Live kidney donation involves a delicate balance between saving the most lives possible and maintaining a transplant system that is fair to the many thousands of patients on the transplant waiting list. Federal law and regulations require that kidney allocation be equitable, but the pressure to save patients subject to ever-lengthening waiting times for a transplant has been swinging the balance toward optimizing utility at the expense of justice.This article traces the progression of innovations created to make optimum use of a patient's own live donors. It starts with the simplest – direct donation by family members – and ends with voucher donations, a very recent and unique innovation because the donor can donate 20 or more years before the intended recipient is expected to need a kidney. In return for the donation, the intended recipient receives a voucher that can be redeemed for a live kidney when it is needed. Other innovations that are discussed include kidney exchanges and list paired donation, which are used to facilitate donor swaps when donor/recipient pairs have incompatible blood types.The discussion of each new innovation shows how the equity issues build on each other and how, with each new innovation, it becomes progressively harder to find an acceptable balance between utility and justice. The article culminates with an analysis of two recent allocation methods that have the potential to save many additional lives, but also affirmatively harm some patients on the deceased donor waiting list by increasing their waiting time for a life-saving kidney. The article concludes that saving additional lives does not justify harming patients on the waiting list unless that harm can be minimized. It also proposes solutions to minimize the harm so these new innovations can equitably perform their intended function of stimulating additional transplants and extending the lives of many transplant patients.

中文翻译：

---

交换、连锁和优惠券，哦，天哪！：评估拯救更多生命如何影响活体肾脏的公平分配

活体肾脏捐赠需要在挽救尽可能多的生命和维持对移植等待名单上成千上万的患者公平的移植系统之间取得微妙的平衡。联邦法律和法规要求肾脏分配是公平的，但拯救遭受不断延长的移植等待时间的患者的压力一直在以牺牲正义为代价来优化效用。本文追溯了创造的创新进展充分利用患者自己的活体供体。它从最简单的家庭成员直接捐赠开始，以代金券捐赠结束，这是一项非常近期且独特的创新，因为捐赠者可以在预期接受者需要肾脏之前 20 年或更长时间捐赠。作为捐赠的回报，预期的接受者会收到一张代金券，可以在需要时兑换活肾。讨论的其他创新包括肾脏交换和列表配对捐赠，当供体/受者血型不相容时，它们用于促进供体交换。对每项新创新的讨论显示了公平问题如何相互建立，以及如何建立新的创新，越来越难以在效用和正义之间找到可接受的平衡。文章最后分析了两种最近的分配方法，这些方法有可能挽救许多额外的生命，但也肯定会通过增加等待挽救生命的肾脏的时间来伤害已故捐赠者等待名单上的一些患者。文章得出结论，除非可以将伤害降至最低，否则挽救更多生命并不能证明伤害等待名单上的患者是正当的。它还提出了将伤害降至最低的解决方案，以便这些新的创新能够公平地发挥其预期功能，即刺激更多的移植并延长许多移植患者的生命。