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.