75% of nephrologists surveyed agree with donor health insurance
Executive Summary
A minority of nephrologists favor rewards for organ donation, many agree with some compensation, and a considerable majority favor donor health insurance, according to a recent survey.
• Time required for evaluation, surgery, recuperation, and follow-up often are underappreciated by donors.
• If money value is put on organs, people in dire financial situations might be induced into giving away one of their organs in return for money.
• Financial coercion would require far more scrutiny by the donation team.
Ethical debate still rages over compensation for organ donors
Of 1280 nephrologists surveyed in a 2014 study, a minority indicated they favor rewards for donation, many agree with some compensation, and a considerable majority favor donor health insurance.1
According to the study, 75% of nephrologists agree with donor health insurance, 26% favor direct financial compensation, and 31% agree with financial rewards for unrelated donors. Sixty-six percent indicated that they believe the rewards will lead to increased donation.
However, 73% of the nephrologists indicated that rewards will lead to exploitation of the poor, and 37% believe that rewards will negatively impact deceased-donor transplantation.
"In our living donor transplant team, we often refer to the donor process as the gift that keeps on taking,’" says F. Keith Stirewalt, PA, MBA, MDiv, advance care planning coordinator and Independent Living Donor Advocate at Wake Forest Baptist Medical Center in Winston-Salem, NC.
Despite the apparent benefits to the recipient, economics of time — evaluation, surgery, recuperation, and follow-up — often are underappreciated until experienced by the donor, he explains.
"These costs’ may present disproportionate burden upon those in lower and middle incomes," adds Stirewalt. For those involved in manual labor, post-surgical physical restrictions disproportionately affect the ability to return to full duty and full pay.
"Transplant surgeons and team members know of the effect on the donor pool," he says. "All too well, they see the significant life change of living with dialysis versus the life change after receiving a kidney."
An unmentioned implication of remuneration centers around kidney paired donation, says Stirewalt. "While some studies indicate that air shipping a paired donation kidney is without difference in short-term graft outcome, most programs prefer donations local to the recipient," says Stirewalt.
In these cases, the economic and time burdens on donors are magnified. "Rewards and compensations may greatly increase the utilization of paired kidney exchanges, ultimately saving the health system significant expense while improving the health of the public," says Stirewalt.
Risk of harm to donors
There are two central ethical concerns involving compensation for organ donors, says Alberto Giubilini, PhD, a research associate at the Centre for Applied Philosophy and Public Ethics at the Charles Sturt University-Canberra in Australia. "First, some people simply do not see the human body or its parts as something that can be exchanged in return for money or for some other form of compensation," he says.
Many people see the human body as something sacred and inviolable, he explains, and different from other items of private property that one can decide to buy and sell.
"The second type of ethical concern is, in my view, more compelling, and has to do with the risks of exploitation and of harms to donors," says Giubilini. If money value is put on organs, people in dire financial situations might be induced into giving away one of their organs in return for money.
"This decision might have serious health consequences for [donors], especially if the transaction happens, as is often the case, in a black market where no adequate medical follow-up is guaranteed," says Giubilini.
However, says Giubilini, there isn’t necessarily a link between compensation for organs and exploitation. "For example, if the State controls the transaction and offers reasonable compensation to organ donors, then it is unlikely that the transaction will turn out to be exploitative," he says.
More scrutiny required
Rewards for donation must be accompanied by even greater scrutiny by the living donation team, urges Stirewalt. "Active coercion can be difficult to identify. Passive coercion — especially financial coercion — would require far more scrutiny," he says.
Giubilini argues that it would be paternalistic to prohibit compensation for organ donors just because of the risk of exploitation or of harms to vendors. "Compensation for organ donors certainly is one way to increase organ supply," he says. "But there are alternatives that can be nearly as effective."
One such alternative is increasing deceased organ donations through opt-out systems, whereby people are considered to be willing organ donors after their death unless they declare otherwise.
"There is strong evidence showing the effectiveness of opt-out systems," says Giubilini. "For some mysterious reason, however, many countries are unwilling to enforce this type of policy."
This results in a great demand for organs and with many people — especially those from poor countries — willing to sell their organs, says Giubilini. "Because many states are unwilling to legalize organ sales either, black markets in organs will continue to flourish," he says. "And it seems to me this is the worst scenario possible."
- Ghahramani N, Karparvar Z, Ghahramani M, et al. International survey of nephrologists’ perceptions and attitudes about rewards and compensations for kidney donation. Nephrol Dial Transplant. 2013;28(6):1610-1621.
- F. Keith Stirewalt, PA, MBA, MDiv, Advance Care Planning Coordinator/Independent Living Donor Advocate, Wake Forest Baptist Medical Center, Winston-Salem, NC. Phone: (336) 716-5811. E-mail: [email protected].
- Alberto Giubilini, PhD, Research Associate, Centre for Applied Philosophy and Public Ethics, Charles Sturt University-Canberra, Australia. E-mail: [email protected].
