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Should we pay donors to increase the supply of organs for transplantation? Yes
Arthur J Matas, professor of surgery
1 Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, Minnesota 55455
matas001@umn.edu
Paymentfor livingkidney donation is illegal in most countries. Arthur Matas believes that legalisation is needed to shorten waiting times, but Jeremy Chapman (doi: 10.1136/bmj.a179) argues that it will reduce the supply of all organs
Today’s biggest problem in kidney transplantation is the shortage of organs; a regulated system of compensation for living donation may be a solution. For patients with end stage renal disease, a kidney transplant provides significantly longer survival and better quality of life than dialysis. The longer candidates wait on dialysis, the worse the results of transplantation. Thus, early transplantation confers an important advantage.
Each year, more patients are placed on the waiting list for a deceased donor transplant than there are available organs. Consequently, each year the waiting list, and the resultant waiting time, get longer. In many parts of the United States, the average wait for a deceased donor transplant is five years; in some parts, it is approaching 10 years. Because of the long wait, the death rate for candidates is increasing: from 6.3% annually in 2001 to 8.1% in 2005. Importantly, those who died were acceptable transplant candidates when listed.
Regulated payment
Any system of payment to increase the supply of organs must be regulated. In the unregulated systems that currently exist, the buyer contracts with the seller to purchase a kidney (often through a broker). Only the rich can benefit and there is little oversight of the donor evaluation, no long term donor follow-up, and no protection of either the buyer or the seller.
However, a regulated system would provide strict control and limit harm. It would include payment made by the government or insurance companies; allocation of kidneys by a predefined algorithm so that every candidate has an opportunity for a transplant; full donor evaluation; informed consent; oversight; long term follow-up; treatment of the donor with dignity and appreciation for providing a lifesaving gift; and illegality of any other commercialisation. The compensation could be a fixed package of life insurance, long term health insurance, and reimbursement for travel expenses and time out of work; it could involve a direct payment or a tax deduction. Because dialysis is much more expensive than a transplant, compensation for donation could be cost neutral to the healthcare system.
Such a system would work only in countries where there is appropriate oversight and where long term health care and follow-up for the donor could be guaranteed. Thus, donors would have to reside in these countries.
Unmet need
The main argument for a regulated system is simple. Compensation for living donors will increase the number of transplants and thus decrease death and suffering on dialysis. Why compensation for living donation? Because even if all potential deceased donors became actual donors, there would still be a substantial shortage of organs. Clearly, every attempt must be made to increase conventional living and deceased donation, but no other alternative (or combination of alternatives) to compensation will provide sufficient numbers of kidneys. The short and long term risks for living donors have been studied extensively, so thorough donor informed consent is possible.
There are additional reasons to consider a regulated system. Firstly, unregulated systems that do not protect living donors currently exist in several countries. Many patients, desperate for a transplant, travel to take advantage of these unregulated systems. Development of a regulated system would minimise this "transplant tourism." Secondly, a regulated system respects the autonomy of potential donors, in contrast to our current paternalistic ban on compensation that assumes individuals are incapable of deciding what is in their own interest. Surveys suggest that the public favours compensation and that compensation would increase donation.
Numerous arguments have been proposed against a regulated system. On detailed analysis, each fails.We accept living donation; thus, to be successful, arguments must differentiate compensated from conventional living donation, which many fail to do. Other arguments used against regulated payment have no supportive data (but that lack could be resolved by a clinical trial) or are illogical—for example, that unregulated systems have failed elsewhere. Arguments that payment for organs will commodify the body ignore the fact that we already compensate people for sperm, ova, surrogate motherhood, and loss of body parts in court cases, without any loss of humanity or dignity. And arguments that the poor will be exploited ignore the fundamental tenet of Western society—that people be allowed to control their own destiny; being poor does not remove the ability to make rational decisions, and people are free to pursue reasonable options to better their lives.
At first glance, compensation for donors might appear repugnant. Yet to me, what is truly repugnant is the sad reality of patients dying and suffering while waiting for a kidney. In an ideal world, there would be no end stage renal disease. But since this is unlikely, I believe we should advocate a change in the law to allow a trial of regulated compensation for living donors to increase the supply of organs and protect the health and dignity of waiting patients.
Competing interests: None declared.
