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Sally Satel responds to the New York Times Room for Debate question: Should people in need of a kidney transplant be allowed to pay someone to donate one of theirs, or would that let the rich exploit the poor?
Tomorrow at this time, 12 people will be dead because they could not survive the wait on the national transplant list in the United States — a queue that can take between five and 10 years to climb in major cities.
Enhancing the rates of deceased donation or instituting “presumed consent” — wherein the organs are taken posthumously unless an individual has specifically forbidden their retrieval — won’t yield enough new organs for transplant. We need more than 100,000 kidneys and the only way to meet this dire need is with living kidney donors.
This is what we should do: test incentives. A series of pilot trials should be run to test an arrangement whereby a state or federal government offers interested, healthy donors a benefit for donating a kidney to a stranger. In-kind benefits underwritten by the government would be offered — perhaps a tax credit, a contribution to a retirement plan or to a designated charity, or early access to Medicare. The current algorithm for distributing kidneys would apply.
The process would entail a six-month waiting period to bar impulsive acts and ensure ample time for education about the operation. The plan should also include medical follow-up for at least five years after donation, which is more than donors are now guaranteed. Finally, the Medicare and Medicaid savings from dialysis would more than cover the $40,000 to $50,000 value of the donors’ benefit.
As a policy, testing incentives for organs strikes me as the gay marriage of public health: there is simply no good reason to oppose it. Emotions? Yes. Reasons? No.
For example, some worry that only low-income people will be interested in participating as donors – and that their organs will go to the well off. Unlikely. First, the demographics of the waiting list indicate that recipients, themselves, are likely to be low-income. Second, many young people with decent earning potential would likely be attracted to the idea of saving someone’s life in exchange for a nest egg or help paying off a loan.
In any event, the question of who wants to become a donor could be answered with a trial. But what is most important to an ethically sound plan is that donors’ decisions are informed, their health is protected, they are rewarded amply and gratitude is shown them.
Why are such trials not being run at this time? Several reasons. The transplant community is too complacent, too wedded to the notion that only “altruism” is a legitimate motive for donating an organ. It’s a romantic conceit, but a lethal one too. The “gift of life” is precious; I received it from a friend in 2006. But altruism, as a strategy, is simply not producing enough organs. It needs to be supplemented with compensated donation.
To be fair, there is some promising movement afoot as the American Society of Transplant Surgeons and the American Transplantation Society collaborate on a position paper that has been previewed as favoring pilot trials of incentives. But we need patients to speak out too.
Sally Satel, a resident scholar at the American Enterprise Institute, is editor of When Altruism Isn’t Enough: The Case for Compensating Kidney Donors.
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