Each week, In Theory takes on a big idea in the news and explores it from a range of perspectives. This week we’re talking about government compensation for organ donors.
Sally Satel is a resident scholar at the American Enterprise Institute and a lecturer in psychiatry at Yale University School of Medicine. She is the editor of “When Altruism Isn’t Enough: The Case for Compensating Kidney Donors.”
My interest in the national organ shortage began one steamy afternoon in August 2004. That day, my doctor told me my kidneys were failing. As a physician myself, I knew immediately that I would need to find a replacement organ or else face a shortened life tethered to a dialysis machine. My search was rocky at first, but finally I did get a kidney from a casual friend — now a very dear one.
At the time of my search, there were about 60,000 people on the national waiting list maintained by the United Network for Organ Sharing. Today, a decade later, there are roughly 101,000. Meanwhile, donation rates from both living and deceased donors are effectively flat. The death toll is 12 people per day — individuals who could not survive the years-long wait for an organ.
Clearly, our current organ transplant policy is a qualified failure. And it is because our current system, by law, mandates altruism as the sole legitimate motive for organ donation. We need to give more healthy young and middle-age people a reason to become living donors.
Tragically, altruism is not enough. The yield from public awareness campaigns, the organ procurement teams that meet with families of the recently deceased and the reimbursement for donors’ expenses has leveled off. Moving to an opt-out system, under which we would harvest people’s organs at death unless they had earlier indicated they didn’t wish to donate them, can do only so much — relatively few people die in ways that leave their organs suitable for transplantation.
So, to save lives, let’s test incentives. A model reimbursement plan would look like this: Donors would not receive a lump sum of cash; instead, a governmental entity or a designated charity would offer them in-kind rewards, such as a contribution to the donor’s retirement fund; an income tax credit or a tuition voucher; lifetime health insurance; a contribution to a charity of the donor’s choice; or loan forgiveness.
Meanwhile, the law can impose a waiting period of at least six months before people donate, ensuring that they don’t act impulsively and that they offer fully informed consent. Prospective compensated donors would be carefully screened for physical and emotional health, as all donors are now. These arrangements would filter out financially desperate individuals who might otherwise rush to donate for a large sum of instant cash and later regret it.
The donors’ kidneys would be distributed to people on the waiting list, according to the rules now in place. (People who wanted to donate a kidney to a specific person — say, a father to a son — would still be able to, alongside this system.) Finally, all rewarded donors would be guaranteed follow-up medical care for any complications, which is not ensured now.
The good news is that the general notion of incentivizing donations is gaining traction. A 2009 poll of the membership of the American Society of Transplant Surgeons revealed that 80 percent supported or were neutral toward the provision of tax credits for donors. In 2014, the American Society of Transplantation and the American Society of Transplant Surgeons published the results of a workshop in which the societies expressed approval of testing third-party, in-kind incentives. A few weeks ago, the American Medical Association passed a resolution in favor of testing the effect of incentives on living and deceased donation. (A reward for deceased donation could take the form of a funeral subsidy or a contribution to the estate of the deceased.)
The objections I heard years ago seem to be wearing thin. Take the objection that rewarding donors “commodifies the body.” We already commodify the body, speaking strictly, every time there is a transplant: The doctors get paid to manipulate the body. So does the hospital and the agency that obtains and transports the organ. Why would we now object to enriching the donor — the sole individual in this entire scenario who gives the precious item in question and assumes all the risk?
At the heart of the “commodification” claim is really the concern that donors will not be treated with dignity. But dignity is affirmed when we respect the capacity of individuals to make decisions in their own best interest, protect their health and express gratitude for their sacrifice. Material gain, per se, is not inconsistent with this. The true indignity is to stand by smugly while thousands of people die each year for want of an organ.
Some worry that that rewarded donation will attract only low-income people. This is possible, though only a trial project can provide the answer. But even if this turns out to be the case, why doubt the capacity of low-income people to make decisions in their own interest? From the standpoint of the recipient, it is low-income individuals who stand to benefit the most, as they are disproportionately represented among those waiting for a kidney.
Yet regardless of who ends up donating, any plan must ensure that donors’ decisions are thoroughly informed, their health is protected and they are amply rewarded. As the organ waiting list grows, the need to test incentives becomes stronger and stronger.
We need to liberate patients from the tyranny of “the gift.” It’s glorious when you are the recipient, as I know better than most, but the penalty for being unlucky should not be premature death. Hollow moralizing from critics in the face of so much needless suffering must be replaced by sensitive and pragmatic policy.
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