People with end-stage kidney disease have two treatment options: dialysis or transplantation. Dialysis is the process of removing waste and excess water from the blood, by hooking up to a machine that mimics the function of the kidney. Transplantation, however, is the optimal treatment for end-stage kidney disease, because it reduces a patient’s risk of death, substantially improves quality of life, and lowers health care costs.
There are two types of kidney donors: deceased and living. Despite having two kidneys, we only need one to survive. Living kidney donation has the greatest potential to increase the number of kidney transplants.
Statistics can be dehumanizing, but help shed some light on the crisis at hand: at the end of 2011 (latest available data from CORR), 1,247 Canadians received a kidney (either living or deceased), and 3,406 were still waiting for a kidney. Supply will never catch up with demand in our current system and only a minority of people who could benefit from a kidney transplant ever receive one.
One strategy to increase the number of kidneys donations that has been discussed, but not tested in Canada, is the use of financial incentives to increase the pool of potential donors.
Though the Human Tissue and Organ Donation Acts across Canada differ in their language, they all state in various terms something to the effect of:
“No person shall offer, give or receive any reward or benefit for any tissue, organ or body for use in transplantation, medical education or scientific research.” Alberta Human Tissue and Organ Donation Act
But this legislation appears out of step with the views of the Canadian public. Despite this legal ban on rewards, gifts or benefit, when over 2000 Canadians were surveyed, the majority were supportive of financial incentives for kidney donation in the form of cash or a tax credit.
We recently published a study on the cost-effectiveness of providing a cash incentive to living donors compared with the current organ donation system. A cost-effectiveness study not only looks at the costs of the financial incentives, as well as the costs of caring for people with kidney failure (i.e. the cost of ongoing dialysis or transplantation), but it also considers the impact on patient outcomes. If something saves money and improves outcomes, its introduction into the health care system is usually a no-brainer.
In our study, we considered a $10,000 cash incentive to a living donor as a one-time compensation, which would be administered by a third party non-profit organization upon donation as a means of increasing the potential pool of donors. Assuming a conservative increase in transplants of 5%, we found that a system where living donors are compensated $10,000 improved the outcomes of recipients and saved the health system money—that is, the strategy of paying donors is highly cost-effective. If transplants were to increase by more than 5%, there would be even better outcomes, with even greater cost savings.
Why would paying donors $10,000 improve outcomes for recipients and save the system money? In short, patients who receive a transplant live longer on average and enjoy better quality of life than those who are unable to get a transplant and who must continue on dialysis. Moreover, dialysis costs more per year, than transplantation overall. The money saved can be used to improve care and shorten waits for other patients.
This financial incentive may be a means of opening up a new pool of potential donors which will add to the current pool of volunteer donors. There have been no trials examining the effects of incentives on donation rates, however, research in other areas of tissue donation does not support the concern that incentives would decrease overall donation rates.
Those opposed to incentives are concerned about the ethics of compensating someone for a kidney: concerns about exploitation, removing the act of altruism from donation, or the commodification of the human body. While these are important, they must be balanced against the ethics of not compensating kidney donors: lower transplant rates that consume precious health care resources, lower quality of life and higher mortality.
We won’t know if or by how much incentives would increase organ donation unless we try it out and assess the impact on donor rates, social justice and public perception. We, however, see the pros far outweighing any potential cons; it is time to stop the rhetoric and gather evidence to support or refute this strategy to increase organ donors.
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I don’t believe donors should be PAID for donation – as a liver donor I’d never accept money for my donation. But changes to PRELOD and or a tax credit which fully compensates for the expenses associated with donation would be good. If you want donors don’t pay us just make sure we aren’t out of pocket.
I am currently going through testing to see if I can be a potential donor for my sister.%featured% I think that as donors we need a safety net. a loss of income or assistance required during the procedure and recovery needs to be compensated. %featured%This would help take the stress off of an already stressful time. Recovering from a surgery that is helping another and our health care system save money should go towards helping a donor during his or her recovery time. It would be nice to have a bit of an incentive to donate but strict testing still needs to be done and money should not be the only reason why. It is a difficult and stressful time and the extra money or tax benifits would be welcomed at this time.
Can we not instead give an incentive to Canadians that do not wish to financially burden their families with a funeral? Perhaps a state-provided funeral would increase the amount of organ donations whilst keeping the act altruistic.
I am a living donor as well. I was just reading that in Utah living donors receive a $10,000 tax credit. This seemed like an excellent idea to me. A way to appreciate the donors but not getting into a straight up financial gift.
My first comment is that of a husband with a wife that is on dialysis. I tried to donate one of my kidneys to my wife and after an extensive screening process I was rejected (worst day of my life) About a year later a friend of ours offered to donate one of his Kidneys again after the screening process was complete he turned out to be a perfect match and we expect the transplant to happen in the next couple of months ( best day of our life) The kidney foundations process ensures the reasons you are trying to donate is just and honorable not reward based. $10,000 will help cover out of pocket costs for the donor while they recover it is not enough of a incentive for an average person to chose to donate you donate because you are a very special person who has the ability to think of others before yourself. After being through the screening proces in Alberta I do not believe people trying to donate for money would be able to get through the system, in fact if you are not motivated by wanting to make the ultimate difference to someone’s life you would not go through the process.
