Perspectives of Transplant Physicians and Surgeons on Reimbursement, Compensation, and Incentives for Living Kidney Donors

Every day potential recipients of organ transplants die because there is a shortage of donors. This situation has stimulated debate on financial incentives for living kidney donors. As it stands right now, neither the government health insurance system nor I can offer compensation as an incentive to a potential living donor. As I posted a few days ago, under the heading, “Living Kidney Donation: Costs and Other Practical Matters,” medical cost are covered, but most non-medical costs are not, although there have been developments in British Columbia.

An academic study was recently published which examines this particular subject of financial compensation for living donors. For the full article, go to: “Perspectives of Transplant Physicians and Surgeons on Reimbursement, Compensation, and Incentives for Living Kidney Donors,” on the Medscape website, http://www.medscape.com/viewarticle/832551.

The study participants included 110 transplant nephrologists and surgeons from 12 countries across 43 transplantation units in Europe, Australasia and North America. Participants were English speaking and from Western high-income countries.

Seven major themes were identified from the study: undermining benevolence, potential legitimacy, compromising human dignity or value, prioritizing removal of disincentives, limited operational feasibility, traversing market forces, and maximizing utility.

832551-fig1

  1. Undermining Benevolence. Participants were concerned that financial incentives would: jeopardize altruism, lead to corruption and abuse, exploit the vulnerable, and result in deterioration in the quality of donors.
  1. Potential Legitimacy. Some participants thought that undermining benevolence was insufficient reason to prohibit financial incentives. They observe imperfect altruism and double moral standards; they argue that public values may be more favourable to incentives than transplant specialists may think and that any judgments about compensation be evidence based; others postulated that a regulated means of compensation may counteract the black market trade in organs; finally, there could be extenuating ethical justification, such as relief of the poverty of the donor.
  1. Compromising Human Dignity or Value. Many of the physicians surveyed were concerned that financial incentives would turn the human body into a commodity; others thought that incentives could lead to excessive risk taking by donors.
  1. Prioritize Removal of Disincentives. Rather than providing incentives, the survey found support for the removal of barriers to donation. Instead of paying someone for donating a kidney, the intention here is to cover expenses in a “cost-neutral way.” The tendency was to view such funds as coming from government, rather than from the kidney recipient. Costs such as travel, childcare, and lost wages due to time off work are under consideration here. It was also asserted by some that since the donor has provided a valuable gift, any reasonable concept of justice would argue that they deserve compensation, and some extended that compensation to include lifelong tax credits.
  1. Limited Operational Feasibility. Any scheme to provide incentives would be difficult due to the complexities in valuing organs, in establishing the ground rules for cash to donors, in defining and enforcing appropriate regulations, in overcoming the sociopolitical barriers in a free and democratic society, and in providing equitable compensation. On this last point, while in principle the idea of reimbursing lost income to the donor was acceptable, the question was raised as to whether a high income person would be paid more than a lower income person, essentially setting a different price tag on one person’s kidney versus the other’s.
  1. Traversing Market Forces. Submitting organ donation to market forces would be dehumanizing. Although incentivizing donation may lead to increased donation rates, participants were reluctant about contemplating a “brave new world of buying and selling organs.” Some, however, thought that, in a capitalist system, “everything in life is driven by the market.” Exploiting socioeconomically disadvantaged overseas donors was viewed as unethical. However, some participants believed in the possibility of “commercial transaction with a kidney amongst consenting adults,” thus maintaining respect for individual autonomy.
  1. Maximizing Utility. The critical shortage of suitable organs and poor outcomes of dialysis therapy provided the impetus and rationale for incentivizing kidney donation. Further, compensation was believed to be reasonable because living donors were providing an economic benefit to society by reducing the number of patients receiving dialysis.

The authors provide an extended conclusion to their findings, which you can read online. For the purposes of this post, I will conclude with a quotation of the final paragraph:

Minimizing disincentives by providing donor reimbursement and reasonable compensation is believed to support equity and justice in living kidney donation. Direct financial incentivization for living kidney donors, even in the context of a regulated market, was regarded by most as unjustified because of the potential moral consequences and uncertain feasibility. Removing financial disincentives and safeguarding the intrinsic volunteerism, value, and meaning of donation were viewed to uphold integrity in living kidney donation.

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