Payments found to increase willingness to donate a kidney
■ While concerns have been raised that paying for organ donation could exploit the poor, a survey found payment motivation was consistent across the financial spectrum.
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What would happen if it were legal in the United States to pay living kidney donors?
Would fewer donors give altruistically, ultimately driving down overall donation rates? Would the poor, motivated by a quick payday, face exploitation and grave health consequences?
Short of a real-world pilot test, physicians and medical ethicists have been left to speculate about the consequences of using financial incentives to secure kidneys for the 83,868 patients on the United Network for Organ Sharing waiting list as of mid-March.
But a study in the March 16 Annals of Internal Medicine used a sophisticated survey of 409 Philadelphia-area commuters to see how willing people would be to donate under 12 different scenarios and found that many concerns about paying kidney donors may be overblown. Among other things, participants were asked how willing they would be to donate a kidney to family members or strangers for no pay, for $10,000, or $100,000.
"The study provides no evidence whatsoever that the poor would be exploited or wouldn't make informed choices," said Scott D. Halpern, MD, PhD, the study's lead author and assistant professor of medicine and epidemiology in the division of pulmonary and critical care medicine at the University of Pennsylvania School of Medicine. "The central finding is that payments do not seem to influence the poor more than the rich. The influence of a $10,000 payment on people earning more than $100,000 a year is the same as a $10,000 payment is for people earning less than $20,000 a year."
Payments would nearly double the likelihood that individuals would donate a kidney to a stranger, the study found, but the influence of those payments was felt evenly across all income groups surveyed. The poorest respondents were the most likely to say they would donate to a stranger for no pay.
Meanwhile, potential donors did seem to take risk into account.
Survey participants were asked how willing they would be to donate to family members or strangers given a 0.1%, 1% or 10% lifetime chance of the donor developing renal failure. The greater the health risk, the less likely respondents were to donate, even when big-money offers were included in the scenario.
But skeptics of paying kidney donors said the study does not answer as many questions as Dr. Halpern and his colleagues assert.
"This new empirical data, while important, is not really sufficient to establish that it's not a policy mistake to allow a market in organs," said David Magnus, PhD, director of the Stanford University Center for Biomedical Ethics in California. He said the study assumes a perfectly regulated market in which the government, through UNOS, controls the distribution of kidneys and no recipients are able to bid up the price through illicit payments.
"Most of the literature [objecting to paying kidney donors] is about the slide from a seller's market to a buyer's market," Magnus said.
Alexander M. Capron echoed that concern. "I'd suggest that people take a close look at the natural experiments around the world. Even where you have government-run programs like Iran, you end up with under-the-table payments to donors," said Capron, professor of law and medicine at the University of Southern California Keck School of Medicine and co-director of the Pacific Center for Health Policy and Ethics.
"Once you make the kidney into a commodity, people are going to treat the human beings like a commodity," Capron said.
Sally Satel, MD, who received a kidney from a living donor in 2006, lauded the study for attempting to answer concerns about paying for kidneys. She said the current shortage -- 13 people waiting for a kidney transplant die each day -- should push the country toward a pilot test.
"It doesn't seem logical to do nothing ... because of an unlikely distant scenario in the face of the immediate and inevitably worsening crisis that we have now," said Dr. Satel, a psychiatrist and author of When Altruism Isn't Enough: The Case for Compensating Kidney Donors.
The American Medical Association favors pilot-testing financial incentives for cadaveric organ donation.