Practical and Ethical Challenges to Paired Exchange Programs

The development of a regional consortium is commendable as it requires coordination between competing institutions. The authors deserve additional credit for openly discussing three programmatic snags that their program experienced in its first 2 years. The first was the number of candidates with high priority waiting for a cadaveric kidney. The consortium decided to permit only two high priority candidates at a time “to avoid an unpredictable period of waiting on the list”. While this policy may frustrate those who are waiting for a transplant and have a willing but ABO-incompatible donor, it is not unjust. Justice requires that equals be treated equally; it does not require that potential exchanges trump all other morally relevant allocation considerations.