Thursday, March 19, 2015

One surgeon's argument against compensating organ donors, but for removing financial disincentives

Here's another addition to the discussion of how and whether to incentivize live kidney donation, and/or remove financial disincentives to donating, by the medical director of Kidney and Pancreas Transplantation at New York Presbyterian Hospital/Columbia University Medical Center,

Cash for human kidneys: A bad idea is back, By David Jonathan Cohen, MD

Here's the part of his argument--about how incentives in a poorly regulated market could introduce lower quality kidneys from less medically qualified donors--that may be less familiar to readers of the "compensation for donors" posts on this blog. My comments follow...

"I’ve arrived at this position based on my three decades of experience as the medical director of one of the largest kidney transplant programs in the United States, performing more than 100 live donor transplants every year. In this role, as I examine potential live kidney donors, I have seen first-hand how far people will go to try to help loved ones. Many unsuitable donors try to persuade me to allow them to donate anyway, despite high medical risks. Others take steps even more extreme—and dangerous. Consider the 37-year-old woman who, without telling me, stopped her anti-depressants knowing that a history of depression might make her ineligible to donate to her friend. Or the 51-year-old cocaine addict who wanted to help her brother and forged a letter from her physician stating that the cocaine was treatment for a nasal condition. Had we not uncovered this, the outcome for donor and recipient would likely have been disastrous. 
Some go to other transplant centers and change their stories or covertly take medications to normalize their blood pressure or blood sugar in hopes of passing the evaluation, putting their own health at risk and potentially leading to the donation of unsuitable kidneys. 
Now imagine if there were a significant financial reward at stake, increasing the incentives to lie or dissemble. Many would surely do their best to disguise any medical conditions that might prevent them from donating in order to collect the reward, thereby adding to their own medical problems and potentially donating kidneys of lesser quality and thus harming the recipients. After all, they would now be donating to a stranger in order to enrich themselves or to address an urgent financial need, not to save a loved one. 
Doctors, too, would be confronted with terrible dilemmas. Take the potential donor who desperately needs cash or cash equivalent to prevent foreclosure on a home, pay for education for their children, or keep their business open. What is the responsible caring physician to do? It’s easy to say that this would not factor into a medical decision, but doctors are human. It’s hard to see how such considerations could be entirely avoided. " 
This is just a small piece of the longer post, so take a look yourself.

I follow this whole debate closely, and I'm struck by how arguments about many aspects (both pro and con, or con and pro, depending on where you stand) are hampered by the lack of data. So arguments are theoretical, and it seems to me that many of the arguments used with confidence to support one conclusion could equally support the opposite.

Here, Dr Cohen notes the desperation which motivates the "many unsuitable donors" who would like to give a kidney to a loved one to conceal aspects of their medical history (so that they can donate anyway). He argues that would only get worse if kidneys could be purchased. (Just to fix ideas, let's suppose that kidneys could only be purchased by the Federal government, that they would be distributed as deceased donor kidneys now are--i.e. without too much regard to ability to pay--and that there would be stringent health checks before donation--and followup after.)  In such an environment, one could imagine that the need for potential donors to mis-represent their medical history would decrease, rather than increase, if, in this hypothetical world with payments, their loved ones would get transplants through the national system. (To be clear, I am also speaking here without data, since outside of Iran there aren't any legal markets for kidneys, and the Iranian market doesn't work at all like the hypothetical I've just described...)

Speaking of Iran, the same kind of argument-that-could-support-opposite-positions is made with respect to whether large monetary payments might 'coerce' unwilling or unsuitable donors to sell their kidneys. That's an interesting question, but Iranian surgeons have sensibly pointed out that there can be coercion without money: if your mom thinks you should give a kidney to your brother you might be coerced, and that kind of coercion might be decreased if kidneys were more available through e.g. a national market.

So...speaking as an experimental economist and market designer who has watched the waiting list for kidneys grow and grow (see my post on kidney statistics)...I'm increasingly inclined towards allowing the States to experiment cautiously with increasing incentives and removing disincentives to donation...

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