Between Scylla and Charybdis: charting an ethical course for research into financial incentives for living kidney donation

Projecting the Economic Impact of Compensating Living Kidney Donors in the United States: Cost-Benefit Analysis Demonstrates Substantial Patient and Societal Gains

OBJECTIVES

The aim of this study was to show how the US government could save approximately 47 000 patients with chronic kidney failure each year from suffering on dialysis and premature death by compensating living kidney donors enough to completely end the kidney shortage.

METHODS

Supply and demand analysis was used to estimate the number of donated kidneys needed to end the kidney shortage and the level of compensation required to encourage this number of donations. These results were then input into a detailed cost-benefit analysis to estimate the economic value of kidney transplantation to (1) the average kidney recipient and their caregiver, (2) taxpayers, and (3) society in general.

RESULTS

We estimate half of patients diagnosed with kidney failure each year-approximately 62 000 patients-could be saved from suffering on dialysis and premature death if they could receive an average of 1½ kidney transplants. However, currently there are only enough donated kidneys to save approximately 15 000 patients. To encourage sufficient donations to save the other 47 000 patients, the government would have to compensate living kidney donors approximately $77 000 (±50%) per donor. The value of transplantation to an average kidney recipient (and caregiver) would be approximately $1.5 million, and the savings from the recipient not needing expensive dialysis treatments would be approximately $1.2 million.

CONCLUSIONS

This analysis reveals the huge benefit that compensating living kidney donors would provide to patients with kidney failure and their caregivers and, conversely, the huge cost that is being imposed on these patients and their families by the current legal prohibition against such compensation.

A regulated system of incentives for living kidney donation: Clearing the way for an informed assessment

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.

Have we reached the limits in altruistic kidney donation?

Altruistic donation (unspecified donation) is an important aspect of living donor kidney transplantation. Although donation to a stranger is lawful and supported in many countries, it remains uncommon and not actively promoted. Herein, we ask the question if we have reached the limit in altruistic donation. In doing so, we examine important ethical questions that define the limits of unspecified donation, such as the appropriate balance between autonomous decision-making and paternalistic protection of the donor, the extent of outcome uncertainty and risk-benefit analyses that donors should be allowed to accept. We also consider the scrutiny and acceptance of donor motives, the potential for commercialization, donation to particular categories of recipients (including those encountered through social media) and the ethical boundaries of active promotion of unspecified kidney donation. We conclude that there is scope to increase the number of living donation kidney transplants further by optimizing existing practices to support and promote unspecified donation. A number of strategies including optimization of the assessment process, innovative approaches to reach potential donors together with reimbursement of expenses and a more specific recognition of unspecified donation are likely to lead to a meaningful increase in this type of donation.

Survey for the Opinion of Medical Students and Medical Staff on a Financial Incentive System for Deceased Organ Donation in an Asian Country

BACKGROUND

Financial incentives for deceased organ donation are associated with many controversial ethical issues. This study examines the perspectives of medical students and staff members on financial incentives for the families of brain-dead organ donors.

METHODOLOGY

A structured survey form was used between December 7, 2017 and January 28, 2018 to elicit opinions on financial incentives for the families of brain-dead organ donors. Forty-three medical staff members and 81 medical students participated in the survey voluntarily. The opinions on the financial incentive system and the relationship between willingness to give information about organ donation to families and a financial incentive system were assessed.

RESULTS

The majority of the participants (81.4%) had positive thoughts on organ donation. More than half of the participants (60.5%) thought that the financial incentive system did not erode the ethical purity of organ donation. As charge doctors, most respondents (84.6%) were willing to give information about organ donation to family members in the presence of financial incentives. However, the percentage decreased significantly to 60.5% when financial incentive was no longer factored into consideration (P < .001).

LIMITATION

The study population is small, and the participants are not representative of the general population.

CONCLUSION

The opinions of medical students and medical staff on financial incentives for deceased organ donation were generally positive. Financial incentives proved to be a potential influencing factor as an option of organ donation to be given to families.

