Why we should not pay for human organs

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Functions, responsibilities, dedication, payment, organization, and profile of the hospital transplant coordination in Spain in 2002

In Spain, the number of donors per million of population and the activity of transplantation is a direct consequence of the continued work of the hospital transplant coordinators. There are 146 procurement hospitals with approximately 534 transplant coordinators (13.6 coordinators per hospital and 12.7 per million of population). A voluntary survey of 74 Spanish transplant coordinators revealed 67.6% to be men and 32.4% women of average age 43 years with specialization of 75.7%, Intensive Care Medicine; 8.1%, Anesthesiology; 6.7%, Nephrologists; and the rest, General Surgery or without any specialization. Among the group who responded to the injury, 86.5% were doctors and 13.5%, nurses. The overall team is composed of 52% doctors, 27.7% nurses and others with 70.3% working part-time and 27%, full-time. Previous experience was noted to be less than 5 years among 51.4%, and more in the rest of the cases. The 85% work under medical direction by management. Their payment includes salary plus activity in 48.7% of the cases; 21.6%, only salary, and 18.9%, only activity. Each coordinator generates between 3 and 7 organ as well as 3 and 11 of tissue donors. In conclusion, comparing this data with the practice in the United States demonstrates the unique aspects of the Spanish system.

Giving until it hurts: prisoners are not the answer to the national organ shortage

This Note argues that prisoners, whether executed or living, should not become organ donors. The introduction acknowledges the shortage of transplantable organs in the United States and the steps that have been taken to ameliorate the crisis. Part I discusses the procurement of organs from executed prisoners, beginning with a brief examination of China, a country where this type of procurement is routinely practiced. Part I also examines organ procurement legislation pertaining to executed prisoners. Finally, Part I asserts the reasons that prisoners should not become donors, including the dead donor rule, the ban against physicians as executioners, the Oath of Hippocrates, the risk of transmissible diseases, and the negative perception that would result if organ procurement was tied to executions. Part II of this Note discusses prisoners donating their organs in return for mitigated sentences. Part II then argues that this practice should not be adopted because of the lack of informed consent and voluntary choice. Finally, Part III of this Note introduces potential solutions to the possibility of maintaining a voluntary system, moving to a presumed consent system, and using financial inducements to create a larger supply of transplantable organs.

[Basic ethical aspects of living organ donation]

A characteristic feature of transplanting organs from living donors is that not only patients in need for treatment but also healthy individuals are submitted to medical interventions. Ethical considerations in this field have to deal with the question of property attributes of the human body and conflicts with traditional medical principles. Altruistic organ donation, appreciated by Christianity as a sign of charity, is indeed contradictory to the classic maxim of medical ethics "primum nihil nocere, " meaning "first of all, do not harm." The autonomous choice of a potential donor has to be balanced thoroughly against his personal physical and psychological risks. Apart from organ donation with altruistic motives, commercial incentives or payment for organ donation, which are increasingly under discussion in many nations, need profound ethical reflection. Organ selling does not lead to long-term economic benefit for individual donors in developing countries and is associated with a decline in health. A market system of organ sales would foster exploitation of the poor, and it is substantially doubtful whether autonomy and self determination are valid under circumstances of poverty and coercion. Commodification of the human body risks viewing persons as marketable objects. The human body,however, is an integral element of an individual's personality and not a resource to be removed. It is therefore fundamental that the social good of altruism is preserved as the major principle in organ donation.

Cost-benefit approach in evaluating investment into donor action: the German case

Donor Action (DA) is an international initiative to help critical care units (CCUs) increase their own donation rates through improved-quality donation practices. Following a validated diagnostic review (DR), areas of weakness can be identified, and the appropriate changes introduced. Data gathered from a number of centers in nine European countries (including Germany) 1 year after the introduction of targeted improvement measures demonstrated a 59.2% (P=0.0015) increase in donation rates. This analysis computes the cost-benefit thresholds of implementing the DA methodology from a German health-economic point of view, taking into account the treatment alternatives for end-stage renal disease (dialysis and transplantation) and comparing the DA program with current organ-donation practice. Lifetime direct medical costs and quality-adjusted life years (QALYs) were calculated for both arms, considering only changes in cadaveric renal transplantation rates. If DA leads to a 59% overall increase in organ donation in Germany, the program will result in 33 QALYs and 1.8-million euro cost savings per million population (PMP). Therefore, DA would be cost-effective below 2.66-million euro implementation cost PMP (or 218-million euro for the whole country). As the partial implementation cost of the program was far below the threshold, DA is more cost-effective than other publicly reimbursed medical intervention.

