cessful transfer of tissue and organs from one person to another has become one of the great

achievements of modern medical science. The practice of living organ donation and transplantation
gives rise to many serious medical, psychological, emotional, social, legal, and ethical issues. There
are risks and benefits both to the donor and the recipient. Body parts become available in a worldwide market, and they become a commodity to be exchanged for money. As a result, this practice may
leave the donors prone to exploitation by recipients, middlemen at the trade, and sometimes even by
personnel at the hospital. There are many religious and secular ethical approaches addressing this
question. In this paper we apply and evaluate the ethical approaches of principlism and the virtue of
charity in living organ donation and transplantation.

1. Principlism in Medical Decision Making: Anglo-American

Tradition
Anglo-American principlism offered, in the twentieth century, the most important contribution for
medical ethics with regard to the ethical debate about living organ donation and transplantation. Both
deontology and utilitarianism have their own merits and demerits and the approaches are entirely
different. In this context, taking the advantage of deontology and utilitarianism together, the AngloAmerican tradition of principlism offers a new ethical approach to medical issues.
The term principlism means "the practice of using 'principles' to replace both moral theory and
particular moral rules and ideals in dealing with the moral problems that arise in medical
practice."1 Tom L. Beauchamp (rule utilitarian) and James Childress (pluralistic deontologist) are the
exponents of Anglo-American principlism. This approach is based on four principles: (1) respect for
autonomy; (2) non-maleficence (primum non nocere, in the first place, do not harm); (3) beneficence,
or doing good (a group of norms for providing benefits and balancing benefits against risks and costs);
and (4) justice (a group of norms for distributing benefits, risks, and costs fairly). The principles of
beneficence and non-maleficence involve an obligation to help others and an obligation not to harm
others.2 The principle of justice involves an obligation to deal fairly with competing claims, 3 whereas the
principle of autonomy or self-determination implies informed consent of the persons involved.
In the following sections, we divide Anglo-American principlism into three parts. In the first part,
we will discuss the four principles. In the second part, we will apply principlism to living organ
donation and transplantation. In the third part, we will give our critical evaluation.

1. 1 The Description of the Four Principles

In this section we describe the four principles of principlism.

1.1.1 The Principle of Respect for Autonomy

Beauchamp and Childress present respect for autonomy in a wider perspective. The concept
"autonomy" is etymologically composed of the Greek words autos (self) and nomos (law or rule). The
Greek word autonoma originally referred to the independence of city-states from outside control and
the freedom to legislate their own laws. 4 The term autonomy generally means "being in a state of selfrule or self-government, i.e., being independent from other nations, states, persons or other living
beings, qua legislation for the direction of one's life." 5 Beauchamp and Childress observe that
autonomy has different meanings like "self-governance, liberty rights, privacy, individual choice,
freedom of the will, causing one's own behavior, and being one's own persons." 6 They further note that
all theories of autonomy considered two norms: "1) Liberty (independence from controlling influences)
and 2) agency (capacity for intentional action)."7
In the opinion of Beauchamp and Childress, the principle of respect for autonomy means the
recognition of the right of other "autonomous" persons to carry out their views and wishes on the
ground of his/her values and beliefs. 8 Beauchamp and Childress also represent the influence of
Immanuel Kant and John Stuart Mill for the interpretation of the respect for autonomy. The main
difference here is that Kant emphasizes freedom of the will whereas Mill stresses freedom of
action.9 Kant's approach is deontological. 10 He argues that with autonomy one directs oneself and
makes "one's own choices" on the basis of moral norms. These moral norms are universal and, at the
same time, "one's own," and they are valid for everyone. 11 Furthermore, Kant states that the "principle
of autonomy" includes "the principle of respect for persons." 12 In addition, Kant observes that
autonomy is the "... practical principle of the will as the supreme condition of the will's conformity with
universal practical reason, namely, the idea of the will of every rational being as a will that legislates
universal law."13
John Stuart Mill's approach is utilitarian. He gives a radical interpretation of autonomy. In his
book On Liberty, he argues that "the principle of utility [is] to permit all citizens to develop their
potential according to their convictions, as long as they do not interfere with a like expression of
freedom of others."14 So, for Mill, autonomy is an essential dimension of a human person. All want to
be authors of their own lives.15 To put it more clearly, the person is free from everything.
Mill's approach takes into account both the non-interference with and an active strengthening of
autonomous expression, whereas Kant holds that "all persons have unconditional worth." What makes
autonomy important for Kant is not primarily that it can form the basis of various rights, but that it is
necessary for any claim to true moral agency. For Mill, autonomy is not valuable in itself because it

directly leads to the production of utility.16 Autonomy is in reference to "the individuality of autonomous
agents."17 Thus, L. Beauchamp and J. Childress incorporate the views of both Kant and Mill for the
principle of respect for autonomy.18 They argue that the principle of autonomy is not illustrated either
as absolute or as too wide.19 However, they are more similar to the Millian concept of autonomy.20

