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Donor Compensation: Ethical, Necessary, Humane

Sally Satel

Resident Scholar, American Enterprise Institute

sallysatelmd.com

Ever since the miracle of organ transplantation became feasible, about half a century ago, there have never been enough kidneys, livers, hearts, and other organs. Kidneys, the organ most in need and most easily donated by the living, can be given by living friends and relatives and even the occasional “good Samaritan donor.” But, by law, they must be given for free, in the spirit of “altruism.”  

Altruism is a beautiful sentiment, and I have personally benefited: two magnificent friends have donated kidneys to me; one in 2006 and then again in 2016.  Thousands others in the U.S., where I live, and elsewhere around the world, are not so lucky – they die waiting. 

Donors would not receive a lump sum of cash

For decades, the transplant community has mounted educational efforts, improved its procurement efforts at the time of death of potential donors, and so on. Compensating donors as a way to recruit people who would like to be rewarded for saving the life of another is long overdue.

Donors would not receive a lump sum of cash; instead, a governmental entity or a designated charity – not the sick person in need –would offer them in-kind rewards, such as a contribution to the donor’s retirement fund; an income tax credit or a tuition voucher; lifetime health insurance; a contribution to a charity of the donor’s choice; or loan forgiveness. Prospective compensated donors would be carefully screened for physical and emotional health, as all donors are now. The waiting period would filter out financially desperate individuals who might otherwise rush to donate and later regret it.

Objections to testing this plan ring hollow. The most common is that compensation “commodifies the body.” We already commodify the body, speaking strictly, every time there is a transplant: The doctors get paid to manipulate the body. So does the hospital. Why, then, object to enriching the donor — the sole individual in this entire scenario who gives the precious item in question and assumes all the risk?

We already commodify the body, speaking strictly, every time there is a transplant

At the heart of the “commodification” charge is the concern that donors will not be treated with dignity. But dignity is affirmed when we respect the capacity of individuals to make decisions in their own best interest, protect their health and express gratitude for their sacrifice. Material gain – benefitting others while enriching one’s self — is not inconsistent with this. The true indignity is to stand by smugly while thousands die for want of an organ.

The Horrendous Cost of Prohibiting the Compensation of Kidney Donors

Frank McCormick

Independent researcher, Former Director of Economic and Financial Research at Bank of America

Nobel-Prize winning economist Alvin Roth has coined the term repugnant transactions to describe transactions that some people want to engage in and that are objected to by people who may not themselves experience any direct harm.  One such repugnant transaction is buying and selling bodily organs. Many people just don’t like the idea of other people buying or selling organs. And in all countries but one (Iran) such transactions are legally prohibited.

Countries are essentially placing a price ceiling of zero on the market for kidneys

But few people realize that society is paying a horrendous price for these feelings of repugnance.  By prohibiting the buying and selling of human organs, countries are essentially placing a price ceiling of zero on the market for kidneys.  As anyone who has taken an introductory economics course can tell you, if the government holds the price of a good below its market clearing price, it will cause a shortage.  And if the government holds the price at zero — far below the market-clearing price — the shortage will be huge. That is what has happened in the market for transplant kidneys, and the impact on people suffering from kidney failure has been catastrophic.  Here is the grim arithmetic for the United States (see “The Terrible Toll of the Kidney Shortage”).

Each year about 126,000 Americans are diagnosed with kidney failure, which means they must either obtain a transplant or go on dialysis and prematurely die.  I and my co-authors estimate that about 50% of kidney failure patients — about 63,000 each year — would medically benefit from a kidney transplant, but because of the severe shortage of transplant kidneys, only about 20,000 per year receive one.  That means the kidney shortage causes about 43,000 patients a year to needlessly suffer on dialysis and die prematurely.  That is 118 patients a day, which is equivalent to about 85 fully loaded 747s crashing each year. 

Kidney shortage causes about 43,000 patients a year to needlessly suffer on dialysis and die prematurely

What can be done to prevent this horrendous loss of life?  The key is to find some way to reward kidney donors. A straight-forward solution advocated by many is to have the government compensate kidney donors and then allocate the increased supply of kidneys to all patients who have a medical need for one. 

Some people argue against paying for organs, but those arguments must be weighed against the real world suffering and death of hundreds of thousands of people each year.  It should never be forgotten that for every donation prevented by such arguments, someone suffers and dies.

Keep Organ Donation Altruistic

Katrina Bramstedt

Adjunct Professor, Bond University (Queensland, Australia)

www.TransplantEthics.com

Our organs are vital to life and when they fail, generally curative treatment is organ transplantation, yet donation never meets demand.  The waiting list for vital organs is vast and many people die while waiting for the “Gift of Life.”

“Gift” and “donation” are two words synonymous with organ transplant.  Also linked is the concept of altruism — that is, the selfless giving (Bramstedt & Down, 2011) of an organ to a waiting patient. But it is not enough to simply label organ donation as something that ‘should be’ altruistic and not commodified via sales.  

Payments for organs can negatively impact the donor candidate’s informed consent process

Along with the stipulation that organ donation shouldn’t come at a financial cost to the donor, it is ethical to reimburse living donors for expenses associated with their organ donation (e.g., surgery, medications, accommodation, travel, meals, time off work, childcare, medical/psychological complications).  Reimbursements of this nature are not ethically problematic and do not detract from altruism.  

Payments for organs means organs are no longer “gifts” nor “donations” but rather commodities

Payments for organs, however, are ethically inappropriate (and illegal in most countries) and such can negatively impact the donor candidate’s informed consent process.  The enticement of organ selling could impair a potential donor’s ability to thoroughly reflect on the risks of living donation (Lentine and Patel, 2012; Nydam et al 2018), while giving priority to the financial gain.  The financial incentive becomes a lure than can be coercive in the consent process, and such would invalidate the concept of valid informed consent. Payments for organs means organs are no longer “gifts” nor “donations” but rather commodities bought and sold, potentially to the highest bidder (Mahdavi-Mazdeh M 2012; Heidary RA et al, 2009).  Such is also a slippery slope to human trafficking (United Nations, 2000).

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