A shortage of cadaveric donor kidneys has created waiting lists for patients on chronic dialysis. Despite many ethical issues, donor kidneys are obtained from cadavers, first-degree living relatives, second-degree relatives (uncles, aunts), emotionally related persons such as spouses, and non-genetic altruistic donors who have a close relationship with the recipient. Most centers do not accept kidneys from minors, persons who have no genetic or personal relationship with the recipient, organs offered by altruistic strangers, or those that are purchased. The pros and cons of using kidneys from donors who are altruistic strangers (donors who have no genetic or personal relationship with the recipient) are reviewed. It may seem that organ acquisition for renal transplantation has moved down a slippery slope from cadaver donors to living non-related but emotionally related donors. However, it can also be argued that the approach to obtaining kidneys has evolved with improvements in safety to the donor and an increasing shortage of organs. It may also be argued that the approach should evolve from a paternalistic physician-centered role to a position in which the patient has more autonomy in deciding whether or not to accept a kidney from an altruistic donor.