The case for paying people to donate kidneys is actively being debated among researchers, transplant professionals, and patients alike. Several groups have set up advocacy websites and even the New York Times‘ editorial board has weighed in. In response to the growing debate, the World Transplant Congress meeting this year included a symposium titled “Paying for Organs in Controlled and Uncontrolled Settings.”
So far, paid kidney donation remains legal in just one country—Iran. The next closest is Australia, which has begun to offset wages lost during the hospitalization and subsequent brief recovery period by paying the minimum wage for up to six weeks. Researchers recently estimated that paying people to donate their kidneys $10,000 would save the overall health care system money by potentially increasing the supply of kidneys for the nearly half a million people on dialysis in the United States. Are we ready for a society where the disadvantaged are a source of replacement parts for those with means?
Kidney disease is a silent epidemic, affecting over 26 million people in the U.S. alone—most of whom are unaware that they even have an asymptomatic progressive disease. Many of these patients will go on to develop kidney failure, which requires either treatment with dialysis or a transplant; there are currently over 100,000 people waiting for a transplant.
Consider this: a 14-year-old boy who could get an excellent kidney fairly quickly from a deceased donor versus from a 55-year-old stepfather who insists on donating his kidney instead.
Survival rates for patients on the transplant waitlist are worse than that of most cancers; 5,000 people die annually waiting for a kidney, and only 36 percent of patients on dialysis live for five or more years, which is the average wait time for a transplant in many parts of the country.
Clearly, transplantation is the treatment of choice for patients with kidney failure—patients do better and live much longer after transplant than with dialysis. Approximately two-thirds of kidney transplants use organs from deceased donors while the remaining occur using kidneys from living donors. But over the past several years, kidney transplant rates have plateaued—and living donor kidney transplantation rates appear to be declining in the U.S. There is rightly a sense of urgency to do more to improve transplantation rates and outcomes for patients with kidney failure.
Worldwide, transplantation using organs from living donors depends on the altruism of the individual donor. Transplant programs—surgeons, physicians, and hospitals—all benefit financially from transplantation, while the benefit to the recipient is self-evident. In the U.S., even the health care system (that is, Medicare) benefits, since the overall costs for transplantation are lower than that for dialysis over time.
But donors are specifically prohibited from receiving any direct benefit—financial or otherwise—despite the fact that they actually save money for Medicare. Instead, since the first successful living donor transplant in 1954, donors have been expected to give up a kidney for little more than the gratitude of the recipient and the reassurances from their newfound (and often temporary) physicians that they will be no worse off with just one kidney.
Are we willing to pay for organs? And if so, what is your kidney worth to you? And, are we truly better off by replacing an intrinsic rationale for donation with an extrinsic one when we offer short-term financial incentives?
For many people, the answer is no. The unintended consequences of such a move could be very disturbing. Creating a market for organs is likely to eliminate the current voluntary nature of donation and result in coercive donation—with the coercion coming not from recipients, but the circumstances, financial and otherwise, of the potential donor. This is likely to result in an organ donor pool that is constituted predominantly by economically and socially disadvantaged individuals, while at the same time crowding out the altruism of organ donation. This crowding out phenomenon may actually lower organ supply despite increased monetary incentives.
These concerns are often countered by suggestions that the financial rewards are beneficial to the donors, and that individuals should be able to do as they please with their own bodies, and that free markets would make transplantation better.
Studies of kidney donors in India who were illegally compensated demonstrated significant deterioration in the health of the donor, coupled with a decline in family income subsequently with no substantial change in the coercive factor—family debt—that led to the organ donation in the first place. Another argument is that while the poor will likely donate more often for the financial rewards, they will benefit more as well since the rich are already traveling to get their kidneys elsewhere—often by private jet.
Kidney disease is a silent epidemic, affecting over 26 million people in the U.S. alone—most of whom are unaware that they even have an asymptomatic progressive disease.
The unintended consequences of commodifying an organ extend beyond the loss of altruistic donors. Consider this: a 14-year-old boy who could get an excellent kidney fairly quickly from a deceased donor versus from a 55-year-old stepfather who insists on donating his kidney instead. The former scenario would be better for the recipient, and the latter creates a potential conflict if donors are being paid.
Recognizing and rewarding donors is a noble goal, and one that is potentially achievable without commodifying donation. Instead of inducing donation with large payments, we ought to reward the altruism of kidney donors—not with short-term and perverse financial incentives or with mere gratitude, but with a commitment to care for them in the long term—and recognize that kidney donation is not without risk.
Financial incentives should be limited to legislation guaranteeing job security and offsetting costs incurred in the donation process. Instead of debating incentives that take advantage of growing socioeconomic inequalities, we should be talking about providing donors permanent access to health care—especially given recent concerns about the long-term negative consequences of organ donation. We should make a commitment to fund research to understand and thereby minimize the health risks to which donors are exposed as well as providing donors health insurance and a registry similar to that of transplant recipients.
If we really care about donors, we will invest in their long-term well-being and dismiss the use of coercive short-term financial incentives that can potentially harm transplantation.