How to improve organ donation: results of the ISHLT/FACT poll

BACKGROUND

Worldwide organ shortages remain a long-standing problem. Efforts to address this have ranged from attempts to improve public awareness to modified mandated choice systems; most have been unsuccessful. In the face of this intractable problem, increased consideration has been given to direct and indirect compensation, and in certain countries, black markets for organs have developed. To examine the attitudes of the transplant medical community regarding these issues, we surveyed members of the International Society for Heart and Lung Transplantation (ISHLT) in conjunction with the Foundation for the Advancement of Cardiac Therapies (FACT).

METHODS/RESULTS

We asked for opinions about how to improve organ donation. Of 739 respondents, 75% supported presumed consent, and 39% identified it as the single best way to increase donation; improved public education was a distant second (18%). Seventy percent supported indirect compensation (e.g., payment of funeral expenses, donation to a charity of the family's choice), and 66% opposed direct compensation (e.g., tax credit, life insurance benefit). When asked whether next of kin should be consulted regarding organ donation, and 84.2% responded affirmatively. However, of these individuals, 77.2% did not think that consultation should be required if the potential donor already had signed a donor card.

MEMBERSHIP

Our membership dramatically favors indirect over direct compensation as a way of increasing organ donation. The majority also favors the wishes of the individual over the family in determining donor status. However, presumed consent is the single best way to significantly improve organ donation, according to the majority of our respondents. More effort should be directed toward policy in these areas as opposed to improving public education, which has failed to yield satisfactory results.

Why liberals should accept financial incentives for organ procurement

Free market libertarians have long supported incentives to increase organ procurement, but those oriented to justice traditionally have opposed them. This paper presents the reasons why those worried about justice should reconsider financial incentives and tolerate them as a lesser moral evil. After considering concerns about discrimination and coercion and setting them aside, it is suggested that the real moral concern should be manipulation of the neediest. The one offering the incentive (the government) has the resources to eliminate the basic needs that pressure the poor into a willingness to sell. It is unethically manipulative to withhold those resources and then offer payment for organs. Nevertheless, the poor have been left without basic necessities for 20 years since the passage of the prohibition on incentives. As long as the government continues to withhold a decent minimum of welfare, liberals should, with shame, cease opposing financial incentives for organ procurement.

Three views of organ procurement policy: moving ahead or giving up?

The supply of organs for transplant remains inadequate to meet the needs of waiting patients, in spite of many programs and approaches to increase rates of donation. Over the years there have been numerous proposals to introduce schemes that would move toward the outright sale of organs. Three articles in this issue of the Journal propose methods for increasing organ supply--two by moving toward a market approach and the third by advocating a change in social culture. All three suffer from shortcomings, including the endorsement and encouragement of the exploitation of those who may offer organs. Although the shortage of organs must be addressed, the social price of a market in organs is too high, and proposals to encourage a rethinking of social responsibility are unlikely to be effective.

Comprehensive cost comparison of adult-adult right hepatic lobe living-donor liver transplantation with cadaveric transplantation

BACKGROUND

An important long-term consideration for living-donor liver transplantation (LDLT) is the expense compared with cadaveric-liver transplantation. LDLT is a more complex procedure than cadaveric transplantation and the cost of donor evaluation, donor surgery, and postoperative donor care must be included in a cost analysis for LDLT. In this study, we compare the comprehensive cost of LDLT with that of cadaveric-liver transplantation.

METHODS

All costs for medical services provided at our institution were recorded for 24 LDLT and 43 cadaveric recipients with greater than 1 year follow-up transplanted between August 1997 and April 2000. The donor costs include donors evaluated and rejected, donors evaluated and accepted, donor right hepatectomy costs, and donor follow-up costs (365 days postdonation). LDLT and cadaveric recipient costs include medical care 90 days pre-LDLT, recipient transplant costs, and recipient follow-up costs (365 days posttransplant) including retransplantation. Cost is expressed as an arbitrary cost unit (CU) that is a value between $500 to $1,500.

RESULTS

Total LDLT costs (evaluations of rejected donors+evaluations of accepted donors+donor hepatectomy+donor follow-up care for 1 year+pretransplant recipient care [90 days pretransplant]+recipient transplantation+recipient 1-year posttransplant care)= 162.7 CU. Total mean cadaveric transplant costs (pretransplant recipient care [90 days pretransplant]+recipient transplantation [including organ acquisition cost]+recipient 1-year posttransplant care)= 134.5 CU, (P =ns).

CONCLUSIONS

The total comprehensive cost of LDLT is 21% higher than cadaveric transplantation, although this difference is not significant.