Living donor kidney transplantation affords superior patient survival, graft survival [1] and quality of life [2] compared to other treatments, especially when performed pre-emptively [3]. Transplantation using kidneys from living donors accounted for 39% of kidney transplants globally in 2022 (Global Transplant Observatory). As living donors undergo surgery solely for the benefit of another, minimizing harms is essential. Thorough evaluation processes have been developed to reduce surgical, physical, psychological, and socio-economic harms of donors [4–9]. Family, friends, anonymous donors and even people with terminal illnesses [10] are often highly motivated to donate a kidney. This also applies to people who, in addition to the wish to donate a kidney, also have a wish for euthanasia. Euthanasia is defined as intentionally ending life, at the explicit voluntary and well-considered request of the patient, due to unbearable suffering with no prospect of improvement. Strict due care criteria, according to the Termination of Life on Request and Assisted Suicide (Review Procedures) Act (2002), must be fulfilled by the attending physician (sometimes referred to as Medical Assistance in Dying). Although deceased donation after euthanasia has been documented [11, 12] and shown to be have comparable long-term outcomes to controlled donation after circulatory death (DCD-III) and donation after brain death (DBD) [13, 14], living donation before euthanasia has never been reported and is absent from clinical guidelines. Evaluation of these individuals forms a new frontier in transplantation. Euthanasia or Medical Assistance in Dying (MAiD) is legal in various countries for patients with medical conditions suffering unbearably without prospect of improvement, including psychiatric illness in some jurisdictions [15]. In the Netherlands, due care criteria must be met (Table 1). Some individuals with psychiatric illnesses requesting euthanasia also express a wish to become a living donor and donate one of their kidneys. Importantly, this study does not incorporate requests for removal of both kidneys or for continuous sedation prior to euthanasia. This article aims to discuss the ethical, psychosocial, and procedural considerations of living donation prior to euthanasia based on three cases from clinical practice. The ultimate aim is to stimulate discussion and policy development.

Protocolized medical workup was performed as standard according to the British guideline for living donor kidney transplantation of 2018 [16], adapted to the Dutch situation. According to protocol, medical evaluation included physical examination, imaging, and serology testing. Medical history was obtained from the donor candidate and the General Practitioner. Psychosocial evaluation, conducted by a transplant psychologist using standardized screening tools covered motivation and decision-making, risk and information processing, psychopathology, social resources, and personal resources and ethical considerations [4]. Neither Dutch nor British guidelines list psychiatric illness as an absolute contraindication for living donation, allowing for case-by-case assessment. Candidates were reviewed by a multidisciplinary team including transplant nephrologist, surgeon, anaesthesiologist, nurse practitioner, social worker and psychologist.

Both formal and informal caregivers were approached as sources of information during the assessment process. Standard living donor nephrectomy principles were adhered to in order to maximise donor safety and preserve optimal long-term renal function for the donor. Kidney selection for donation was based on established donor safety principles, whereby the kidney with the less favourable anatomical and/or functional characteristics was preferentially procured, while the donor retained the kidney with the best expected long-term function. This assessment incorporated comparative evaluation of renal parenchyma, split renal function on indication, kidney size, vascular anatomy, and other relevant clinical considerations. For the purposes of this study, donors were given verbal and written information about the aims and procedures. All three gave written informed consent for case review and publication and were given the opportunity to review the case description and manuscript. To ensure privacy and anonymity no names, dates or identifying information were reported. This retrospective file review does not fall under the Medical Research involving Human Subjects Act (WMO) and therefore under Dutch law does not require approval by the Institutional Review Board. All procedures were carried out in accordance with the ethical standards as laid down in the 2024 Revision of the Declaration of Helsinki.

Three case studies of candidates for living donation prior to euthanasia are presented in Table 2. In all three cases, euthanasia was sought due to suffering from a psychiatric condition. Of the 3 candidates, case 2 was declined for medical reasons, and case 1 and 3 donated. In both cases, donation was successful and no detrimental effects were observed on mental or physical health. In case 1 and 2, euthanasia was performed a minimum of 3 months after donation or conclusion of screening; in case 3 living donation was transformative and the request for euthanasia was subsequently withdrawn. The 3 cases gave rise to unique medical, procedural, psychological and ethical considerations.

