Living related kidney donors are still the donors of choice for renal transplantation at most US transplant centers. Nevertheless, many centers are strongly paternalistic and do not allow the potential donor at added risk to determine his own medical suitability. There are several reasons for this paternalism, yet all are flawed. Therefore, we suggest that it is generally ethically justified to allow the informed competent donor at small or unknown added risk to determine his own medical suitability. We offer guidelines to help determine how much added risk a potential donor should be allowed to accept.