Protections intended to thwart organ trafficking may inadvertently also "protect" legitimate patients and donors from receiving life-saving medical care.
The Paradox of Protection: How Overregulation Threatens Living Kidney Donation in Mexico, by Francisco J. Reyna-Sepulveda and Javier Sanchez-Maldonado, Transplantation, Publish Ahead of Print, July 27, 2026. | DOI: 10.1097/TP.0000000000005860
"Globally, unrelated and nondirected living kidney donations have become important mechanisms for expanding transplant access.1 Structured programs in the United States and Spain support unrelated donation through rigorous psychological evaluation, independent donor advocacy, and transparent oversight systems.3,4 For example, nondirected donors serve as critical initiators of kidney paired donation chains, substantially amplifying transplant opportunities beyond a single donor-recipient pair.3-5 However, a recent regulatory shift in Mexico threatens to effectively preclude these pathways in practice, leaving living kidney donors (including living liver donors) with genuine altruistic intent declined and vulnerable patients losing critical access to life-saving transplants.
"WHEN ALTRUISM REQUIRES PROOF
"On August 4, 2023, the National Transplant Center and the Federal Commission for Protection against Health Risks issued a High Health Directive (Alta Directiva Sanitaria), establishing mandatory standardized protocols for Mexican transplant centers.6 This directive emerged in response to well-documented regional concerns regarding organ trafficking, transplant tourism, regulatory gaps, and the “legal simulation” of donor-recipient relationships. These concerns are entirely legitimate and align with the principles articulated by the Declaration of Istanbul on Organ Trafficking and Transplant Tourism.7
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"Although the directive does not explicitly outlaw nondirected donation, its evidentiary requirements effectively preclude it at the committee level. As a result, viable donor candidates may be categorically declined for regulatory rather than medical reasons.
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"Although data isolating the exact proportion of donor evaluations declined solely for documentation rather than medical or psychosocial factors are currently unavailable, Mexican National Registry data highlight a concerning sign.9 During the 12 mo preceding the directive’s publication, 438 unrelated living donor kidney transplants were performed nationally, compared with 354 during the subsequent 12 mo—a 19% decline. "
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"This directive severely limits Mexico’s potential to establish domestic paired-exchange networks or participate in cross-border paired kidney exchanges. The Global Kidney Exchange model, for instance, incorporates pairs from middle-income countries into US-initiated chains to overcome financial and immunological barriers.10 This approach has been accompanied by ethical discussion in the transplant literature, particularly regarding concerns about potential inducements and unintended exploitation.10"
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"Ultimately, the critical question is not whether expanding living kidney donation should be permitted, but whether a transplant system can be considered ethically complete if a viable living kidney donor candidate is categorically declined for regulatory rather than medical reasons."
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