Ethical Issues with Selection Criteria with Kidney Transplant in the United States

Chronic kidney disease (CKD) is associated with other ailments, such as cardiovascular disease and high blood pressure. According to the Center for Disease Control and Prevention [CDC] (2021), about 37 million people in the U.S. are diagnosed with chronic kidney disease, which translates to 15 percent of adults. Moreover, adults above the age of 65 are more likely to have chronic kidney disease than their younger counterparts. CKD is more likely to cause death if it goes undetected. However, CKD is medically treated using various medical procedures. A kidney transplant is a medical procedure used to address kidney failure or end-stage kidney disease (ESKD) (CDC, 2021). For instance, more than 125,000 people in the U.S. suffered from ESKD in 2016. Additionally, more than 726,000 people were subjected to dialysis and kidney transplant. A kidney transplant is a medical procedure that involves a kidney recipient, a kidney donor, and a medical care institution. Both the kidney recipient and donor have to be subjected to a comprehensive selection criterion to decide their eligibility for a kidney transplant. However, the selection process is characterized by various ethical issues. This paper will assess ethical issues associated with the selection criteria for a kidney transplant.

Identified Issues and Ethical Concerns Associated with the Selection Criteria in Kidney Transplant

Physiological assessment is an imperative exercise in determining the physical fitness of a kidney transplant patient. This selection criterion is used to identify conditions that might exclude a kidney patient from accessing a kidney transplant procedure. The Body Mass Index (BMI) is one of the physical assessments determined to decide whether a kidney transplant patient is eligible for the medical procedure (Ates & Cebeci, 2018). The BMI is used to determine if a patient has an ideal weight, overweight, or obese. Patients with a BMI greater than 40 are classified as obese and are not eligible to undergo a kidney transplant procedure. The majority of people in the United States are classified as being overweight and obese. For example, approximately 39.8 percent and 31.8 percent of adults in the U.S. are obese and overweight, respectively (Fryar, Carroll, & Ogden, 2018). Thus, using the BMI as a determinant in deciding the kidney transplant operation presents ethical issues.

The prevalence of chronic ailment in the United States exerts pressure on the healthcare system. Some of the common chronic diseases include diabetes, cancer, acquired immunodeficiency syndrome (AIDS), and coronary artery diseases. These illnesses affect an individual’s physiological and psychosocial wellbeing (Naicker, 2020). Their nature to recur and become untreatable undermines kidney transplant patients during the selection period. For example, patients with cancer awaiting to receive a kidney transplant from a donor might be less prioritized over patients with no history of chronic diseases. Thus, the selection criterion based on recurrent chronic disease poses ethical concerns.

Evaluation of kidney transplant patients based on psychosocial selection criteria is a significant process in the renal transplant program. Organ transplant is an important procedure for both the donor and the recipient. The kidney transplant program relies on a comprehensive evaluation of patients and donors to determine the safest and best plan to offer medical assistance in the healthcare system. The psychosocial selection criteria focus on the mental and social health of the patients, which should inform the medical practitioners on decision-making. The patient’s psychosocial evaluation should be performed by a qualified mental health officer.

Health insurance coverage is essential in safeguarding the social and economic domains of patients. The U.S. government encourages its people to have a health cover that will cater to their medical expenses. In 2019, ninety-two percent of the public in the United States had subscribed to health insurance coverage. Health insurance coverage is one of the selection criteria evaluated to decide the kidney transplant procedure. Medical practitioners and institutions affirm that lack of health care coverage by an individual might result in the high cost of the operation on the patient, and post-renal transplant care on either the recipient or donor (McCormick, Held, Chertow, Peters, & Roberts, 2021). Different medical institutions use this criterion to exclude patients that lack health insurance coverage.

Impacts of the Issues

Renal transplant patients, classified as obese, are more likely to be less prioritized on the transplant waiting list. Ates and Cebesi (2018) found that 5.6 percent of renal transplant candidates were unable to access the medical operation after they were classified as inactive because of their BMI. The waiting time for a kidney transplant might take up to 5 years. During this period, kidney transplant patients might undergo physiological changes that influence their eligibility and priority. Thus, the use of BMI as a selection criterion among kidney transplant patients is characterized by ethical issues. Medical practitioners posit that obese patients are more likely to experience prolonged recovery time after the transplant operation. Obese patients might receive weight loss therapy to lower their BMI. Weight loss therapy involves a series of activities, such as physical activities, caloric restriction, and bariatric surgery (Urbanski, Inaganti, Agu, Sarwer, & Gardiner, 2020). The use of BMI as a predeterminant in accessing kidney transplant shows ethical dilemma to patients that are obese and need medical attention.

Ethical issues concerned with a recurrent chronic ailment as a selection criterion for kidney transplant patients include fairness and equity. Fairness and equity are significant concepts in kidney transplantation between recipients, donors, and the medical care provider. However, during the selection process in determining the most eligible recipient to undergo a kidney transplant, patients with the chronic ailment are least considered. For example, three kidney recipients with different medical conditions, such as AIDS, diabetes, and obesity might be ranked differently based on their chances to survive. However, all these patients have a right to medical care attention (Naicker, 2020). The ethical concern of valuing kidney transplant patients based on other underlying conditions denies them the right to fair and equitable treatment. Thus, the selection criteria used to decide which patients should be prioritized undermines the achievement of universal healthcare for all.

