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October 17, 2019

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Donors should not profit, but covering care is ethical, makes sense

It is encouraging to note data from the United Network for Organ Sharing that show more than 30,000 organ transplants were performed in the United States last year, reaching the highest total in the country’s history. Nevertheless, the supply of organs — donated by living and deceased donors — will fall short of the number of patients added last year to the transplant waiting lists.

With the persistent shortage, there are those who would seek to increase the organs available for transplantation by providing financial incentives as a motivation for organ donation. These financial incentives would represent a monetary gain or “valuable consideration” and are currently prohibited by the National Organ Transplant Act of 1984 (NOTA) to buy and sell organs.

The financial incentives (valuable consideration) proposed include a contribution to the donor’s retirement fund, an income tax credit or a tuition voucher or global health insurance. Even though cash would not be exchanged, these incentives have a monetary value and target individuals who otherwise would not have these resources/finances, for example, to secure their retirement or those not qualifying for health insurance through the Affordable Care Act.

For those who are enticed by such incentives, they would simply be trading the commodity they have (a kidney) for a commodity they need (a mortgage payment or health insurance). In the United States, 1 in 7 people live below the poverty line. The target group of donors/vendors becomes inescapable — it becomes the economically distressed who supply organs for transplantation.

Every other country in the world has wrestled with the dilemma of targeting the poor to be the source of organs by such incentives, and other than Iran (whose professionals now regret such a policy) every country will not permit such financial incentives.

The World Health Organization rejects a system that would foster a social stratification in obtaining organs for transplantation. The WHO Guiding Principles of Organ Donation and Transplantation states clearly that “cells, tissues and organs should only be donated freely, without any monetary payment or other reward of monetary value. Purchasing, or offering to purchase, cells, tissues or organs for transplantation, or their sale by living persons or by the next of kin for deceased persons, should be banned.”

However this WHO Principle emphasizes that “the prohibition on sale or purchase of cells, tissues and organs does not preclude reimbursing reasonable and verifiable expenses incurred by the donor, including loss of income, or paying the costs of recovering, processing, preserving and supplying human cells, tissues or organs for transplantation.” Making reimbursement available for the actual costs or losses incurred, regardless of donors’ financial resources, would not enrich donors but merely make donating a kidney a financially neutral act. Since covering expenses results in neither a better — nor worse — financial situation for the donor, there would be no need to modify NOTA’s prohibition on paying for organs to assure coverage of donor costs.

The Declaration of Istanbul calls for the provision of health care for the living donor — but importantly related to the donation act of kidney removal.

Despite the Affordable Care Act, approximately 10 percent of Americans do not have health insurance. The financial neutrality components would include coverage of the cost for the annual follow-up visits for the kidney donor, to include: blood pressure, physical examination, assessment of renal function, urinalysis and assessment for diabetes or any other medical condition; but not by a health insurance package that would cover the cost of care for example of a malignancy during the rest of the donor’s lifetime or for trauma care following a motor vehicle accident.

If a donor’s medical insurance does not provide lifelong medical follow-up and treatment of any conditions related to the nephrectomy or if the donor’s health insurance leaves the donor responsible to pay for a portion such care, those costs should be covered. Donors should also be provided with life insurance to cover death as a result of being a living donor. Interval (perhaps in some instances becoming annual) exams that are covered for the donor should enable the collection of data that determine what remains an unknown lifetime risk of kidney failure, and it also would provide the opportunity to treat the donor if kidney disease is developing in the donor.

Thus far, the government has not supported the provision of financial incentives as a motivation for organ donation — presumably because it does not want to be responsible for placing anyone at risk of kidney failure in their lifetime — as a result of being a donor.

But we can all agree that a program of financial neutrality that provides care for the donor is an ethically proper approach for those who wish to be a donor. Otherwise, the stale arguments that have been a point and counterpoint in the debate of financial incentives are going nowhere for the help of donors and the needs of the patients that would benefit from organ transplants.

Dr. Francis Delmonico is immediate past president of the Transplantation Society; professor of surgery at Harvard Medical School, Massachusetts General Hospital; and chief medical officer at New England Organ Bank, Boston, Mass. He wrote this for

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