. We want doctors to just give the best care to the people that are in front of them. And I felt like that was probably the right stance for me to take as well. For people I know, right, suppose I know somebody who has diabetes and needs a kidney. Even if I think that, like, well, you know, they could have taken better care themselves. They could've, you know, drank less soda. I would be thrilled if somebody donated to them and they were able to extend their life by 10 to 15 years, which is the norm. And so when you consider somebody imaginatively, right, if you consider somebody you know. Even if you think that, well maybe they were partly responsible, as we are mostly, most of us always partly responsible for our health—we could all be eating better. It would still be really, really thrilling and heartwarming if our loved one was able to extend their life through a donation. So I thought, you know, despite the possibility that I could be saving somebody who had been previously irresponsible, the more that you read personal stories about people who need kidneys, they're really heart-wrenching. And it's actually pretty rare to come across a case of somebody who's waiting for a kidney and to, and to be so cold-hearted as to think, like, well they don't even deserve it. I think that's pretty unusual.

LF: One of the phrases you used earlier by way of characterizing how this process worked, in your case and a number of other cases, you talked about the "daisy chain." And I'm guessing that a lot of our listeners may not have a sense of exactly what that means. Can you explain what that means?

AW: Yeah. And this is important because this was a really big factor in my decision to do this. Because not only does it turn out that I can benefit somebody, and I can benefit somebody pretty tangibly. Chances are if an altruistic donor, they call it a non-directed donor, where there's no particular person you want to donate to. One non-directed donor can effectively improve or save many lives. And this is a really exciting thing for, for philosophers, and it actually comes from economics. So somebody, somebody named Al Roth won a Nobel Prize in Economics for inventing this idea of a kidney chain. And so the way it works is, you know, if you needed a kidney, and a loved one of yours was willing to donate, they may or may not be a match. So what you might be able to do is that the two of you as a pair could get paired up with two other people who also weren't a match. And maybe you could crisscross, right. Like maybe the other person's loved one could donate to you, and your loved one could donate to the other. And so that happens sometimes, that's called paired donation. But because the HLA blood types and all of the immunotypes don't always work out that a pair can match with a pair, there are a lot of people waiting. And so if you have somebody like me who is an undirected donor and was just willing to donate anybody, what you do is I donate to somebody, and then their loved one essentially now they're the undirected donor, and they can donate to anybody. And that person has a loved one, who then becomes an undirected donor, and they can donate to anybody. And so my transplant, my donation, can result in several transplants in a row by linking up and sort of connecting the dots and closing the circle that had been open-ended of a bunch of paired donations. The longest chains have been in the thirties.

LF: Wow.

AW: My chain was, so far that I know of, three people. So the morning that I donated, which was about seven weeks ago, three transplants happened simultaneously. All in the same hospital. And I don't know any of them, and they don't know me. It was all anonymous. So my chain was three, but it may be longer in the future, right. So I was told, after a little delicate inquiring, I was told that the potential donor at the end of the chain wasn't in the right health to donate right away, but when they recover from—they might have had a, they might have just had a virus. You have to be very, very healthy, even on the day of donation. If you have a virus, it's not a good time to do surgery. Because the recipient is immunosuppressed.

LF: Right.

AW: So in my heart of hearts, I'd like to think that maybe this chain can get even longer. Maybe that last person yet will donate in the future. But I'm on a little, I don't want to seem pushy. So I might wait a little bit to ask the transplant center if the chain ended up being longer.

LF: Do they have to worry about somebody kind of at the last minute in the chain changing their mind? And does that disrupt the whole chain then?

AW: It would disrupt the whole chain. What I've been told is it's very rare for that to happen. There's nothing binding someone to this decision. We want, we want this to be all very voluntary, right. We wouldn't be in favor of some informed consent document where you bind your, your future self to the irreversible promise of donating. So they're very clear, they were clear with me and I'm sure they're clear with everybody, that you can back out at any minute. Five minutes before surgery when they're wheeling you down the hall, you can back out and that's okay. And they claim they're not going to be pushy about it. So someone could be involved in this paired program and, you know, their loved one could, could get the good, their loved one could get the transplant, and then it is possible that they could shirk their own promise, shirk their own responsibility. But I'm told that hardly ever happens. Almost everybody follows through.

LF: I think we have to stop there. Dr. Ward, thank you for joining us in this conversation.

AW: Thank you very much.

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at bioethics.msu.edu for full episode transcripts and other resources related to this episode. A special thank you to H-Net: Humanities and Social Sciences Online for hosting this series. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel in the Center for Ethics. Music is by Antony Raijekov via Free Music Archive.