Incentives for postmortem organ donation: ethical and cultural considerations.

Chronic shortage in organs for transplantation worldwide is leading many policymakers to consider various incentives that may increase donation rates. These range from giving holders of donor cards some priority on the transplant waiting list or a discount on health insurance premiums, to giving families who consent to donation a medal of honour, reimbursement of funeral expenses, tax incentives or even financial compensation. Of the various proposed incentive mechanisms, the one that has consistently garnered the most criticism and objection in the literature is that of paying families who consent to donate the organs of a deceased loved one. Arguments against such a policy abound: it could exploit the poor, influence the family to prematurely withdraw care, encourage families to withhold medical information that would result in transplanttransmission of disease, and finally, it would commercialise the value of human life and result in the perception of human organs as commodities. Indeed, to date no Western country has adopted a policy of financial compensation to families for consenting to organ donation. Recently, a country suffering from severe shortage in organs has implemented a policy of financial incentives that uses cash payments. Wu and Fang describe a recent pilot programme in China that compensates families for postmortem donation, through an independent third party (the Red Cross Society of China) and based on consent or presumed consent (ie, no documented past objection) of the deceased. The particular context within which this programme is implemented validates and even exacerbates some ethical concerns that have been voiced in the Western medical and bioethics literature. Two distinctive features of this programme—paying families in extreme financial distress and the context of cultural resistance—carry particular ethical implications that I will address in this commentary. VULNERABILITY AND VOLUNTARY CONSENT The Chinese programme involves payment to families as an expression of gratitude for their good deed (funeral expenses, $1600 to purchase a grave plot and a $3200 allowance). However, families in need can apply for ‘extra compensation’ based on their degree of need or the financial loss they suffered as a result of the death of the loved one. This is described by Wu and Fang as a charitable act towards those most in need. They explain that a committee reviews the specific financial circumstances of the family in question; for example, how many dependants there are and whether the surviving spouse can support the family. Based on its evaluation (but without any official transparent criteria) it determines what additional amount will be paid (up to $4800). A family in need can therefore receive between $5000 and $10 000 for consenting to organ procurement from their deceased relative. To put this incentive into context, in 2012 the annual per capita net income of rural households in China was ¥7917 (about $1270), which means that the compensation offered for consent to organ procurement would be equivalent to about 4–8 years’ income. One might argue that this is a win-win situation: lives are saved through the donated organs, and the family is receiving a form of financial social assistance it needs to help it survive the tragedy. However, when a very large financial incentive is offered to an extremely vulnerable population, the tremendous pressure to accept the offer may cast a doubt over the voluntariness of the consent. Imagine a family that just lost its breadwinner, perhaps even facing medical bills—is such a family in a position to refuse such an amount? Indeed, Wu and Fang mention that 90% of the families who consented within this new programme ‘faced financial difficulties’. This particular scenario of extreme financial need combined with a very large payment highlights ethical concerns that have been put forth in the literature for years regarding financial compensation for postmortem donation as threatening the voluntariness of the family’s consent. Moreover, considering the vulnerability of the family and the looming threat of growing medical bills, one might wonder what effect this additional incentive might have regarding the decision to withdraw care, another concern often voiced in the literature.