Perhaps you are all heart. Then, the mere suggestion of relinquishing a kidney to a patient in need should not seem the least bit controversial. But, what might $10,000 help to change your mind and, perhaps, turn your heart into gold?
Canadian researchers believe paying living donors for a kidney may actually be more cost-effective than the current system based solely on altruism – even if the financial incentive boosts charitable giving by 5 percent.
“We have a problem. We don’t have enough organ donors coming forward,” Dr. Braden Manns, an associate professor and clinical professor in nephrology at the University of Calgary who led the study, told NBC News. “We need to figure out a way to solve that problem.
We shouldn’t throw out, out of hand, solutions that could increase donations.” At the very least, the analysis, published last month in the Journal of the American Society of Nephrology, rekindles an ongoing debate about whether it's practical — and ethical — to offer financial incentives for human organs.
At the very least, the analysis, published last month in the Journal of the American Society of Nephrology, rekindles an ongoing debate about whether it’s practical — and ethical — to offer financial incentives for human organs.
Black Market Trade
A recent account in the Telegraph claimed British patients waiting for organ transplants are being offered surgery using illegally trafficked kidneys – on sale for tens of thousands of dollars — at a government-controlled hospital in Sri Lanka. The allegations fueled concerns about a rising black market trade in human organs in many parts of the world including South Asia, India, Iran, the Philippines and China.
“Horrific accidents happen daily, sometimes influencing multiple parties to act irresponsibly without considering the ethical and legal ramifications related to organ transplants,” said Renée-Marie Stephano, President of the Medical Tourism Association®. “Organ transplants are more often than not a matter of life and death. Any debate surrounding the process should not be taken lightly.”
A recent account in the Telegraph claimed British patients waiting for organ transplants are being offered surgery using illegally trafficked kidneys – on sale for tens of thousands of dollars — at a government-controlled hospital in Sri Lanka.
Contemporary issues influencing organ transplants were presented and discussed at the 6th World Medical Tourism & Global Healthcare Congress, last month, in Las Vegas.
“There is little doubt that commercialization of organ donation is fraught with drawbacks, dangers and potential immoral consequences,” said Dr. Ehtuish Ehtuish, of the Libyan National Organ Transplantation Program, who participated in a panel discussion at the Medical Tourism Association® conference.
“On the other hand, it is clear that efforts to increase the rate of organ donation through education have failed and sole moral incentives have not worked. Organs are currently limited by supply and, in the hope of expanding available organs, it seems prudent to provide incentives not only to encourage donation, but also in order to express appreciation.”
Moral Issues
Some kidney experts say that even if the method is cost effective to pay people for organs, the moral issues the practice generates might backfire.
“Sometimes these things have unintended consequences,” said Dr. Stephen Pastan, a board member for the National Kidney Foundation and a transplant surgeon at Emory University in Atlanta. “If we paid $10,000, a lot of altruistic donors would say that it’s just a cash transaction. Donations could go down.”
Arthur Caplan, Ph.D., head of the division of medical ethics at NYU Langone Medical Center, also points out there are religious objections to the practice.
“The last Pope called human organ markets a ‘moral abomination,’” he said to “Day in Health.” “Legalizing payments to donors in the United States could also take the steam out of efforts to stop organ trafficking in countries where poor people are being horribly exploited.”
Some kidney experts say that even if the method is cost-effective to pay people for organs, the moral issues the practice generates might backfire.
Dr. Caplan suggests focusing on increasing the number of people who donate their organs after death.
“Instead of having to check a box on your driver’s license or fill out a paper saying you want your organs donated, this should be the default,” he said.
In other words, Dr. Caplan notes that people should fill out forms to opt out of donating after death, instead of having to do so if they want to donate. This strategy, used in a number of European countries, could significant increase the number of kidneys available without having to pay living donors to boost the supply.
Theoretical Question
Right now, the question is theoretical. In the United States, Canada and other countries — except Iran — paying people to donate organs is illegal.
Still, Manns and his team wanted to find out if offering financial incentives would save money over the current system of keeping people on kidney dialysis for years. They compared cost data from a cohort of kidney patients identified in 2004 and followed them for three years.
Dr. Ehtuish Ehtuish, of the Libyan National Organ Transplantation Program (above, right), participated in a panel discussion on ethics at the World Medical Tourism & Global Healthcare Congress, with John Connell, of the University of Sydney (below).
The researchers determined that paying living kidney donors $10,000 apiece would save about $340 per patient, compared with the ongoing costs of dialysis, and would also provide a modest boost of .11 in quality-adjusted life years, or QALY scores, a measure of the quality and length of life.
The figure is based on money from an independent thirdparty entity, like the Canadian Blood Services or perhaps through OPTN (Organ Transportation Network) in the United States. Manns called those assumptions “very conservative” and if kidney donations actually rose by 10 percent or 20 percent, the cost savings would jump to $1,640 and $4,030 per patient.
“It’s a substantial gain for the people who get the individual transplant,” said Manns, and a system-wide gain when multiplied by the thousands of people on kidney transplant waiting lists.”
In the United States, OPTN reports more than 98,000 people are waiting for kidneys. Last year, more than 4,500 people in the United States died waiting for kidneys. Meanwhile, the number of kidney donors has fallen steadily for the past several years, to 13,040 in 2012, despite the growing need, figures show.
Elephant in Room
In Canada, the issue is the same: Wait lists of 2-3 years, and about 30 percent of patients die while waiting, said Manns.
“The obvious question, the elephant in the room is, ‘Why don’t more people donate?’” he said.
The same research team conducted an earlier survey of 3,000 Canadians that found 70 percent of members of the general public thought that some form of compensation for organ donation would be OK, but that only 25 percent of transplant doctors agreed. But, about half of people who said they wouldn’t be likely to donate an organ changed their minds if the deal included a $10,000 payment.
A 2010 study by Scott Halpern, a bioethics expert at the University of Pennsylvania, found that many of the fears that financial incentives could cloud a person’s decision about donation weren’t actually true.
While Manns’ study focused on paying all donors directly, others have previously suggested offering incentives that might include compensation for health costs, a break on life and health insurance or even tax relief for kidney donors.
The idea of compensating people for their organs doesn’t sit well with Lora Wilson, 53, of Pittsburgh, Pa., who donated a kidney in 2006 to a 71-year-old grandmother in New Jersey.
“For me, I just don’t like the idea that body parts are for sale,” said Wilson, who is director of an orthopedic group. “You may start with a $10,000 incentive, but what’s to say someone of means wouldn’t say, ‘I’ll pay $100,000?’ I don’t feel very comfortable with it.”
There are also questions of whether financial incentives would coerce poor and vulnerable people into donating for money, despite medical risks, Pastan said. But, a 2010 study by Scott Halpern, a bioethics expert at the University of Pennsylvania, found that many of the fears that financial incentives could cloud a person’s decision about donation weren’t actually true.
Stalled Conversation
All of these issues are part of a decades-long debate about paying for organs, a conversation that stalls because no one really knows what effect incentives would have, experts say. In the United States, the National Organ Transplant Act of 1984 expressly prohibits selling organs and a Senate report that accompanied it warned that “human body parts should not be viewed as commodities.”
In an editorial accompanying Manns’ study, University of Pennsylvania researchers, Dr. Peter Reese and medical student Matthew Allen, argue that “the time is ripe” to at least consider studying the real-world impact of incentives. They’re proposing a research agenda and a limited-scope trial that would finally answer lingering questions about paying for body parts.
“We really don’t know how big the opportunities are here and we really don’t know the risks,” said Reese.