The present and future of transplant organ shortage: some potential remedies

Transplantation remains the modality of choice for patients with end stage renal disease (ESRD). However, while there has been a steady rise in the number of patients with ESRD the supply of donors (combine living and deceased) has fallen far behind the need, resulting in an increasing number of qualified patients remaining on the wait-list, and thousands being removed from the list every year because of death or becoming too sick for transplantation. This has also fed to transplant tourism around the world. Several countries have implemented a variety of policies to overcome their organ shortage that are presented in this article. There is an urgent need for developing policies geared to the cultural norms of different societies and universally accepted ethical principles to remedy this public health issue.

Would government compensation of living kidney donors exploit the poor? An empirical analysis

Government compensation of kidney donors would likely increase the supply of kidneys and prevent the premature deaths of tens of thousands of patients with kidney failure each year. The major argument against it is that it would exploit the poor who would be more likely to accept the offers of compensation. This overlooks the fact that many poor patients desperately need a kidney transplant and would greatly benefit from an increased supply of kidneys. The objective of this study is to empirically test the hypothesis that government compensation of kidney donors would exploit the poor. Exploitation is defined by economists and several noted ethicists as paying donors less than the fair market value of their kidney. Exploitation is expressed in monetary terms and compared with the economic benefit recipients receive from a transplant. Data are from the Scientific Registry of Transplant Recipients and the United States Renal Data System annual data reports. Educational attainment is used as a proxy for income. We estimate that if the government rewards living donors with a package of non-cash benefits worth $75,000 per kidney, donors would not be exploited. Much more important, this compensation would likely end the kidney shortage, enabling many more patients with kidney failure to obtain transplants and live longer and healthier lives. The value of kidney transplantation to a U.S. recipient is about $1,330,000, which is an order of magnitude greater than any purported exploitation of a living donor (zero to $75,000). Consequently, the aggregate net benefit to the poor alone from kidney transplantation would increase to about $12 billion per year from $1 billion per year currently. Most of the benefit would accrue to poor kidney recipients. But poor donors would receive the fair market value of their kidney, and hence would not be exploited. If the government wanted to ensure that donors also received a net benefit, it could easily do so by increasing the compensation above $75,000 per donor.

Banking on Living Kidney Donors-A New Way to Facilitate Donation without Compromising on Ethical Values

Public surveys conducted in many countries report widespread willingness of individuals to donate a kidney while alive to a family member or close friend, yet thousands suffer and many die each year while waiting for a kidney transplant. Advocates of financial incentive programs or "regulated markets" in kidneys present the problem of the kidney shortage as one of insufficient public motivation to donate, arguing that incentives will increase the number of donors. Others believe the solutions lie-at least in part-in facilitating so-called "altruistic donation;" harnessing the willingness of relatives and friends to donate by addressing the many barriers which serve as disincentives to living donation. Strategies designed to minimize financial barriers to donation and the use of paired kidney exchange programs are increasingly enabling donation, and now, an innovative program designed to address what has been termed "chronologically incompatible donation" is being piloted at the University of California, Los Angeles, and elsewhere in the United States. In this program, a person whose kidney is not currently required for transplantation in a specific recipient may instead donate to the paired exchange program; in return, a commitment is made to the specified recipient that priority access for a living-donor transplant in a paired exchange program will be offered when or if the need arises in the future. We address here potential ethical concerns related to this form of organ "banking" from living donors, and argue that it offers significant benefits without undermining the well-established ethical principles and values currently underpinning living donation programs.

Opting out: a single-centre pilot study assessing the reasons for and the psychosocial impact of withdrawing from living kidney donor evaluation

Understanding why individuals opt out of living donation is crucial to enhancing protections for all living donors and to identify modifiable barriers to donation. We developed an ethical approach to conducting research on individuals who opted out of living kidney donation and applied it in a small-scale qualitative study at one US transplant centre. The seven study participants (64% response rate) had varied reasons for opting out, the most prominent of which was concern about the financial burden from lost wages during the postoperative period. Several reported feeling alone during their decision-making process. Although no participants used an alibi, a centre-provided statement of non-eligibility to donate, all believed that centres should offer alibis to help preserve donor autonomy. Given the complexity of participants' decisions and the emotions they experienced before and after deciding not to donate, we suggest approaches for independent living donor advocates to support this population. This study demonstrates that research on individuals who opt out of donation is feasible and yields valuable insight into methods to improve the evaluation experience for potential living donors.

KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.

Psychosocial Outcomes 3 to 10 Years After Donation in the Adult to Adult Living Donor Liver Transplantation Cohort Study

BACKGROUND

Studies of liver donors' psychosocial outcomes focus on the short term and rely largely on quality-of-life measures not specific to donation. We sought to examine long-term donation effects on 3 psychosocial domains: perceived physical, emotional, and socioeconomic outcomes.

METHODS

Individuals donating 3 to 10 years previously at 9 centers were eligible for telephone surveys. Survey responses were examined descriptively. Cluster analysis was used to identify distinct donor groups based on response profiles across psychosocial domains. Potential predictors of response profiles were evaluated with regression analysis.

RESULTS

Five hundred seventeen donors (66%) participated (M = 5.8 years postdonation, SD = 1.9). Fifteen percent to 48% of donors endorsed current donation-related physical health problems and concerns, and 7%-60% reported socioeconomic concerns (eg, insurance difficulties, financial expenditures). However, on average, donors experienced high psychological growth, and 90% felt positively about donation. Cluster analysis revealed 5 donor groups. One group showed high psychological benefit, with little endorsement of physical or socioeconomic concerns (15% of donors). Four groups showed less favorable profiles, with varying combinations of difficulties. The largest such group showed high endorsement of physical concerns and financial expenditures, and only modest psychological benefit (31% of donors). Men and nonHispanic whites were most likely to have unfavorable response profiles (Ps < 0.01). Compared with donors aged 19 to 30 years, older donors were less likely to have unfavorable profiles; these differences were significant for donors in the >40 to 50 year age group (Ps < 0.008).

CONCLUSIONS

Even many years postdonation, donors report adverse physical and socioeconomic effects, but positive emotional effects as well. Identification of response profiles and predictors may improve targeting of postdonation surveillance and care.

Incentivizing Organ Donor Registrations with Organ Allocation Priority

How donor organs are allocated for transplant can affect their scarcity. In 2008, Israel's Parliament passed an Organ Transplantation Law granting priority on organ donor waiting lists to individuals who had previously registered as organ donors. Beginning in November 2010, public awareness campaigns advertised the priority policy to the public. Since April 2012, priority has been added to the routine medical criteria in organ allocation decisions. We evaluate the introduction of priority for registered organ donors using Israeli data on organ donor registration from 1992 to 2013. We find that registrations increased when information about the priority law was made widely available. We find an even larger increase in registration rates in the 2 months leading up to a program deadline, after which priority would only be granted with a 3-year delay. We also find that the registration rate responds positively to public awareness campaigns, to the ease of registration (i.e. allowing for registering online and by phone) and to an election drive that included placing registration opportunities in central voting locations. Copyright © 2016 John Wiley & Sons, Ltd.

Incentivizing Authorization for Deceased Organ Donation With Organ Allocation Priority: The First 5 Years

The allocation system of donor organs for transplantation may affect their scarcity. In 2008, Israel's Parliament passed the Organ Transplantation Law, which grants priority on waiting lists for transplants to candidates who are first-degree relatives of deceased organ donors or who previously registered as organ donors themselves. Several public campaigns have advertised the existence of the law since November 2010. We evaluated the effect of the law using all deceased donation requests made in Israel during the period 1998-2015. We use logistic regression to compare the authorization rates of the donors' next of kin in the periods before (1998-2010) and after (2011-2015) the public was made aware of the law. The authorization rate for donation in the period after awareness was substantially higher (55.1% vs. 45.0%, odds ratio [OR] 1.43, p = 0.0003) and reached an all-time high rate of 60.2% in 2015. This increase was mainly due to an increase in the authorization rate of next of kin of unregistered donors (51.1% vs. 42.2%). We also found that the likelihood of next-of-kin authorization for donation was approximately twice as high when the deceased relative was a registered donor rather than unregistered (89.4% vs. 44.6%, OR 14.27, p < 0.0001). We concluded that the priority law is associated with an increased authorization rate for organ donation.