Each week, In Theory takes on a big idea in the news and explores it from a range of perspectives. This week we’re talking about government compensation for organ donors. Need a primer? Catch up here.
Francis L. Delmonico is a Harvard Medical School professor of surgery at Massachusetts General Hospital and an adviser to the World Health Organization on organ donation and transplantation. Alexander M. Capron is a professor at the University of Southern California and former director of ethics, trade, human rights and health law at WHO.
Organ transplants have extended and improved the lives of more than a million patients over the past 60 years. This is a testament to the dedication and creativity of medical professionals as well as to the generosity of both living and deceased organ donors.
Nonetheless, the rising rate of kidney disease means that some patients won’t get the transplant they’re waiting for. That shortage of organs has led to proposals to lift the prohibition on payment that has been part of U.S. organ donation law since 1984. But buying organs would be wrong. And aside from being wrong, it would also harm existing, voluntary donation programs and be ineffective in increasing the supply of organs. There are better ways to increase the number of organs donated than paying for donations.
[Other perspectives: Generosity won’t fix our shortage of organs for transplants]
In recent decades, thousands of organs have been bought from the destitute around the world, for transplantation into the social elite in their own countries or “transplant tourists” from other nations. This has tarnished the reputation of organ transplantation and led to poor medical outcomes. In all countries, it is the poor who sell organs as a way out of their financial straits — usually only temporarily.
Sales of kidneys by living “vendors” — “donor” is the wrong term — undermine efforts to build robust programs of voluntary, unpaid organ donation from living related donors and deceased donors. In country after country, the same phenomenon occurs: Financial incentives “crowd out” voluntary donation. Kidney patients have no reason to turn to relatives and, more important, governments have no need to develop the infrastructure and public support for deceased donation when organs can be obtained from poor strangers.
For example, Iran — the only country that has a government-sanctioned program of paying donors — hasn’t eliminated its waiting list, which is proportionately larger than in the United States. When kidney sellers are surveyed a year or more after the removal of their organ, they report much worse health and regret having sold a kidney. The highest rates of transplantation are found in countries like Spain and Croatia that have well-organized programs of unpaid donation.
The principle of non-commercialization of human organs has been enshrined in professional statements, such as the Declaration of Istanbul, and international legal instruments, such as the Council of Europe Convention against Organ Trafficking. Since that convention opened for signature in March, 16 countries have signed on to update their criminal law to include its provisions, which include organ purchasing and surgeons’ use of purchased organs in the definition of “organ trafficking.”
A number of policies adopted by developed nations provide a model for ensuring that live organ donors do not bear financial burdens. For example, Principle 5 of the World Health Organization’s “Guiding Principles” on organ donation clearly states that “[t]he prohibition on sale or purchase of cells, tissues and organs does not preclude reimbursing reasonable and verifiable expenses incurred by the donor.”
As WHO explains, covering donors’ costs, “including medical expenses and lost earnings,” is appropriate because they may otherwise “operate as a disincentive to donation.” Indeed, during the recent recession, the rate of living kidney donations decreased in the United States because some potential donors could not afford to bear the expenses associated with organ donation or did not meet the requirements for programs that cover some of these financial costs and losses.
The existing national laws and international agreements all recognize that reimbursing donors for the costs of donating is permissible, as these costs are not inherent in the gift of the organ itself. Covering these actual costs merely makes sure that donors are not worse off financially after their gift, as opposed to improving their financial situation.
Unfortunately, the current U.S. program is inadequately funded and unduly restrictive. It is “means tested,” with cost coverage based on the income of the recipient as well as the donor. “Financial neutrality” — treating all the financial costs for donors, such as traveling for medical testing before the donation and lost income while recuperating from the donation, like other, reimbursable expenses — should not be dependent on the donor’s wealth, much less that of the recipient. Removing all financial disincentives to becoming a living kidney donor would result in more transplants and fewer patients on dialysis, thus saving taxpayers a great deal of money.
The Department of Health and Human Services can help all organ procurement organizations become more efficient and effective. For example, transplant programs are understandably concerned that their performance will be unfairly judged since no adjustment is made for using organs from higher-risk donors. Such organs are therefore discarded even when some patients with multiple health problems would willingly accept them as a better alternative to dialysis. HHS can also promote practices that show our collective respect for, and gratitude to, voluntary living donors and the families of deceased donors for their generous solidarity with patients in need.
If U.S. law is changed to turn human organs into commodities, organs will be obtained from the poorest and most vulnerable — not only in our society but also from around the world. Countries with pervasive poverty that have recently adopted anti-sales laws would find it impossible to resist the pressure to repeal their own regulations. That would doom their nascent deceased donation programs and make transplantation less an emblem of medical ingenuity and more an engine of exploitation and injustice.
Explore these other perspectives: