Renal transplant centers vary markedly in their rates of living donor kidney transplantation. Recent surveys also document marked differences among centers in both appreciation of medical risk for donation and what constitutes ethical donor selection. Because of this marked variability, some donors likely are being inappropriately denied or others are being inappropriately accepted. In addition to defensible donor education about risk and benefit, three fundamental obligations of the center are identified: (1) to recognize that it is often ethical to participate in acts of individual risk and sacrifice that are performed to benefit others; (2) to not deny transplantation without good reason to donors and recipients who apply to the center; and (3) to neutralize, but not overreact to, center self-interest, which stems from the professional benefits of transplantation and the center's desire to help potential transplant recipients. The basic medical facts surrounding donation must be understood by all parties as part of ethical decision making. Donor risk can be presented quantitatively using US Renal Data System data as a baseline. Confirmation of accurate donor understanding of risks, benefits, and alternatives is always a fundamental center obligation. Donors should not be rejected except for the general reasons we identify, and when these reasons do not seem to apply, the decision to deny transplantation should be reconsidered.