Should we pay donors to increase the supply of organs for transplantation? Yes
Arthur J Matas, professor of surgery
1 Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, Minnesota 55455
matas001@umn.edu
Paymentfor livingkidney donation is illegal in most countries. Arthur Matas believes that legalisation is needed to shorten waiting times, but Jeremy Chapman (doi: 10.1136/bmj.a179) argues that it will reduce the supply of all organs
Today’s biggest problem in kidney transplantation is the shortage of organs; a regulated system of compensation for living donation may be a solution. For patients with end stage renal disease, a kidney transplant provides significantly longer survival and better quality of life than dialysis. The longer candidates wait on dialysis, the worse the results of transplantation. Thus, early transplantation confers an important advantage.
Each year, more patients are placed on the waiting list for a deceased donor transplant than there are available organs. Consequently, each year the waiting list, and the resultant waiting time, get longer. In many parts of the United States, the average wait for a deceased donor transplant is five years; in some parts, it is approaching 10 years. Because of the long wait, the death rate for candidates is increasing: from 6.3% annually in 2001 to 8.1% in 2005. Importantly, those who died were acceptable transplant candidates when listed.
Regulated payment
Any system of payment to increase the supply of organs must be regulated. In the unregulated systems that currently exist, the buyer contracts with the seller to purchase a kidney (often through a broker). Only the rich can benefit and there is little oversight of the donor evaluation, no long term donor follow-up, and no protection of either the buyer or the seller.
However, a regulated system would provide strict control and limit harm. It would include payment made by the government or insurance companies; allocation of kidneys by a predefined algorithm so that every candidate has an opportunity for a transplant; full donor evaluation; informed consent; oversight; long term follow-up; treatment of the donor with dignity and appreciation for providing a lifesaving gift; and illegality of any other commercialisation. The compensation could be a fixed package of life insurance, long term health insurance, and reimbursement for travel expenses and time out of work; it could involve a direct payment or a tax deduction. Because dialysis is much more expensive than a transplant, compensation for donation could be cost neutral to the healthcare system.
Such a system would work only in countries where there is appropriate oversight and where long term health care and follow-up for the donor could be guaranteed. Thus, donors would have to reside in these countries.
Unmet need
The main argument for a regulated system is simple. Compensation for living donors will increase the number of transplants and thus decrease death and suffering on dialysis. Why compensation for living donation? Because even if all potential deceased donors became actual donors, there would still be a substantial shortage of organs. Clearly, every attempt must be made to increase conventional living and deceased donation, but no other alternative (or combination of alternatives) to compensation will provide sufficient numbers of kidneys. The short and long term risks for living donors have been studied extensively, so thorough donor informed consent is possible.
There are additional reasons to consider a regulated system. Firstly, unregulated systems that do not protect living donors currently exist in several countries. Many patients, desperate for a transplant, travel to take advantage of these unregulated systems. Development of a regulated system would minimise this "transplant tourism." Secondly, a regulated system respects the autonomy of potential donors, in contrast to our current paternalistic ban on compensation that assumes individuals are incapable of deciding what is in their own interest. Surveys suggest that the public favours compensation and that compensation would increase donation.
Numerous arguments have been proposed against a regulated system. On detailed analysis, each fails.We accept living donation; thus, to be successful, arguments must differentiate compensated from conventional living donation, which many fail to do. Other arguments used against regulated payment have no supportive data (but that lack could be resolved by a clinical trial) or are illogical—for example, that unregulated systems have failed elsewhere. Arguments that payment for organs will commodify the body ignore the fact that we already compensate people for sperm, ova, surrogate motherhood, and loss of body parts in court cases, without any loss of humanity or dignity. And arguments that the poor will be exploited ignore the fundamental tenet of Western society—that people be allowed to control their own destiny; being poor does not remove the ability to make rational decisions, and people are free to pursue reasonable options to better their lives.
At first glance, compensation for donors might appear repugnant. Yet to me, what is truly repugnant is the sad reality of patients dying and suffering while waiting for a kidney. In an ideal world, there would be no end stage renal disease. But since this is unlikely, I believe we should advocate a change in the law to allow a trial of regulated compensation for living donors to increase the supply of organs and protect the health and dignity of waiting patients.
Competing interests: None declared.
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