Is compensation for organ donation ethical?
Current system in "dire straits"
The evolution of "transplant tourism" drives home the point that people are willing to go to extreme lengths to procure an organ, according to Leslie M. Whetstine, PhD, an assistant professor of philosophy at Walsh University in North Canton, OH. "Despite the fact that the public overwhelmingly supports organ donation in this country, our actions unfortunately do not reflect that sentiment," she says. "In the United States, there are over 100,000 people on the waiting list, and each day 18 people will die on it."
The National Organ Transplant Act of 1984 prohibits buying and selling organs, but it doesn't prohibit incentives to donate. "Bone marrow donors can now get compensated with vouchers for education or housing, and a number of states allow for tax deductions/credits for living donors," says Whetstine. "While it remains to be seen if such inducements will have an impact on the shortage, creative programs that seek to influence donors within the limits of the law will likely continue."
Considering that tax credits and education vouchers are now allowed as incentives for living donors, Whetstine says "it isn't difficult to imagine other types of motivators. Health insurance, compensation for loss of wages, and reimbursement for travel have all been proposed at one point or another for living donors."
Other suggestions to persuade individuals to donate after death include covering funeral expenses for the decedent, cash payment to their designee or charity of choice, and even offering priority on the waiting list should the individual find him- or herself in need of an organ in the future. "A colleague of mine suggested child care vouchers, or other goods that the majority of Americans may find helpful in an otherwise floundering economy," says Whetstine.
The medical community's ethical obligations require authentic screening programs, donor advocacy, and a genuine commitment to upholding the prohibition on buying and selling organs, says Whetstine. "This last requirement may prove to be the most difficult, as the debate over compensation continues to grow more heated while cultural norms shift," she says.
Compensation supported
A May 2012 survey of 3000 adults conducted by NPR — Thomson Reuters showed about that 60% support compensation in the form of credits for health care needs for organ donation, and 41% supported cash as a form of reimbursement. (To view the survey questions and complete results, go to: http://bit.ly/JnHUz1.)
"The biggest obstacle facing hospitals and staff may be how to enforce rules that may be out of sync with changing views and attitudes," says Whetstine. One of the most pervasive arguments against organ vending has been the claim that the poor would necessarily be exploited if organs were commodified, she notes. "These fears are legitimate if one is talking about some sort of black market," she says. "However, new data suggest that if proper oversight and strict regulations were implemented, the sale of organs may yield much more benefit than harm."
According to a 2010 study, the prospect of payment does not create an impediment to informed consent or unfairly prey upon the poor, and in fact, lower income individuals are more apt to participate in living donation, specifically kidneys, regardless of incentives.1 "This study shed further light on whether the public still perceives organ vending as a corrupt enterprise, or if the fact that 18 people will have died by tomorrow while waiting for an organ has caused us to reevaluate those rules," says Whetstine. "This is to simply say that the current system is in dire straits. The public may no longer support the National Organ Transplant Act's prohibition on cash incentives."
Given the extreme disparity between supply and demand, it seems that altruism might be insufficient for individuals to sign a donor card, let alone motivate them to volunteer as living donors, argues Whetstine. "Curiously, instead of hosting a public discussion regarding acceptable incentives for donation, the transplantation community has responded to the pressing demand for more organs by revisiting the use of Donation After Cardiac Death donors, a practice that is mired in ethical controversy," says Whetstine.
Organ procurement organizations are proceeding with protocols including Donation After Cardiac Death in the Emergency Department, the use of extra-corporeal membrane oxygenation in Donation After Cardiac Death, and organ recovery ambulances, she explains. "Such an approach is dishonest and ultimately harmful to the public trust," says Whetstine. "The transplantation community would be better off engaging in an open discussion of incentives, rather than foisting ethically questionable procurement practices upon the public with the promise that all is well."
References
- Halpern SD, Raz A, Kohn R, et al. Regulated payments for living kidney donation: An empirical assessment of the ethical concerns. Ann Intern Med 2010;152(6):358-365.
Source
- Leslie M. Whetstine, PhD, Assistant Professor, Philosophy, Walsh University, North Canton, OH. Phone: (330) 244-4697. Email: [email protected].
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