AST/ASTS Workshop on Increasing Organ Donation in the United States: Creating an “Arc of Change” From Removing Disincentives to Testing Incentives
D. R. Salomon,*, A. N. Langnas, A. I. Reed, R. D. Bloom, J. C. Magee, R. S. Gaston for the AST/ASTS Incentives Workshop Group (IWG)a
Article first published online: 31 MAR 2015
"The American Society of Transplantation (AST) and American Society of Transplant Surgeons (ASTS) convened a workshop on June 2–3, 2014, to explore increasing both living and deceased organ donation in the United States. Recent articles in the lay press on illegal organ sales and transplant tourism highlight the impact of the current black market in kidneys that accompanies the growing global organ shortage. We
believe it important not to conflate the illegal market for organs, which we reject in the strongest possible terms, with the potential in the United States for concerted action to remove all remaining financial disincentives for donors and critically consider testing the impact and acceptability of incentives to increase organ availability in the United States. However, we do not support any trials of direct payments or valuable considerations to donors or families based on a process of market-assigned values of organs. This White Paper represents a summary by the authors of the deliberations of the Incentives Workshop Group and has been approved by both AST and ASTS Boards.
"The overarching theme that emerged from this Workshop was that challenges of considering any form of incentives for organ donation should be viewed as a series of decisions to be made along an ‘‘arc of change.’’ This arc begins with optimization of the current system, but should proceed rapidly to identify and remove existing disincentives that impede the organ donation process. Removing disincentives should be the immediate priority.
"The debate regarding implementation of any incentives is limited by vague semantics: one person’s incentive (provision of health insurance for donors) is another’s removal of disincentive (lack of consistent access to post-donation healthcare). In the near term, an operational process of removing disincentives would help define where the line now exists in the United States, and the potential impact of incentives to be better defined. Additionally, the line between incentives and removing disincentives must also be determined by existing medical practices, ethics, health policy and law including the National Organ Transplant Act passed by Congress in 1984 (20). This line would also be defined by the attitudes of the American public. Engaging the public in consideration of the potential of incentives to increase organ availability was recognized as an important task for both Societies. A shared statement on the current state of the field and the potential for incentives was considered a good start. Developing an operational plan together to address the challenges should follow.
"An Arc of Change for Living Donors: Exploring Incentives
By the end of the meeting, it was agreed that though donors assume medical risk and, in most cases, the financial costs associated with donation, everyone else involved in the organ transplant process (recipients, physicians, hospitals, and associated professionals) benefits, most often financially. Might changing this dynamic encourage more potential donors to become actual donors? Thus, the IWG considered whether some kind of payments might be made
to donors as honorariums. But the IWG realized that the challenge would be to determine how compensation for such risks could be operationalized. Simply paying out money to donors based on some schedule of increasing risks was unlikely to be acceptable at this time and the legal framework for such a practice is uncertain. However, starting the process of establishing a consensus on the relative risks of living donation was considered to be a good first step and consistent with the growing imperatives to optimize the safety of living organ donation."