My second comment is the cost of treatment is extremely high if the medical system and society could save the cost of long term dialysis treatments and divert that money to other treatment and research we all benefit .
Paula already spoke to many of my concerns, so let me just add that I think we have to be very mindful of the donor’s situation (both pre- and post- op). They could be doubly vulnerable: (1) motivated by financial incentive alone and desperate, and also (2) vulnerable after-the-fact because they have 1 kidney remaining. Do you have a solution in mind that would allow for some degree of protection, screening, and transparency to optimize the decision-making setting?
Elizabeth Doyle
http://www.elizabethdoyle.weebly.com
@Says_LizDoyle
Thank you Elizabeth.
There are many interesting ethical discussions around some of the points you have raised.
Personally, I’m not sure, as a society, we are allowed to ban those who are motivated by financial gains from taking certain measures. For example, a police officer may take the job because he needs money to feed his family. Should we pass judgment on his decision? Or should he only be allowed to take the job to help others?
We had envisioned a system where the donor would be afford the same protection as they have under the current system. Rigorous physical and psychosocial screening, along with a consent process that is intended to inform the patient of their risks.
I hope this clarifies some of your queries.
My greatest concern with financial incentives for donating organs is that people who are short on cash will start donating organs as a way of getting money quickly. You also open up the risk that exists in countries like India where people have been found by the side of the road with one of their kidneys removed. This is a slippery road to be on and we need to be careful about monetary gain from organs. While people may feel that the pros outweigh the cons, I don’t see that. If someone decides to donate based on cash incentive and the surgery doesn’t work, how will this affect the recipient who may feel that the donor got something out of it but he, the patient, did not? Perhaps the recipient will feel that the donor sold a “bum” kidney. How will the donor feel five years down the road if his/her remaining kidney gives out and now they themselves end up on dialysis? How about the young single mother who sells her kidney out of desperation and so on and so forth. This is not the road we want to be on when it starts becoming a mudslide. I strongly feel donation needs to be completely altruistic. Any cash incentive should be strictly to cover the donors expenes in full.
Thank you Paula.
When we conducted our survey, we did not find any evidence that those in a lower socio-economic bracket would be more willing to donate for money.
We envisioned a system where the donors would be treated as they are treated now – thoroughly screened, with adequate long-term health care.
There is strong evidence that people who have one kidney are not at an increased risk of chronic kidney disease, compared to the general population.
We do currently have reimbursement of expenses for donors, but donation rates are stagnated. This is one strategy we felt warranted further explanation.
Hi Lianne.
A recent article (http://jama.jamanetwork.com/article.aspx?articleid=1829682) documented a very low risk of developing severe kidney disease after live kidney donation (31/10,000 15 years after donation). However, this risk was higher than in people who hadn’t donated a kidney (4/10,000).
The accompanying editorial (http://www.ncbi.nlm.nih.gov/pubmed/24519296) emphasized that living kidney donors have a very low risk of themsleves developing serious kidney disease, and raised some concerns about whether the risk of kidney disease in the comparison group was correctly calcuated.
Nonetheless, this very large study (over 96,000 kidney donors) did find an increased risk of kidney disease in kidney donors, which contradicts your statement above that there is no risk to kidney donors.
Does this information change your views about paying kidney donors?
Thank you Andreas.
Interesting article and it’s a tough call. Living kidney donation violates one of the foundations of modern medicine: do no harm, as you are operating (with some risk) on someone who is completely healthy.
That aside, I believe this is an important piece of the “informed consent” process. I won’t get into the strengths/limitations of the study, but I still believe that people can choose, with properly informed consent, what they choose to do with their body, especially when the end, in my opinion, justifies the means (taking a loved one off dialysis).
Having donated a kidney myself, this was an intriguing article. What occurred to me was if donors were to be compensated some sum of money, funded by a non-profit organization, we are setting up yet another organization requesting donations to exist. Currently I feel that every time I turn around, open my mail or answer my phone I am besieged with requests for donations – all from very worthy causes.
As someone lucky enough to be able to provide donations it isn’t a problem but some non-profits have a very hard time getting sufficient donation to keep running. Donor fatigue is very prevalent, especially in less known areas such as support for work in Africa (again an area with which I’m familiar).
Rather than setting up another draw on those who donate, what about trying to work out an arrangement with Health Canada and the Canada Revenue to give people a tax credit by considering an live organ donation a charitable donation – the credit might be spread over several years, depending on how much money is saved by the donation of a kidney. Could some of the money saved by not needing dialysis be put towards the funding of this “charitable donation” – or however this sort of things works. Just a thought.
Thank you for your comments Gail – and for being a living donor.
We had envisioned a system where it was the health care system that would compensate the donor, via a non-profit organization. We did not see it as a system that would require fund-raising. As our model shows, paying living donors could save money to the health care system, depending on how many additional donor step forward.