First, as these patients were suffering so severely from psychiatric illnesses, there were concerns about their ability to provide informed consent. All three candidates had to demonstrate capacity to make informed decisions and adequate understanding of the procedures and consequences of donation. Even though all three candidates were convinced at the time of work-up that they would proceed with euthanasia, we asked them to consider a scenario in which they may not undergo euthanasia and would live the rest of their lives with only one kidney to make sure that they understood that this scenario was also possible. In all three cases, there was consensus that candidates’ mental health problems did not cloud their capacity for judgement, risk perception and informed decision-making. Candidates could relay the most important risks and reported realistic expectations of the process of surgery and recovery. As with all potential kidney donors, we also assessed the voluntariness of these donations. In cases 1 and 2 the donor was known to the recipient, the candidates had offered the kidneys themselves, and the work-up did not reveal any suggestion of coercion. Case 3 was an unspecified anonymous (non-directed) donor; therefore, there was no potential for pressure from a potential recipient.

In living donation ethics, it is necessary to balance respect for the autonomy of the candidate with the duty to protect them as healthy individuals against the risks and burdens of living donation. In people who are considering or accepted for euthanasia, and are thus already suffering unbearably, the principle of non-maleficence may apply even more. Moreover, (the timing of) euthanasia is not certain and there is also a chance that the donor candidate may live many years after donation. Therefore, euthanasia was not factored into the medical decision-making: we assumed normal life expectancy due to the uncertainty of euthanasia when assessing medical risk (kidney functioning and potential for short and long term complications). This line of reasoning is supported by case 3 whereby the donor withdrew her euthanasia request after donation, supporting the need for conventional risk thresholds.

With regard to psychological risks and benefits, careful psychosocial evaluation is imperative given that all three cases had a euthanasia wish due to unbearable psychological suffering. There is some evidence that chronic psychopathology may be associated with poorer mental health outcomes of living donation [9, 17]. While all donors had a chronic mental illness, they were stable during evaluation meaning that there were no recent major fluctuations in psychopathology or changes in mental health status. The potential impact on further exacerbation of mental health symptoms, as well as their ability to cope with pain or potential complications, were discussed with all three candidates. Candidates themselves did not expect that donation would have a negative impact on mental health, but rather a positive impact. Candidates believed that donation could give meaning to the final phase of their lives; donation could be a positive event in an otherwise difficult life. For case 3, donation was transformative and led to withdrawal of the euthanasia request. In this case, the psychological benefits of donation clearly outweighed the risks. The risk of psychological harm from donation was weighed against the harm of being declined as a donor. Especially for specified (directed) donations, the impact of being declined may be significant due to the consequences for the intended recipient. Cases 1 and 2 viewed donation refusal as more harmful than the procedure itself. There is evidence from research that being turned down as a donor can result in feelings of guilt toward the recipient, feelings of disappointment, and in some cases anger when the candidate is not in agreement with the decision [18, 19]. At our centre, psychiatric illness is not an absolute contraindication, which facilitates honest disclosure and allows adequate assessment, intervention and support. We made certain that all three candidates received social support through formal channels (mental health professionals, residential support workers) and informal channels (family, friends) and that mental health professionals involved in their care were available to offer treatment if needed post-donation, in addition to the support provided by the transplant psychologist.

In living donation ethics, it is necessary to balance respect for the donor’s autonomy with the duty to protect against potential harms. In the case of living donation prior to euthanasia, harms could be induced by hastening transplantation or having to postpone euthanasia. For the recipient, it is undesirable to undergo transplant earlier than medically necessary. For the donor candidate, having to delay euthanasia to make transplant possible may prolong suffering and may be experienced as coercive. Transparent communication and planning is therefore key. Voucher systems [20], though not currently used in Europe, may help decouple timing in such cases. In cases 1 and 2, directed deceased donation following euthanasia had been considered by the candidates and could have avoided the risks of surgery and burden of recovery. However, directed deceased donation is legally not permitted in the Netherlands (the ethics of which are explored elsewhere [21]). Only through living donation could they direct their organs to their loved ones. Moreover, they preferred to die at home to minimize distress of family members. Living donation prior to euthanasia was at the time the only way to fulfil all of these wishes.

