Financial incentives for organ donation a polarizing issue, but it’s time to test the waters

“If you do not donate then many people will die.”

That is not a statement linked to kidney donation, but it could be. It’s from a 2013 post on the basics of donating (but really, selling) plasma. Donation centers around the country vary in payment—anywhere from $75 to as low as $20 a treatment. But some individuals say they can get up to $300 a month after donating (there is that word again) their plasma, and that is helping in making ends meet.

So it is a system, run by private enterprise, that offers money in exchange for a medical product. Could selling a kidney be that much different?

“If you do not donate (a kidney), then many people will die.”

That is true: from 2004 to 2013, 63,742 persons died or became too sick for transplantation while awaiting a kidney, according to the Organ Procurement and Transplantation Network. Currently, 101,400 people are awaiting a kidney.

If every individual who wanted a kidney got a kidney, how could we improve the survival rate among patients with end-stage renal failure? How could it improve quality of life?

Could a check for $50,000 make that decision to donate easier?

Well known and respected transplant surgeon Tom Peters from the University of Florida College of Medicine and colleagues think so. Results from a survey they had conducted in June 2014 and published online in JAMA Surgery last month examined the willingness of voting U.S. citizens to become living kidney donors and to determine the potential influence of compensation for donation. The survey included 1,011 registered U.S. voters likely to vote, including 427 male and 584 female, with 43% of participants between ages 45 and 64 years.

The results? The researchers found that 689 (68%) would donate a kidney to anyone and 235 (23%) only to certain persons; 87 (9%) said in the survey they would not donate.

The reliability of altruism

Those are big numbers. In essence, 91% would donate a kidney; 68% would donate it to anyone that asked. We have seen such results before. On paper, people who respond to polls say that, if asked, they would donate a kidney. If just half of that 68% of the U.S. population actually donated a kidney, we would have over 112 million kidneys at our disposal. End of organ shortage.

So altruism has its limits. The researchers then asked if a donation of $50,000 paid by the health care system would increase the likelihood of donating. Indeed, 59% of all the respondents indicated that such a payment would make them even more likely to donate. Thirty-two percent were unmoved by compensation. and 9% were negatively influenced by payment. The question about compensation was asked after respondents had indicated whether they would donate a kidney.

“More Americans believe that living kidney and marrow donors, who currently may not be paid by law, are more deserving of compensation than donors of ova, sperm, and blood, who currently can be paid,” the researchers write in their paper. “Because too many U.S. patients are dying owing to the inadequate kidney supply, and because paying living kidney donors could increase the number of kidneys, we conclude that this option must be seriously considered.”

They are right. It is time to test the waters on incentivizing donors. “The issue of financial incentives in organ donation has been deliberated for more than two decades,” the authors wrote. It hasn’t gone much further than that because of a thing called NOTA––the National Organ Transplant Act, which forbids buying and selling organs in the U.S. That must be modified so that such testing can take place.

Here are some good reasons to give financial incentives for organ donation a try:

There are people dying waiting for a new kidney. The physician takes an oath to “do no harm,” and one could argue that putting a volunteer––or even a paid––donor on the operating table for elective surgery has the potential of doing harm. But are physicians also doing harm if patients die while waiting for a transplant?

As the authors note, laws that allow one to legally sell sperm and blood—all done in environments that could create risk—should also allow one to sell a kidney. “Amending existing federal law so that pilot studies concerning donor compensation can go forward is a reasonable start, and our findings show that it should be politically feasible,” the authors said. “Results of such clinical trials should be the basis of regulatory policy. If pilot studies support paying living kidney donors, perhaps one day there might be a long waiting list of persons wanting to donate rather than a list of Americans waiting for kidneys that never come.”

That might be optimistic. Is $50,000 enough as a one-time payment to accept the risks of surgery, deal with the pain post-surgery, and the potential of impairing your remaining kidney and requiring a transplant yourself (research is still conflicting over whether donors face the risk of kidney disease later in life). Peters and colleagues said they settled on $50,000 because they felt it was a substantial amount and because it was less than the annual cost to treat a dialysis patient (treatment costs alone).

We don’t want to return to the “God Committees” of the 1960s, when local citizens decided which patients with kidney disease would get a scare resource: a dialysis machine. The committees’ decisions indeed meant life for some––and death for others––based on criteria that include strong family connections, employment, and being a contributor to society.

It is a tough job for the United Network for Organ Sharing (UNOS) to avoid that scary piece of history. Like the early days of dialysis, donated organs cannot keep up with the demand. The median wait time for an individual’s first kidney transplant is 3.6 years and can vary depending on health, compatibility, and availability of organs.

And even with a financial incentive, it may turn people off. In a Newsweek article featuring the JAMA study, the magazine asked its online readers, “How many of you would donate a kidney with a $50,000 payment?” Only 34% said yes, they would donate.

Money can’t buy everything. -by Mark Neumann