Removing financial disincentives to organ donation: an acceptable next step?

The numbers are all too familiar, and are repeated so often in the arena of kidney disease that they start to lose meaning, becoming slightly hollow, empty, and spokenwith a feeling of resignation. There are.90,000 people on the kidney transplant waiting list and this number is growing. The number of kidney transplants performed annually is only one-fifth of the waiting list overall. The mortality rate while awaiting transplant is 7% per year, and there are recent concerns that donation rates are actually falling (1). It is in this context that novel methods to increase organ donation must be considered thoroughly and thoughtfully. A number of efforts to increase deceased donation have been implemented over the past decade to address these grim statistics. These include the expansion of donor registries at departments of motor vehicles, laws that prevent family members from reversing the stated wishes of an individual who has consented to be an organ donor, initiatives supported by agencies of theUSDepartment ofHealth andHumanServices to improve practices in obtaining family consent, and encouragement in utilization of older donors, as well as establishment of policies that permit utilization of organ donors who meet the definition of death via circulatory arrest rather than brain death have been widely accepted over the past decade (2,3). Similar innovations have been made in expanding living donation. Desensitization programs have been increasingly utilized to permit blood type and/or HLA-incompatible pairs to proceed with transplantation (4). The establishment of kidney exchange networks that assist willing but incompatible (blood type or HLA type) donors to help their recipient-to-be is growing exponentially (5). Altruistic donors who wish to donate but have no particular person in mind have been gradually accepted and are now welcomed as ameans to help the organ shortage and to help in the initiation of paired kidney chains (6). With these very important advances, where are we now? These efforts thus far have been only modestly effective at sustaining, rather than dramatically expanding, organ donation (1). With this perspective, many individuals (in health care, policy making, and patient advocacy) have raised the question of whether financial incentives should be considered. The feasibility of incentive programs has been established in other countries. In Iran, for example, a system of regulated paid donation has resulted in a near-elimination of the waiting list, with the important recognition that kidney transplantation is predominantly performed using unrelated living donors (7). A cost analysis comparing expenses of dialysis and transplantation demonstrated that in the United States, a cost savings of .$90,000 could be achieved for each recipient if living donation could replace dialysis (8). The authors suggested strategies in which this savings could be utilized to support and encourage living donation (9), which was recently elaborated on in an international workgroup meeting dedicated to the subject (10). When it comes to payment for organ donation, just because it can be done does not fully addresswhether it should be done (11). Ethical arguments against regulated payments for living kidney donation include the extent to which financial incentives may interfere with truly informed consent due to changes in perception of risk, the potential that lower-income individuals will be disproportionately motivated by financial incentives and increasingly placed in positions of subservience to a wealthier population, and the risk that financial incentives will negatively affect rates of altruistic donation. Interestingly, a recent survey of residents in the greater Philadelphia area suggest that lower-income individuals are more likely to be willing to donate a kidney both altruistically (without payment) or with a hypothetical incentive of $10–100,000 than higher-income counterparts, but did not find evidence that payments negatively influence an individual’s willingness to altruistically donate (12). It is with these issues at hand that Barnieh and colleagues report a novel perspective on public attitudes toward payments to organ donors in this issue of CJASN (13). They performed a survey of Canadian citizens using a web-based questionnaire to determine if financial incentives were considered acceptable and would alter individual perceptions for both deceased and living kidney donation. The survey targeted not only health care professionals and patient groups that are tied to nephrology care but also the general public. They report a general acceptance of the concept of financial incentives for both deceased (approximately 70%) and living (approximately 40%) donors, but it is important to distinguish the type of incentive that was supported, and what type was viewed less favorably. Interestingly and importantly, very few found Division of Renal Diseases and Hypertension, Transplant Center, University of Colorado Denver, Aurora, Colorado