Finally, the wider societal implications must be considered. Deceased organ donation is based on altruism and trust in the transplant system among the general public. It is not clear whether living donation prior to euthanasia, particularly in the context of psychiatric illness, will influence public trust in the transplant system. Therefore, careful and transparent evaluation is critical.

With the rising number of euthanasia requests due to unbearable (psychiatric) suffering in the Netherlands [22], this type of donor candidacy may become more common in the future. Euthanasia is also legally permitted in other countries and under consideration in new legislation elsewhere [23]. As a result, similar requests for living donation prior to euthanasia may arise internationally. To facilitate ethically responsible transplant care, open dialogue, and development of clinical guidance is necessary. Publication of these cases can not only stimulate dialogue but provide a benchmark against which others can be compared [24]. We urge transplant professionals to approach such requests seriously rather than dismissing them outright. As shown here, careful evaluation can lead to successful living donor transplantation without harm to the donor. Although each case began with the same intent, the outcomes differed, providing unique insight into motivations and the emotional and clinical complexities involved. Based on our experiences, we have outlined a number of challenges and lessons learned.

Firstly, decision-making around living donor candidacy must remain independent from the euthanasia request. The medical assessment should presume the donor may live long after donation, as euthanasia may ultimately not proceed. The evaluation must safeguard against any deterioration in physical or mental health, ensuring that withdrawal of the euthanasia request does not expose the donor to new health risks. A multidisciplinary post-donation care plan is recommended. Secondly, core ethical principles of living donation are especially critical in these cases. Rigorous assessment of capacity to give informed consent and risk-benefit ratio are essential. Multidisciplinary collaboration—including specialized mental health professionals, ethicists, and external professionals involved in the candidate’s care—is vital to ensure consensus on candidacy. Specialized knowledge of euthanasia, particularly in psychiatric cases, is often limited within transplant teams; consulting national euthanasia experts or committees may provide necessary support. Thirdly, these cases were emotionally taxing for the transplant team, especially due to the psychiatric suffering and young age of one candidate. Personal beliefs, stigma, and societal taboos around euthanasia may conflict with professional responsibilities. Institutional support structures—such as supervision, peer-support, and debriefings—should be readily accessible. Learning from prior cases, as presented here, may help overcome barriers, and centralized centers of excellence could consolidate expertise. Finally, there is limited understanding of stakeholder perspectives on living donation prior to euthanasia. Qualitative research involving donors and recipients could help clarify motivations, perceived risks, and benefits. One area to be investigated is whether individuals in the process of evaluation for euthanasia should be actively informed about the option of living organ donation. In the case of Organ Donation after Euthanasia an important aspect of policy is that organ donation can only discussed after the euthanasia process has been completed and approved. This is to protect the individual against potential coercion or pressure to proceed with euthanasia for the sake of the (deceased) donation. In the case of living donation prior to euthanasia, requiring completion of the euthanasia process prior to a donation discussion may be less relevant, as highlighted by Case 3, whereby the euthanasia request was withdrawn after living donation. Actively informing individuals with a euthanasia wish about living donation could either be experienced as coercive or as an opportunity to do something meaningful prior to death, however, research is currently lacking. Public perceptions also warrant exploration, including potential objections, societal acceptance, and any impact on willingness for deceased donation. Jansen and Gardiner (2024) caution that ethical challenges can pose barriers to clinical implementation of organ donation in the context of euthanasia. Careful consideration of stakeholder perspectives is necessary to guide development of policy and ethically responsible implementation.

Living kidney donation prior to euthanasia poses complex ethical, medical, psychological and societal challenges. It requires careful assessment, multidisciplinary collaboration, and transparent communication. Our findings support the feasible of such donations under rigorous safeguards and suggest directions for future guidance and research.