Psychosocial selection criteria are characterized by ethical issues as described by Engel and Kuntz (2021). Kidney transplant programs are lenient about the severe mental retardation and current affective disorder. Mental retardation is considered irrelevant in the psychosocial selection criteria. For example, the use of social workers is mainly relied on in assessing patients in pre-renal transplants compared to the use of psychiatrists and psychologists (Engel & Kuntz, 2021). Social workers may not be qualified, mental health professionals. Therefore, the use of less qualified personnel in the psychosocial selection criteria is an ethical issue affecting the kidney transplant program in the United States.

The use of health insurance coverage as a selection criterion is selective and raises ethical issues. Patients that lack health care coverage are discriminated against based on their financial status to access medical attention. Moreover, a kidney donation from living donors is a step to save the lives of recipients that are in dire need of a kidney transplant. Therefore, denying kidney donors and recipients the opportunity to access medical care for renal transplants is unethical. The government should encourage living donors to donate a kidney for transplant by offering medical incentives. For example, McCormick et al. (2021) suggested that the Health Resources and Services Administration (HRSA) should provide insurance policy, and give tax credits to kidney donors as some of the disincentives in addressing disparities in accessing medical care. Therefore, kidney donors should be subjected to fair treatment by being offered financial assistance, in case of death or disability associated with a kidney transplant.

Ethical Theories and their Application in Addressing the Ethical Concerns

Medical practitioners have a responsibility to ensure arising ethical issues in selecting criteria for a kidney transplant patient are addressed. Clinicians are guided by a set of principles defined in different ethical theories (Amer, 2019). Moreover, Amer (2019) posits that ethical theories guide medical practitioners to assess right from wrong. In the medical field, common types of theories applied include principlism, utilitarianism, and duty-based (Amer, 2019). These theories exhibit varying results when applied in addressing ethical issues in medical assessment procedures. Therefore, in addressing ethical issues related to psychosocial, lack of a health insurance cover, physiology, and recurrent chronic ailment, two ethical theories are going to be applied. Amer (2019) suggests the application of consequence-based (utilitarian) and duty-based (deontology) theories. Discrimination and inequity are some of the major ethical issues affecting kidney recipients and donors during a kidney transplant procedure.

Utilitarianism and deontology theories encourage happiness and respect for patients, respectively. The utilitarian approach encourages medical practitioners to make the right choices and actions to ensure happiness among patients and the whole community (Amer, 2019). Duty-based theory encourages medics to inform their patients with utmost honesty to prevent harm. The selection criteria for a kidney transplant among various patients might show unfairness and discrimination. Its outcomes affect the patient, their family, and the whole community. However, clinicians should make decisions based on utilitarianism and deontology theories. Everyone has a right to fair treatment regardless of their social, economic, and physiological status.

In conclusion, a kidney transplant is an important medical procedure that aims to save lives. It allows patients suffering from renal-related ailments to live a normal life without fear and depression. Medical care ought to be universal, fair, and equitable across different races and gender. The use of selection criteria to weigh which kidney transplant patient must wait longer to receive treatment is unethical. The federal government and other medical stakeholders should collaborate to develop a sustainable criterion that addresses inequities among patients. Moreover, medical care providers should develop a selection criterion that does not compromise the wellbeing of kidney transplant patients but encourages fair access to medical care attention. The focus on predeterminants, such as BMI, other chronic diseases, lack of health insurance cover, and psychosocial should only be used to guide medics in determining the most appropriate medical option. Therefore, the public should be educated on the importance of a healthy lifestyle to prevent CDK at an early stage.


Amer, A. B. (2019). Understanding the ethical theories in medical practice. Open Journal of Nursing, 09(02), 188–193.

Ateş, D., & Cebeci, F. (2018). Obesity in the kidney transplant process. Experimental and Clinical Transplantation: Official Journal of the Middle East Society for Organ Transplantation, 16 Suppl 1(Suppl 1), 61–63.

Centre for Disease Control and Prevention. (2021, February 25). Chronic kidney disease in the United States, 2019. Centre for Disease Control and Prevention.

Engel, K. L., & Kuntz, K. K. (2021). Psychosocial evaluation in kidney transplantation. In Psychosocial Aspects of Chronic Kidney Disease (pp. 357–374). Elsevier.

Fryar, C. D., Carroll, M. D., & Ogden, C. (2018). Prevalence of overweight, obesity, and severe obesity among adults age 20 and over: United States, 1960-1962 through 2015-2016.

McCormick, F., Held, P. J., Chertow, G. M., Peters, T. G., & Roberts, J. P. (2020). Reducing the shortage of transplant kidneys: A lost opportunity for the US Health Resources and Services Administration (HRSA). American Journal of Kidney Diseases: The Official Journal of the National Kidney Foundation. Advance online publication.

Naicker, S. (2020). Hiv/aids and chronic kidney disease. Clinical Nephrology, 93(1), 87–93.

Urbanski, M., Inaganti, S., Agu, C., Sarwer, D., & Gardiner, H. (2020). Body mass index as a patient selection criterion for kidney transplant. CommonHealth, 1(1), 1–11.

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