I discuss ways to extend kidney exchange by initiating nondirected donor chains with some deceased donor organs, and by developing international kidney exchange (along the lines of what Mike Rees calls reverse transplant tourism). Reducing barriers to participation by transplant centers would also help (e.g removing financial barriers with some kind of standard acquisition fee) and removing barriers for enrolling easy to match pairs, including compatible pairs. I also discuss ways to increase deceased donor registration, including priorities for donors, and providing other kinds of incentive for donation.
Here are some relevant passages from the rest of the paper:
"Extending the reach of kidney exchange
"One way to make kidney exchange accessible to more patients would be to simplify participation. Developing a standard acquisition charge for living donor kidneys would remove some barriers that arise e.g. from different costs of nephrectomies at hospitals that may need to ship each other kidneys. And matching algorithms could be adjusted to guarantee hospitals that they and their patients won’t lose transplants or sacrifice patient care if they enroll all pairs in exchange (and not just hard-to-match pairs).17 Enrolling easy-to-match pairs, including compatible pairs, can be organized to help those pairs find better matches, and also makes it much easier to find matches for hard-to-match pairs.9, , Incentives for transplant centers to enroll their non-directed donors are already being implemented (a chain typically is terminated with a patient on the waiting list of a center that enrolled a non-directed donor).
"Another way to accomplish more transplants through exchange would be to allow some non-directed donor chains to be initiated with deceased donor kidneys1 which, properly organized, could facilitate more transplants and shorten the wait for deceased donor kidneys for all patients.
"Kidney exchange in the developed world could also be extended to patient-donor pairs from countries in which treatment for ESRD is essentially unavailable for large parts of the population. Such patient-donor pairs could, for example, be invited to come to the U.S. to participate in kidney exchange , financed by the American taxpayer from the savings that result from removing an American from dialysis through receiving a transplant, which are more than sufficient to finance the additional surgeries. (The bureaucratic obstacles to such exchanges and financial arrangements will be formidable, but the potential to aid both domestic and foreign patients is substantial.)
How else to increase donation?
"There remain many avenues other than kidney exchange through which the shortage of transplantable organs might be reduced.
"In the U.S., the scope for recovering many more transplantable organs from deceased donors seems somewhat limited for most organs, given current technology and recovery rates. But there is suggestive evidence that more frequent opportunities to register as a deceased donor would increase registration, and that the manner in which registration is solicited can influence rates of family consent for donation.
"There is growing consensus that donors should not face financial disincentives from donating, , and recent evidence that the costs borne by living donors are substantial enough to reduce donation in recessions. , There is consequently great interest in exploring ways to remove disincentives or provide inducements for donation.
"Several novel features of recent Israeli legislation are worth study. Deceased donation is encouraged by giving registered donors and next-of-kin of deceased donors some priority to receive deceased donor organs. Living kidney donors are also reimbursed 40 days wages, at their own wage rate, to offset the costs of donation. Initial indications are that the new Israeli law is increasing donation.
"The most contentious part of the discussion of how to increase donation concerns cash compensation to donors, particularly living kidney donors. With the prominent exception of Iran, which specifically permits cash payments for kidneys , there does not appear to be a legal market for the purchase and sale of organs for transplant anywhere else, although illegal black markets are widely reported, and occasionally prosecuted.
"However the critical shortage of transplantable organs around the world prompts continual discussion of whether to relax the ban on cash compensation. For example, the March 2014 issue of the Journal of Medical Ethics devoted five articles to the subject, all by philosophers. While this discussion is too important to be left only to philosophers, neither can it be confined to the ongoing debate among transplant professionals, given the public resources devoted to transplantation and the important implications transplantation has for health policy.
"The arguments, pro and con, will already be largely familiar to those who follow this debate. I will simply try to add some context to the discussion by noting that the ban on organ sales is not unique: other kinds of markets have also been banned in the past, and presently, and laws have changed over time.
"Of course, banning markets does not always end them: black markets for narcotics make clear that outlawing markets is simpler than abolishing them. In the United States, the manufacture and sale of alcoholic beverages was illegal from 1920 to 1933, during which time black markets for alcohol thrived. Less familiarly, an 1824 editorial in The Lancet comments on the black market in which medical schools bought cadavers for dissection from grave robbers, known as “resurrection men,” because the only cadavers that could legally be dissected were from executed murderers. (The Anatomy Act of 1832 expanded the sources of legal cadavers for dissection in Britain.)
"Let’s call a transaction repugnant if some people want to engage in it, and others, who aren’t materially affected, don’t think they should be allowed to .
"By this definition, sales of kidneys are widely repugnant, as are (or were) the sale of narcotics, alcohol, and cadavers. But note that the ban on kidney sales is different from these other bans, since there is, or was, general disapproval of narcotics, alcohol, and dissection. But there is no similar disapproval of kidney donation and transplantation; it is only sales that are repugnant.
"This turns out not to be too unusual: a transaction that is not otherwise repugnant sometimes becomes so when money is added to the mix. For example, charging interest on loans was largely banned in medieval Europe, although loans were permitted. (The relaxation of that ban has had profound effects on the modern economy.) Note that repugnance doesn’t only change in one direction—some transactions that used not to be repugnant are widely banned today. Indentured servitude, for example, is no longer legal in the U.S., although it was once a common way of purchasing passage across the Atlantic.41
"Some transactions are banned in some places and not others, e.g. those concerning sale of blood and blood products, and reproductive goods and services such as sperm, eggs, and surrogacy. Legal markets in some places and not others give rise to “fertility tourism,” and many countries that ban payment for blood plasma import plasma products from the U.S., where such payments are legal.
"The repugnance to kidney sales involves concerns about the identity and welfare of potential sellers. The same concerns cause many proposals for allowing some forms of compensation to address the need to avoid exploiting the poor and vulnerable, as existing black markets for kidneys are widely seen to do. The debate on how to proceed seems likely to focus on removing disincentives to donate and providing incentives that are not seen as leading to coercive or exploitative situations. The debate can be furthered by identifying specific sources of repugnance, and considering how inducements could be structured to avoid them. , ,
"In the meantime, kidney exchange has proved to be a way of bringing some of the benefits of exchange to transplantation without running into the barrier of repugnance. So it seems promising to consider ways of extending its reach, as discussed above."