1.1.2 The Principle of Non-Maleficence

The principle of non-maleficence asserts one's obligation not to inflict harm intentionally. This has
been closely related in medical ethics to the maxim primum non nocere: Above all (or first) do no
harm. For Beauchamp and Childress the principle of non-maleficence contains the following rules: "do
not kill, do not cause pain or suffering to others, do not incapacitate others, do not cause offense to
others, do not deprive others of the goods of life." 21 The principle of non-maleficence is supported by
many ethical theories, especially utilitarian and nonutilitarian theories. 22

1.1.3 The Principle of Beneficence

Beneficence is taken from the Latin word bene (well: comes from bonus, good) and facere (to
do).23 The term beneficence has different meanings such as "the doing of good, active promotion of
good, kindness, and charity."24 The principle of beneficence refers to a moral obligation to act for the
benefit of others.25 It is a universal moral obligation in many moral theories and it is widely regarded as
a fundamental moral obligation in health care. Acting so as to benefit oneself may include directing
our natural self-interest to the benefit of others. It obliges one to help others for their own legitimate
interests. In some ethical theories, especially utilitarianism, beneficence (to benefit others) and
benevolence (the "character trait or virtue of being disposed to act for the benefits of others") have
played a central role.26
The principle of beneficence includes two principles, namely, the principle of positive beneficence
and the principle of utility. The principle of positive beneficence demands that physicians should do
good for others, and to do positive benefit for society.27 The principle of utility requires that "in medical
practice and research [] risks of harm must constantly be weighed against possible benefits." 28 This
principle of utility points out that "we also have a moral duty to weigh and balance possible benefits
against possible harms in order to maximize benefits and minimize risks of harm." 29 According to
Beauchamp and Childress, the principle of utility is taken as a norm in medical problems because
there is a kind of balance between benefit and harm in the principle. In brief, there should be a
balance between 'possible beneficial actions' and 'possible harmful actions.' 30

1.1.4 The Principle of Justice

Beauchamp and Childress explain that different terms such as fairness, desert (deserved), and
entitlement (entitled) are used by philosophers to express the concept of justice. 31 On the basis of
these concepts, one can define justice as "fair, equitable, and appropriate treatment in light of what is
due or owed to persons."32 We find the idea of justice in many moral theories, including those of
bioethics.33
Beauchamp and Childress present distributive justice as "fair, equitable, and appropriate
distribution

in

society

determined

by

justified

norms

that

structure

the

terms

of

social

cooperation."34 The scope of distributive justice includes decisions on property, resources, taxation,
privileges, opportunities, public and private institutions such as the government, and the health care
system.35 Scarcity and competition cause several dilemmas in distributive justice. 36
Beauchamp and Childress observe that no single principle of justice can solve these problems. 37 In
order to avoid problems in distributive justice, they propose two principles of justice: the principle of
formal justice and the material principle of justice. The principle of formal justice is called "'formal'
because it states no particular respects in which equals ought to be treated equally and provides no
criteria for determining whether two or more individuals are in fact equals." 38 When material principles
of justice are treated, there should be equal treatment, and they distinguish "the substantive
properties for distribution."39 Some authors formulate valid rules for material principles of distributive
justice. They are: "1) to each person an equal share 2) to each person according to need 3) to each
person according to effort 4) to each person according to contribution 5) to each person according to
merit 6) to each person according to free-market exchange." 40 Beauchamp and Childress comment that
certain theories of justice consider all six norms as logical, whereas other theories include more than
one of these norms only.41
Moreover, several systematic theories have been applied to decide the distribution of goods and
services, especially in the case of health care. They are the following: 1) Utilitarian principles give a
variety of steps for maximizing public utility. 2) Libertarian theories stress "rights to social and
economic liberty." 3) Communitarian theories describe "the principles and practices of justice that
evolve through traditions in a community." 4) Egalitarian theories state "equal access to the goods in
life that every rational person values." 42 Beauchamp and Childress observe that these different theories
of justice attempt either to get "a balance between competing social goals or to eliminate some social
objectives while retaining others."43 They propose both utilitarian and egalitarian concepts of justice as
a help for the allocation of minimum health care.44

1.2 The Application of Principlism to Living Organ Donation and

Transplantation
We have seen the concept of four principles. In this section we apply principlism to living organ
donation and transplantation.

1.2.1 The Application of the Principle of Respect for Autonomy

The concept of autonomy in living organ donation and transplantation can be seen from a
normative (Kantian) and a radical or liberal (Millian) point of view. A normative understanding of
autonomy does not allow living organ donation at the cost of respect to human person. Autonomy
should be considered in the context of the dignity and the vulnerability of the persons, 45 when applied
to living organ donation and transplantation. The respect for the dignity of the human person in organ
donation and transplantation does not favour paid donation since it leads to the degradation of
persons as means. So the principle of dignity requires that organ donation should be on the basis of
"free and generous gift." 46 The concept of dignity also respects the dying person and the potential
organ donor, especially children and physically incapable persons. For example, persons who are in a
"vegetative" state cannot be considered as potential donors. 47 Organ transplantation also highlights the
vulnerability of human beings, especially in the case of body. Organ transplantation "intervenes in the
vulnerability of both the patient and donor." 48
However, a radical interpretation of autonomy allows any kind of living organ donation and
transplantation. The individual has the full right over his/her body if he/she makes a decision without
any force. In this case, it is the freedom of the donor to sell organs and it is also the freedom of the
recipient to buy the organs. In the radical interpretation of autonomy, the donor and the recipient
have full freedom in transplantation. One is not concerned about any fundamental lifestyle or any
religious values. On the contrary, all values are seen from the perspective of personal autonomy of the
individual.49 This is the radical approach of autonomy to living organ donation and transplantation.
Voluntary consent and forced consent are another issue under discussion in living organ donation
and transplantation.50 The voluntary consent of the human subject is essential for living organ
donation. An individual is not obliged to donate his/her organ, even in a situation of grave emergency.
Additionally, individuals must not be forced to donate organs even in a justified emergency.51 This
means that the person involved should have the legal capacity to give consent. One should be so
situated in the condition as to be able to exercise free power of choice. Again, one should be free from
the intervention of any element of force, fraud, deceit, pressure, overreaching or other ulterior form of
constraint or coercion. He/she should be provided with sufficient knowledge and comprehension of the

subject matter involved so as to enable him/her to make an enlightened decision. 52 The consent should
be

"fully

informed and free

of

coercion." 53 To be

precise,

the

donors

should

be

mentally

competent.54 Further, forced voluntarism of consent (coercion) happens when there is some form of
psychological force from outside. This may come from the recipient or from a third person through
some kind of "moral pressure on the potential donor." This force may also be linked with financial
motivation.55 Hence, G. R. Dunstan argues that consent is the main foundation for donation. 56
The principle of autonomy requires that the patient, or the living donor, has genuine consent in
deciding whether to make a donation or not. 57 The general principle that surgery cannot be carried out
without the consent of the person to be operated upon is equally applicable to organ transplantation
as well. The operation to remove the organ from the donor must, therefore, have the donor's consent.
Recipients also should give their consent for the operation. 58 A free, informed consent, especially when
explicitly given, is certainly the best way to express our social solidarity.59
Sometimes it is very difficult to make an assessment of fully informed consent of the potential
donors. For instance, in the case of a liver failure patient, the need for the organ is very acute. This
situation might force the living liver donors to make an immediate decision. 60 More problematic are
decisions made on behalf of minors and incompetents. 61 In such cases, both the principles of respect
for autonomy and justice are involved. For instance, let us consider a possible dilemma within a
family: a child is suffering from a progressive liver or kidney disease and is in need of a transplant and
the only suitable donor is a minor sibling. The parents face legal and moral conflicts of duties. They
have a legal responsibility to protect both children. But a parent cannot exercise authority over a child
when the proposed course of action is not in favour of the child's interests, especially when this child
may face risks relating to the surgical intervention. The main form of appeal in such a case is the
child/donor's psychological interest. One cannot establish a voluntary and free consent in a case where
there is psychological pressure from family members on a particular member to donate his/her
organs. This course of action may involve a potential conflict with the principle of respect for
autonomy, as it appears to be an example of treating children as means. 62 So what we need is, as Paul
Ramsey argues, a "reasonably free and adequately informed consent." 63
Another observation is that autonomy is seen from the realm of social solidarity. For instance, an
incapacitated person is unable to make his/her consent. 64 Nikola Biller-Andorno, George J. Agich, Karen
Doepkens, and Henning Schauenburg observe that the law or ethical theory of autonomy does not
work with the potential living donors like children and persons who are unable to give genuine
consent. In this context, autonomy should be seen from the context of each individual case. The
emotional and relational context of the donor to the recipient will help to make adequate ethical

decisions. In their opinion, this is a comprehensive framework for donors who are unable to give "full
informed consent."65 However, this still seems to be an unresolved problem.
Autonomy is the moral key to living organ donation. Sometimes, autonomy brings about an ethical
dilemma in the realm of living organ donation. If the donor's decisions are not autonomous or selfdetermined, this can lead to treating a person without sufficient respect. Autonomy requires that the
donor must be able to exercise the power of free choice. As we have seen above in the matter of living
organ donation, no physiological benefit is to be expected by the donor. It is clear that the first matter
of critical importance is that the amount of risk, pain, and length of incapacity is communicated to the
donor so that an informed decision can be made. 66 But, at the same time, Thomas A. Shannon notices
the relevance of the principle of autonomy in the case of the shortage of organs for transplantation.
He says that sometimes in our society and in medical practice autonomy proves inadequate to help us
to resolve critical social issues. In order to solve the problem of a shortage of organs (or similar
problems), autonomy should be seen together with the idea of common good. 67 Here organ donation
and transplantation is seen more from the perspective of the freedom of the person within the realm
of solidarity.
As a whole, the ethical debate about the autonomy (right) of the healthy person to donate his/her
organ has both merits and demerits. 68 The respect for autonomy is the main issue in living organ
donation and transplantation.

1.2.2 The Application of the Principle of Non-Maleficence

Our question is, how can we apply the principle of non-maleficence to living organ donation and
transplantation? The fundamental ethical and legal starting point is the common law or principle that
one should not be killed or seriously injured. This is why the donation of a living heart is excluded.
From a legal standpoint, this is not a matter to be settled with reference to an individual's consent.
Since it is a matter of public interest, one cannot consent to certain forms of harm. Even with the
consent of the person concerned, the principle of non-maleficence forbids mutilation. 69 Thus, the main
problem in living organ donation is not 'freedom of choice', even if some kind of force is exercised on
certain occasions. But, there is a risk to the healthy donor. For instance, in the case of a liver
transplant, the estimation of the risks is not clear for the donor.70 This discourages certain types of
living organ donation and transplantation.
However, in certain circumstances harm can be avoided or limited solely by inflicting injury.
Sometimes injury is acceptable in order to avoid a greater harm, 71 which is the justification for modern
medical treatment. Many surgeons regard the removal of a healthy organ, such as a kidney, from an

individual who has given autonomous consent and faces minimum risk, as an ethically acceptable
action. Hence, it is seen that the starting point of an ethical inquiry into living organ donation is the
assessment of harm and risk taking. 72 The autonomous organ donor is one who takes reasonable risks
to save someone else's life. If the supply of cadaveric organs is sufficient, there is no need to engage
in any risk or discomfort involved in living donation. 73 There are no physiological benefits for the donor,
but there are psychological benefits. Living donation, in spite of risk and discomfort, is generally
accepted in the clinical context due to the scarcity of cadaver donors.
Furthermore, Beauchamp and Childress observe that sometimes we have to do harm to the body in
order to prevent harm.74 In relation with this, Irwin Kleinman and Frederick H. Lowy say: "Ethical
dilemmas by their very nature necessitate compromise. Living organ donation compromises the
principle of non-maleficence, since healthy donors are allowed to assume risks." 75 Moreover, they
propose another argument in the form of the following question, viz., which does more harm: "the
operation on the donor or the potential harm resulting from not donating?" 76 In their opinion, living
organ donation makes an ethical compromise when the donor consents to an operation to donate
his/her organs.77
Another observation is that in the case of blood donation, one does not see any harm or risk to the
donor. Hence, it is acceptable according to the principle of non-maleficence. In the case of living organ
donation, it is not the same. For instance, in cornea donation, when the donation decreases the sight
of the donor, it is a "bad means to a good end." 78 But in the case of kidney donation, donation is
morally right. The reason is that even if the donor faces some risk, there is no functional decrease of
the organs.79 In this case, one justifies the principle of non-maleficence with regard to living organ
donation. In the opinion of Mark Siegler, today we can see an equilibrium between harm and benefit in
medicine.80 The harm to the donor and the benefit to the recipient are taken together in living organ
donation and transplantation. So Rosamond Rhodes observes that organ transplantation changes the
traditional notion of doing no harm.81

1.2.3 The Application of the Principle of Beneficence

How can we apply the principle of beneficence to living organ donation and transplantation? In
transplantation we are damaging the donor by the simple fact that we are doing surgery on him/her.
However, the immediate availability of a kidney with the highest possible quality and potential benefit
is clearly in favour of the recipient, though there is some medical harm to the donor.82 Hence, the
question faced by surgeons is whether it is right to remove parts of one person's body to promote the
health and well-being of others. It is ethically acceptable if harm to the self is a side effect. 83

Beneficence is not obligatory in some cases. For instance, the donation of a kidney is good but not
a moral obligation. In some cases it may cause harm to the donor. It is a serious danger for one to
offer both kidneys for transplantation. Beneficence does not include this kind of extreme altruism. One
is not morally bound to do good to other persons in all circumstances. 84
There is another ethical problem that is connected with paid organ donation and beneficence. Even
if the donor promotes good by helping patients who are in a critical stage, paid donation causes a
harm to the donor and to the society. Beneficence does not favour harm to others, but it protects the
rights of others.
Another debate in relation to beneficence is paternalism. 85 There is always a conflict between the
principle of beneficence and the principle of autonomy. In certain medical cases, paternalism makes
the demand that "beneficence should take precedence over autonomy." 86 For Edmund Pellegrino and
David Thomasma, beneficence includes autonomy and paternalism, which could foster good to the
patient.87 According to Carol Gilligan, the notion of beneficence is grounded on the relational dimension
of the self.88 Further, one can see that both paternalism and Mill's harm principle 89 depend on the
principle of beneficence.
Regarding living organ donation and transplantation, donors face unknown risks. Here the ethical
problem is: who should make the decision? The donor or the personnel at the hospitals? In the US,
many transplantation centers prefer a paternalistic decision. They will not allow the donor to seriously
risk his/her life. For instance, when one donor has the problem of "orthostatic proterinuria," 90 the
centers will not allow him/her to donate. 91 There are certain reasons for these types of paternalistic
interventions: 1) The donor has to face risks in a major surgery.92 2) Some physicians allow
paternalistic intervention because they consider the risk of the donor and the benefit of the recipient
within the scope of proportionality.93 3) There may be an obstacle regarding informed consent such as
the external (family) or internal (guilt) coercion. 94
Physicians want to do their best for the donor. However, we can see the eventual conflict between
the physicians and the donor.95 This is very clear in the case of kidney donation. 1) Physicians may not
be in favour of emotionally related and genetically unrelated donor (spouse). 96 2) In certain cases, the
values of the physician and the donor may not go together. Donors want to take risks. The
paternalistic attitude of many transplant centers fails to give proper respect to the donor, especially to
those who are taking serious risks. 97 3) Sometimes transplant centers do not encourage kidney
donation.98 However, in many other cases the transplant team may express very positive attitude to the
donors and the recipients.99

Another problem is that the paternalistic counselors make decisions for their donors. 100 It would be
against informed consent if the decision is made by others instead of the donor.
From a critical point of view, the general understanding of non-maleficence prohibits living organ
donation, especially when there is a high harm to the donor. But, beneficence to the recipient
promotes living organ donation. In this case, there is a contradiction between the principle of nonmaleficence and beneficence. Another observation is that beneficence works more on the level of the
physical well-being of the person, but we lose sight of the psychological and social aspects. The
difficulty with the theoretical approach of beneficence is that it does not have an integrated concept.

1.2.4 The Application of the Principle of Justice

The moral demand for justice has wide implications for living organ donation and transplantation in
the context of a fair distribution of its benefits and harms. This raises the question of how to respect
people's rights, especially the rights of the donors and potential recipients in the context of living
organ donation and transplantation. 101 In other words, how can we justify the risks and the benefits
both of donors and recipients.
In the view of D. Bakker, when looking at the principle of justice in connection with the reception, it
is clear that an individual can avoid being kept on the waiting list by accepting a kidney from a living
related or unrelated donor. Can we say that this is fair? Does this provide equal opportunity for
everyone in need? Of course, we can argue that it is not fair. But, on the other hand, not many
transplant surgeons would put a patient on the waiting list when a living related or living unrelated
donor is ready to donate his/her organs.102
One of the most pressing problems of justice in the medical profession is in allocating organs for
transplant.103 The allocation of human organs and tissues for transplantation consists in the specific
application of ethical norms to its social practice. The main problems of allocation do not usually
concern living donors since most transplanted organs are taken from cadavers. However, questions of
justice arise both about procedures for contributing organs and about procedures of allocating organs
on hand. The questions about procedures for contributing organs are limited to the provision of live
organs for transplant. One is not treated unfairly when his/her own voluntary choices are achieved,
and there is no reason to believe that highly altruistic and compassionate choices cannot be fully
voluntary. The question whether it can be fair to compel persons to donate one of their paired organs
in times of short supply and sudden need is more difficult to address.

In order to clarify distributive justice, let us discuss the age-based allocation in organ donation and
transplantation. For instance, due to their age, many end-stage kidney recipients are not included for
transplantation. Age is one of the important considerations in medicine for choosing recipients for
transplantation. Success of transplantation is higher in younger patients than in older patients.
Sometimes age-based rationing is justified because of scarcity. However, some philosophers justify
arguments in favour of age-based allocation.104 For example, Norman Daniels says that we should make
a "prudential individual decision about the health care from the perspective of an entire lifetime rather
than a particular moment in time."105 According to UNOS, organ allocation is done on the basis of
"priority to urgency of need and then to length of time on the list." 106
There are other issues of injustice in living organ donation and transplantation. In the case of
kidney donation, what should be the criterion to select two potential donors? For example, a woman
needs a kidney for transplantation and there are two possible donors: one is the woman's fourteenyear-old daughter and the other is her thirty five-year-old mentally disabled brother. Many would
choose taking the kidney from the mentally retarded person. This also highlights the issues of justice
in living organ donation and transplantation.
Another ethical problem is equality and social justice in paid donations. Social justice demands
equality in distributing organs and prohibits private sale. The Transplantation Society states that paid
donations for transplantation will increase inequality in health care:

If wealthy individuals from other countries are placed on transplant lists - they compete with local patients for scarce
cadaver kidney - private hospitals in Europe now perform kidney transplants for foreigners who can afford the
substantial fees The unacceptable consequences of this is that kidneys go only to patients who can pay.107
Hence, poor people cannot get organs because they cannot pay.108 And paid donation creates an
opportunity for the rich to exploit the poor.109 Rosamond Rhodes notes that even though poor people
donate their organs and encourage transplantation experimentation, they do not get organs for
transplantation. In his opinion, we should give adequate emphasis to the rights of each
person.110 Transplantation seems to be unattainable by poor people. 111 Again, Arthur L. Caplan and Beth
Virnig observe the injustice that prevails in America: "If you are rich, you can get a transplant; if you
are rich or poor you can donate organs and tissues to be transplanted to others. This situation is not
fair, and the American people know it." 112 The same can be seen in India. Poor people cannot afford
transplantation. Subsequently, they face death. This situation shows the violation of justice. 113 Other

victims of injustice are the poor donors (for example, in India) who are exploited by the middlemen
and professionals.114 Without being given sufficient information about the transplantation, these donors
are exploited; this happens especially in the case of women and children.
Furthermore, there are clear contrasts in the practices of organ donation and transplantation in
different countries like India and North America. In many western countries, organ donation takes
place with a high standard of social and distributive justice. There is health care insurance. But in
India one does not have medical insurance. 115 In this context, T. Koch observes that "the failure to
assure equal access to medical care creates divisions and inequalities denying equality among citizens.
This in turn affects the supply of transplantable contributions integral to the just sharing between
members of a community."116
There are other ethical problems of injustice in the paired indirect kidney exchange programme or
cross over renal transplantation on the basis of ABO-incompatibility and the impact on potential O
recipients. There is some kind of disproportionality to certain group of recipients. Some persons can
benefit while others have to suffer. Certain groups of persons have to wait for a long time, especially
recipients in the O blood group. The reason is that the majority of ABO incompatible "donor-recipient
pairs involve a potential" O blood group receiver. Hence, the waiting time of O recipients is lengthened
by the ABO incompatible indirect exchange programmes. 117 This is an injustice to this vulnerable group.
In short, the principle of justice is very significant in the case of living organ donation and
transplantation. We need an adequate method for assuring justice in cases where donation is made by
the mentally disabled persons, since injustice prevails in this field. Another question is whether society
should concentrate on rescue strategies such as dialysis, kidney transplantation, and artificial heart
transplantation, or whether the society should concentrate on the prevention of disease and disability?
118

Is organ transplantation only for rich people? In this context, what should be the basic norms to

ensure justice? All these questions remind us of the relevance of addressing justice in health care.