PerspectiveFinancial Incentives for Living Kidney Donors: Are They Necessary?
Introduction
“Altruistic” organ donation, in which donors (or their families) do not materially gain from donation,1 is the prevailing international norm in organ procurement programs. However, in the face of the perceived failure of current altruistic donation programs to generate a sufficient supply of kidneys to meet demand, the introduction of a regulated market that offers payment in return for living provision of a kidney is sometimes held to be the only effective strategy by which the lives currently lost while awaiting kidney transplantation might be saved.2, 3, 4, 5, 6, 7 For some, financial incentives or other benefits representing a material gain for living kidney donation thus become a moral “imperative.”5, 8 This argument from life-saving necessity (necessity argument) is implicit in many proposals for the introduction of markets in human kidneys, but is rarely challenged by market opponents.
Proponents and opponents of financial incentives agree that efforts to reduce the premature loss of lives from end-stage renal disease (ESRD), including optimization of organ donation, are ethically warranted. Removal or reimbursement of the financial costs incurred by living kidney donors is also widely regarded as ethically acceptable.1, 9, 10 Debate instead habitually centers on differing evaluations of the consequences of financial incentives, especially regarding their impact on kidney vendors. Although we hold serious concerns regarding risks of impaired autonomy, exploitation, and harm to kidney vendors,11 in this article, we set aside these familiar components of the incentives debate and focus solely on examining the necessity argument and the rarely contested empirical assumptions it contains (Box 1). Examining data from the United States, in which context the necessity argument is usually invoked, we consider the claims that the current system of altruistic donation cannot meet current and future demand, and that conversely, financial incentives would produce a substantial increase in, if not sufficiency of, kidneys for transplantation. We consider the donor potential within the existing altruistic system and discuss alternative uncontroversial strategies by which society might meet its ethical obligation to prevent the premature loss of human life from ESRD.
Section snippets
Evaluating The Problem
The supply-demand gap between the number of waitlisted candidates and the number of kidney transplantations performed each year in the United States is invoked to support the claim that unmet needs for transplantation constitute a “disaster,”12 costing thousands of lives and requiring immediate intervention in the form of incentives for living kidney provision. We therefore begin by considering the scale of this gap.
Table 1 compares current supply and demand, noting that demand may be
Evaluating Possible Solutions
In 2003, Sheehy et al23 estimated the annual number of brain-dead potential donors in the United States to be between 10,500 and 13,800. By comparison, there were 8,144 actual donors in 2012.24 Substantial variation exists between donor service areas in terms of donor and organ yield metrics, indicating scope for greater efficiency.24 For example, it has been estimated that more than 5,000 additional kidneys would be transplanted annually if all organ procurement organizations performed at the
The Promise of Financial Incentives
The confidence that advocates of the necessity argument place in the efficacy of incentives is rarely linked to specific incentive schemes. Instead, market advocates often suggest that a range of incentives would be effective, and policy makers need only test which would have the greatest impact or be most preferred by a particular community.49 Beard et al2 conclude that “likely kidney prices for living donors in developed countries will be in the tens of thousands of dollars.”(p211) The
Are Incentive Trials Justified at This Time?
Proponents of the necessity argument point to the deaths of individuals awaiting kidney transplantation as the consequence of prohibition of financial incentives2, 3, 4, 5, 6, 7 and thus contend there is a moral imperative to reduce waitlist mortality by the introduction of regulated markets for kidneys.3, 4, 5, 12 Although the consequentialist rhetoric of the necessity argument has exerted a powerful influence on debate, the actual potential of a regulated market to increase the overall supply
Acknowledgements
Both authors are members of the Declaration of Istanbul Custodian Group, and Dr Martin is co-chair of The Transplantation Society Ethics Committee. The views presented in this paper are the authors' own and do not represent the opinions or positions of either organization.
This commentary uses data from annual reports of the US Renal Data System (USRDS) and the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR; produced by the Minneapolis
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