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Special Section: Open Forum
We thank Margot M. Eves for her thoughtful comments on earlier drafts. Drs. Ross and Thistlethwaite received funding from a grant from the Robert Wood Johnson Investigator Award in Health Policy.
Introduction: The History of Prisoners as Living Donors
In a 1964 article on kidney transplantation in JAMA, Dr. Thomas Starzl, one of the pioneers of organ transplantation, described 12 kidney transplants that had been performed since November 1962 at the University of Colorado.1Two involved deceased donor kidneys, the other 10 involved living donor kidney grafts. The relationships between the living donors and recipients were one mother to child; five sibling pairs; two spouses; and two who were unrelated. One of the donors was a volunteer who had responded to an advertisement and the other was a prisoner (who 12 days postoperatively "disappeared from the ward and has not been seen since").2Later that year, Starzl and colleagues described 40 kidney transplants performed at the University of Colorado. Nine of the donors were prisoners.3
The first symposium on ethics and transplantation was held in England in 1966, funded by the Ciba Foundation.4At that meeting, several participants challenged Starzl's practice of appealing for donors at state prisons. Starzl argued that fewer than 100 of the 4,000 inmates expressed any interest, supporting his position that they were free to refuse and were acting on their own volition. He also suggested that they were under less pressure than some people experience from their families. He emphasized that "the consent form contained two written stipulations: (1) no pay was involved and (2) no reduction in the period of servitude was offered."5He also noted that that many of the prisoners were nearing the completion of their sentence, supporting his position that they understood that this action would not shorten their penal obligation. However, by late 1966, Starzl stopped accepting prisoners as donors after "private and informal conversations with Professor David Daube," a British legal scholar who was an attendee at the Ciba-sponsored symposium. Starzl stated, "The latter discussant had convinced me that the use of penal volunteers, however equitably handled in a local situation would inevitably lead to abuse if accepted as a reasonable precedent and applied...