Transplant medicine performs miracles every day. Even better, the system is based on altruism; people selflessly donate organs, either as living donors or at the time of their death. Unfortunately, this system is failing. We are unable to supply the organs that are needed and thus, at least when we discuss end stage renal disease, we spend vast sums of money on dialysis each year. Here, Dr. Satel argues that financially rewarding donors is a workable, ethical solution.
—Adam Cifu, MD
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In September 2021, xenotransplantation made stunning progress. Doctors at NYU Langone Medical Center attached a pig kidney to blood vessels in a dead woman’s leg (with her family’s permission). It produced urine and cleared waste products during the 54-hour observation period. A team at the University of Alabama at Birmingham implanted genetically modified pig kidneys into the body of a man been left brain-dead by an accident. The kidney performed for 77 hours, the duration of the experiment.
I care about pig kidneys because, as a two-time kidney recipient, I may need a third someday. Given the serious organ shortage, I would gladly accept one from a pig.
While xenotransplantation has made real progress, it will remain experimental for at least five to ten years. This means that people who need kidneys will continue to depend upon on loved ones, as I did for two transplants, or on people who have donated at death.
Our transplant system is founded upon altruistic donation. It’s a lovely sentiment – and I have twice been its indebted beneficiary – but altruism isn’t enough. More than 90,000 Americans are waiting for a kidney. In 2022, 25,500 received one, and some 42,000 were added to the national waiting list. During the average day, 11 people die for want of a kidney.
Not only is the shortage of organs heartbreaking and unfair, it is also expensive. In 2022, Medicare’s End Stage Renal Disease program spent about $50 billion a year on dialysis for 600,000 people. Put differently, five percent of Medicare spending goes to the less than one percent of the beneficiaries with end stage kidney disease.
What to do? Some propose an opt-out, or presumed consent system. In such an arrangement, we would presumptively harvest people’s organs at brain death unless they had previously indicated they didn’t wish to donate them. But opt-out can only do so much, as relatively few people die in ways that leave their organs suitable for transplantation.
Another proposal, one which I support, is to reward donors. This would entail amending the National Organ Transplant Act of 1984, which prohibits those in need of an organ from enriching donors. It also explicitly outlaws donors from realizing material benefit. (The Act does, however, permit recipients to cover any costs that their donors incur in the process of donating, and both private and public insurance covers donors’ medical screening, surgery, hospitalization).
A donor-reward system would need to protect against low-income people rushing to donate. To ensure fairness, it should rely on a third-party procurement rather than allowing patients to use their personal wealth to pay donors. That third party would be the federal government, given the enormous savings incurred by liberating patients from dialysis.
In a well-designed plan, donors would not receive an immediate cash payment; instead, a governmental entity or a designated charity would offer deferred rewards, such as a contribution to the donor’s retirement fund; a refundable income tax credit disbursed over a period of years; a tuition voucher; lifetime health insurance; a contribution to a charity of the donor’s choice; or loan forgiveness.
The value of the reward should be between $50,000 and $100,000, which physicians and others who endorse donor compensation believe would be sufficient to address the organ shortage. This analysis estimates that a reward of $77,000 could encourage sufficient donations to save 47 000 patients annually.
After medical and psychological screening, qualified donors would enter a waiting period of at least six months before they could donate. This would ensure that donors do not act impulsively and have given fully informed consent. The waiting period and the deferred rewards would filter out financially desperate individuals who might otherwise rush to donate for a large sum of instant cash and later regret it.
The program would distribute donors’ kidneys according to the rules now in place. Kidneys from both deceased and non-directed living donors would go to a first-come-first-served queue of patients with a glomerular filtration rate of 20 mL/min/1.73 m2 or less who want to be considered for a transplant, are healthy enough to tolerate surgery, and are a good immunological match, among other factors.
People who want to donate a kidney to a specific person — say, a father to a son — would still be able to do so and would be eligible for compensation as well. Finally, all rewarded donors would be guaranteed follow-up medical care for any complications – something not ensured now -- and reimbursed for any costs (i.e., lost wages, childcare) that the donation entailed.
While polls, like this recent one, reveal the public to be in favor of rewarding donors, objections must be addressed. Some demur that rewarding donors “commodifies the body.” We already commodify the body, strictly speaking, every time there is a transplant: The doctors get paid to manipulate the body; the hospital charges for the kidney’s removal. Why would we now object to enriching the donor — the agent who gives the precious item in question and assumes all the risk?
At the heart of the “commodification” claim is the concern that donors will not be treated with dignity. But dignity is affirmed when we respect the capacity of individuals to make decisions in their own best interest, protect their health, and express gratitude for their sacrifice. Material gain, per se, is not inconsistent with these values.
Some worry that rewarded donation will attract only low-income people. This is possible, though only a trial project can provide the answer. But even if this turns out to be the case, why doubt the capacity of low-income people to make decisions in their own interest? From the standpoint of the recipient, it is low-income individuals who stand to benefit the most, as they are disproportionately represented among those waiting for a kidney.
We cannot be assured that rewarding donors will reduce the queue dramatically, but we can be positive that the present system fails far too many patients. Long experience with paid donation of ova and blood plasma results in ample supplies. Indeed, the U.S. is the biggest supplier of plasma in the world.
One might even look to Iran. Although the country has an arrangement that would be unpopular in the US and that should not be adopted here (the recipient gives cash to the donor to supplement a government payment), waiting time has been meaningfully reduced.
At the very least, donor compensation is a public health experiment worth undertaking, perhaps as pilot trials, as proposed by House Rep. Matt D. Cartwright (D-Pa).
The transplant field has long campaigned under the moving rhetoric of “the gift of life.” Lamentably, not enough people are willing or able to offer this gift. Until xenotransplantation or other technologies for artificial organs become routine – as they surely will – people in need should not be sentenced to premature death.
Sally Satel MD is a senior fellow at the American Enterprise Institute, a lecturer at Yale University School of Medicine, and editor of When Altruism Isn’t Enough: The Case for Compensating Kidney Donors (2009).
It is exploitative to pay people for kidneys - this was not adequately addressed in the piece. I don't think I could be persuaded otherwise, but to do so you'd need to be honest about the exploitative nature and somehow demonstrate the harms are less than the status quo.
Yes, we have a shortage of kidneys. I'm not sure how I feel about paying people for donating. There are so many ways that could go sideways - unintended consequences and all. But one of the big reasons people choose to not get a kidney transplant is due to losing disability benefits once they go off dialysis (this coming directly from a social worker in a local transplant center). I guess you could say that this then frees up a kidney for someone who does want one though.