Living kidney donation is one of medicine’s most ethically charged procedures. The donor undergoes major surgery and assumes real physical risk with no direct medical benefit, while the recipient gains freedom from dialysis and, often, years of extended life. Because the stakes are so asymmetric, the entire legitimacy of the practice rests on the donor’s consent being genuinely voluntary and informed. In Singapore, this is enforced through the Human Organ Transplant Act, which requires every living-donor transplant to be reviewed by a national Transplant Ethics Committee, or TEC. Each committee meeting includes a layperson and two doctors uninvolved in transplant medicine, drawn from a national list overseen by the National Organ Transplant Unit. Donors and recipients are interviewed separately, and a rejection by the TEC effectively prevents transplantation anywhere in the country, placing enormous weight on the decisions made before a case even reaches formal review.

The authors argue that ethical judgment cannot be reduced to procedural compliance. Transplant teams themselves carry a broader responsibility to evaluate the relational dynamics that may undermine the voluntariness and authenticity of consent. Their three cases, involving candidates between 40 and 60 years old who voluntarily disclosed previously concealed intimate relationships during evaluation, illustrate how difficult this responsibility becomes when the information at stake is not medically relevant but is deeply morally significant.

In the first case, a recipient candidate disclosed to the transplant team a nearly decade-long extramarital relationship that had recently ended, but refused to tell the spouse who wished to donate a kidney to free them from lifelong dialysis and preserve the marriage. The team recognized that the donor’s offer rested on a presumption of mutual marital fidelity, and that knowledge of the affair might change the donor’s decision entirely. This created a direct conflict between the donor’s right to material information and the recipient’s right to privacy, particularly since the information had been shared in good faith. Some team members worried that the recipient’s decision to end the affair might itself have been implicitly coerced by the donor’s sacrificial gesture, raising questions about whether genuine informed consent was even possible under such emotional pressure. There was also concern that the donor might later use the gift as leverage to pressure reconciliation if the infidelity came to light. The team ultimately deferred, but did not prohibit, the transplant, hoping to give the recipient time for grief, reflection, or counselling. Notably, the recipient felt penalized for honesty, upset that candid voluntary disclosure had led to personal disadvantage.

The second case reversed the roles. Here, the donor disclosed a three-year extramarital affair that had preceded the recipient’s dialysis dependency, motivated by a desire to become a better spouse after witnessing the recipient’s fortitude during illness. The donor had ended the affair a full year before even raising the possibility of donation. The ethical concerns now centered on the recipient, whose consent would be obtained through ignorance of the donor’s infidelity. Yet the team reasoned that while emotionally significant, this information was not clearly material to the recipient’s evaluation of surgical risk, transplant prognosis, or expected clinical outcome. The recipient’s reason for accepting the kidney, escaping the burdens of dialysis, was independent of the donor’s past conduct. The team also acknowledged that some recipients might prefer not to know about spousal infidelity, exercising what ethicists call negative autonomy, and that preferences for disclosure vary widely across individuals. Crucially, they could not ascertain the recipient’s preference without revealing the truth itself. After deliberation, the team recommended proceeding, judging that deferral would not rewrite the marital history but could delay the recipient’s access to improved quality of life, potentially causing greater harm. The donation went ahead, and the donor made no subsequent disclosure of the affair.

The third case was the most complex. Both donor and recipient concealed an ongoing intimate relationship from their spouses and presented themselves as close friends. The donor claimed the offer was motivated by altruism, friendship, and compassion, while the recipient sought emancipation from dialysis. On the surface, the threshold for informed consent was met: both parties understood and accepted the risks and benefits, and both were voluntary in their decisions. Informed consent, the team noted, is owed to the donor and the recipient, not to their spouses, even if the spouses were misinformed about the nature of the relationship. But doubts emerged about whether the donor’s offer could be coerced as proof of devotion or driven by fear of abandonment, and whether the recipient might feel compelled to remain in the relationship because of the donation. The team also faced a deeper institutional bind: the transplant would be contingent on continued deception of both spouses, who would be placed in caregiving roles they had never agreed to, raising fairness concerns. The risk of exposure might not be high, but the reputational risk to a publicly accountable team was significant, particularly if marital breakdown or family conflict involving children followed. The team reached a unanimous decision on conditional deferral, giving the pair time to decide the future of their relationship before reconsidering the transplant. Both candidates, though disappointed, accepted the outcome.

What unites these cases is a common ethical question: should living-donor transplantation proceed when concealed intimate relationships materially affect the relational context in which donation occurs? The authors argue that spousal living donations are typically grounded in love, devotion, marital commitment, and preservation of the family unit. A decision to donate based on a material misunderstanding of the true nature of the donor-recipient relationship compromises autonomous decision-making. Because the donor alone assumes the physical risk, factors that undermine the donor’s ability to provide informed consent should carry greater ethical weight than those affecting the recipient. Privacy remains important, but it does not absolve transplant programs of their responsibility to safeguard the integrity of donor consent.

The authors also emphasize that conditional deferral, rather than outright prohibition, offers a proportionate response in many situations. Deferral provides time for relational instability to be addressed, for disclosure to be considered where appropriate, and for reliable post-operative support to be ensured. Since none of these cases involved urgent need for transplantation, and given that a TEC rejection effectively precludes transplantation anywhere in Singapore, deferral preserves the possibility of future transplantation once the identified concerns have been resolved. The authors frame this as proportional restraint rather than moral adjudication of private wrongdoing. They also point to Singapore’s Human Organ Transplant Regulations 2004, which statutorily require consideration of public interest and community values, concepts that may reasonably extend to preventing foreseeable harm to spouses, families, and marital relationships.

Ultimately, the authors conclude that transplant programs should not reject living kidney donation solely on the basis of moral discomfort with aspects of the donor-recipient relationship. But confidentiality and respect for autonomy alone are insufficient to justify proceeding when teams become aware of concealed extramarital relationships that materially affect the relational context of donation. Ignoring such relational realities risks reducing ethical oversight to procedural compliance rather than principled judgment. To the authors’ knowledge, this is the only known work discussing the impact of concealed intimate relationships in living-donor transplant, a gap they argue warrants further empirical and normative research to guide programs confronting these ethically complex situations.

Subject of Research: Ethical evaluation of concealed marital infidelity in living kidney donor and recipient consent

Article Title: Consent in the dark: Can living kidney donation proceed amid marital infidelity?

Article References: Consent in the dark: Can living kidney donation proceed amid marital infidelity?. (n.d.). https://doi.org/10.3389/ti.2026.16580

Image Credits: AI Generated

DOI: 10.3389/ti.2026.16580

Keywords: living kidney donation, informed consent, transplant ethics, marital infidelity, donor welfare, Transplant Ethics Committee, Singapore, Human Organ Transplant Act, institutional integrity, psychosocial evaluation, conditional deferral, public trust