Ethical Principles Governing Organ Transplantation Apply to Paired Exchange Programs

We appreciate Flechner et al.'s thoughtful response and NKRs' commitment to living donor kidney transplantation (1). Efforts to expand access to transplantation, especially for patients who are difficult to match, should be applauded and encouraged. Yet, the authors raise, but do not fully address, an important challenge: how to motivate transplant centers to participate in the NKR while balancing ethical concerns, namely the equitable access to transplantation for all patients. It seems clear that patients should not be penalized for a centers' decision not to be "all-in" or be deprioritized compared to patients from "all-in" centers.