Sally Satel: more on compensating kidney donors

April 18 in The Pacific Standard: Sally Satel on The case for compensating kidney donors

"The current system is a qualified failure. For the past decade, transplant operations for all organs have hovered between 27,000 and 29,000 annually, and, in 2014, was the lowest it's been in 11 years.The European model of "presumed consent," wherein a person's organs are taken posthumously unless an individual has specifically forbidden their retrieval, is not a potent solution as less than one percent of deceased individuals are medically eligible to donate.

"Hence, there is a desperate organ shortage in the United States. The situation in other countries, especially poorer countries without good access to dialysis — a death sentence without immediate transplant — is even worse. As a result, the overseas black market is burgeoning. The World Health Organization estimates that 10 percent of all transplants are performed under shadowy, illicit conditions where the risks are high: Corrupt brokers deceive impoverished and illiterate donors about the nature of surgery, cheat them out of payment, and ignore their post-surgical needs. For the recipient, organ quality can be poor and post-operative management dicey. (The exception appears to be Iran, where organ sales are monitored by the government. There, potential donors exceed the number of needy patients.)
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"Compensating organ donors is not a new idea. In 1983, Al Gore, who championed NOTA, explicitly suggested rewarding donors if altruistic volunteering did not keep up with demand. Moreover, NOTA's legislativehistory implies that the law's felony provision against "valuable consideration" in exchange for an organ was intended to prohibit brokered or direct cash sales between buyer and seller. It is silent regarding a system of in-kind, third-party compensation.

Here is a plan for donor benefits: A governmental entity, or a designated charity, would offer in-kind rewards, like a contribution to the donor's retirement fund, an income tax credit, or a tuition voucher worth roughly $50,000 in value. (This is the amount typically proposed by advocates of incentives.) To enhance deceased donation, a funeral benefit could be offered.

With a third party providing the reward, all recipients, not just the financially secure, will benefit. An imposed waiting period of at least six months would help limit impulsive live donation and, most important, any subsequent remorse. Prospective donors would be carefully screened for physical and emotional health, as is done for all donors currently. Their kidneys could be distributed, according to exiting allocation policies now in place for cadaver organs.

Donors would be guaranteed follow-up medical care for any complications, which is not ensured now. And the cost of the benefits could be underwritten by the enormous savings from dialysis.

Will rewarded donation attract only low-income prospective donors? Perhaps. One option is to require a minimum income for donors, but that strategy prevents all interested parties from participating. Better to start with the assumption that low-income people are capable of making decisions in their own interest. In the end, regardless of who ends up donating, a sound plan ensuring that donors are thoroughly informed, their health protected, and their sacrifice amply rewarded is an ethical one.

How to achieve this? We should start with pilot projects. The Department of Health and Human Services probably could initiate pilot trials, if motivated. The Center for Medicare and Medicaid Innovation has impressively broad authority. In theory, the Center could issue NOTA waivers to academic medical centers interested in administering a pilot program wherein living donors would be rewarded with five years of Medicare coverage.

States should also get involved. The late Pennsylvania Governor Robert P. Casey, who had received a heart and liver transplant a year earlier, signed a 1994 law that would enable a bereaved family of an organ donor to get a burial benefit of up to $3,000 paid by the state directly to the funeral home. State health officials ended up with cold feet, fearing that the law flouted NOTA, but some bold state should proceed with a funeral benefit and force the Department of Justice to action, spurring a vital national debate in the process.

Congressional action is another approach. Lawmakers could amend NOTA to permit pilot trials of incentives by clarifying the intent of the law as a restraint on cash exchange between buyer and seller with or without a broker. The need for a new approach to expanding the supply of donors should resonate with lawmakers on several levels. The first is public health (needless deaths), the second is fiscal (the enormous cost to Medicare — roughly seven percent of its budget is spent on dialysis and its complications), the third is human rights (the global black market); and the fourth is race (minorities are disproportionately disadvantaged by the organ shortage as they are less likely to be referred for transplant)."