Tuesday, July 12, 2022

Evidence based medical policy: compensation for donors, by Luke Semaru and Arthur Matas in the AJT

The American Journal of Transplantation has posted ahead of print a great article proposing clinical trials of a sensible system by which kidney donors might be compensated.  It's main point is that evidence might be useful...

 A Regulated System of Incentives for Living Kidney Donation: Clearing the Way for an Informed Assessment by Luke Semaru, and Arthur J. Matas

First published: 25 June 2022 https://doi.org/10.1111/ajt.17129

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/ajt.17129

Abstract: "The kidney shortage continues to be a crisis for our patients. Despite numerous attempts to increase living and deceased donation, annually in the United States, thousands of candidates are removed from the kidney transplant waiting list because of either death or becoming too sick to transplant. To increase living donation, trials of a regulated system of incentives for living donation have been proposed. Such trials may show: 1) a significant increase in donation, and 2) that informed, incentivized donors, making an autonomous decision to donate, have the same medical and psychosocial outcomes as our conventional donors. Given the stakes, the proposal warrants careful consideration. However, to date, much discussion of the proposal has been unproductive. Objections commonly leveled against it: fail to engage with it; conflate it with underground, unregulated markets; speculate without evidence; and reason fallaciously, favoring rhetorical impact over logic. The present paper is a corrective. It identifies these common errors so they are not repeated, thus allowing space for an assessment of the proposal on its merits."

The article begins with some relevant history:

"The  concept  of  incentives  for  living  donation  arose  early  in  the  history  of  kidney  transplantation.  In  the 1960s, the framers of the Uniform Anatomical Gift Act noted “every  payment  is  not necessarily  unethical”,  but  “until  the  matter  of  payment becomes a  problem  of  some  dimensions,  the  matter  should  be  left  to  the  decency  of  intelligent  human  beings”.1  In  1983, the  matter  of payment  became a problem when,  in response to the organ shortage, a physician  (whose license had previously  been revoked) established a company to broker international  kidney sales. Impoverished  residents of low-income countries  were to be flown  to the United States to sell their kidneys at a nominal  price. This was met with general condemnation,  and in part, led to passage of the  National  Organ  Transplant  Act (NOTA,  Public Law 98-507) which made it a federal crime to “knowingly  acquire, receive or otherwise transfer any  human  organ for valuable consideration for use in human  transplantation...”.  At  the  same  time,  the  World  Medical  Association,  the  World  Health  Organization,   the  Council  of  Europe,  and  the  International  Council of the Transplantation  Society, among others, issued statements  of opposition to the sale of organs. "


"We are not tempted to conclude,  for example, that,  since in the 1920s Prohibition brought  about  an increase in political corruption  and organized crime, the sale of alcohol,  when  legal  and  regulated,  would  do  the  same.  For the same reason, we should not be tempted to conclude  that, since participants in unregulated  markets were swindled by outlaws, incentivized  donors in a regulated system will fare the same."

No comments: