Reconsidering Kantian arguments against organ selling

Referring to Kant's arguments addressing the moral relationship between our bodies and ourselves is quite common in contemporary debate about organ selling, although he does not provide us with any specific arguments related to this debate. It is widely argued that the most promising way to show the moral impermissibility of organ selling is to mount an argument on Kantian grounds. This paper asks whether it is possible to argue coherently against organ selling in a Kantian framework. It will be shown that by mounting the argument on Kantian grounds no compelling argument can be given against sale of organs, either because the arguments apply to donation of organs, too, or the arguments are not convincing for other independent reasons. In the first section, it will be argued that donation and selling are not distinguishable in a Kantian framework, since the concern about commodification of the body and its parts shall be raised by both actions. In the second section, some contemporary accounts inspired by Kant will be presented and discussed separately. It will be argued that the reasons for promoting organ donation while arguing against selling clash with each other in an unconvincing way.

The ethical implications and religious significance of organ transplantation payment systems

One of the more polarizing policies proposed to alleviate the organ shortage is financial payment of donors in return for organs. A priori and empirical investigation concludes that such systems are ethically inadequate. A new methodological approach towards policy formation and implementation is proposed which places ethical concerns at its core. From a hypothetical secular origin, the optimal ethical policy structure concerning organ donation is derived. However, when applied universally, it does not yield ideal results for every culture and society due to region-specific variation. Since religion holds significant influence in the organ donation debate, three religions-Catholicism, Islam, and Shinto-were examined in order to illustrate this variation. Although secular ethical concerns should rest at the core of policy construction, certain region-specific contexts require cultural and religious competence and necessitate the adjustment of the optimal template policy accordingly to yield the best moral and practical results.

A Cost-Benefit Analysis of Government Compensation of Kidney Donors

From 5000 to 10 000 kidney patients die prematurely in the United States each year, and about 100 000 more suffer the debilitating effects of dialysis, because of a shortage of transplant kidneys. To reduce this shortage, many advocate having the government compensate kidney donors. This paper presents a comprehensive cost-benefit analysis of such a change. It considers not only the substantial savings to society because kidney recipients would no longer need expensive dialysis treatments--$1.45 million per kidney recipient--but also estimates the monetary value of the longer and healthier lives that kidney recipients enjoy--about $1.3 million per recipient. These numbers dwarf the proposed $45 000-per-kidney compensation that might be needed to end the kidney shortage and eliminate the kidney transplant waiting list. From the viewpoint of society, the net benefit from saving thousands of lives each year and reducing the suffering of 100 000 more receiving dialysis would be about $46 billion per year, with the benefits exceeding the costs by a factor of 3. In addition, it would save taxpayers about $12 billion each year.

Comparison of Double RBC Collection by Blood Cell Separators

BACKGROUND

The problem of red blood cell (RBC) shortage occurs because of the expanding demand for blood utilization and the dfficulties in donor recruitment and retention. Resources can be maximized by using current technology to collect two units of RBC from the same donor during a single collection session.

OBJECTIVE

To evaluate the performance, collection efficiency (CE), production cost, and donor satisfactions of two commercially available blood cell separators (BCS) for double dose red cell (DDRC) collection. Donor safety, clinical effectiveness, and patient safety were studied.

MATERIAL AND METHOD

Thirty-one repeated male donors from the blood bank, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University were recruited for DDRC collection by two BCSs, the Alyx™, Fresenius Kabi, NC, USA, and the MCS®+, Haemonetics Corporation, Scotland. The donation intervals were at least 16 weeks. The target RBC volume was 360 mL (180 mL x 2 units). Pre- and post-donation hematologic parameters were monitored and quality tests for DDRC were performed. Donor reactions (DR) were observed and donor satisfaction questionnaires were collected after donations. Eighty-six units of RBC were transfused to 33 patients. Transfusion reactions (TR) were observed, and hematocrit (Hct) increments were determined pre-transfusion and 24 hours post-transfusion.

RESULTS

The Alyx™ was faster for collecting and filtrating RBC (p<0.001) and had better CE (p<0.001). All DDRC from both BCSs met all the quality standards, required by both the American Association of Blood Banks (AABB) and the Food and Drugs Administration (FDA), which were hemoglobin (Hb) >42.5 g, Hct 50 to 70% and the residual white blood cells (WBC) <5x10(6). The Alyx™ processed less whole blood (WB) volume but provided DDRC with higher RBC yield, Hb content, and RBC volume than that of MCS® + (p<0. 001). However; the MCS®+ had one advantage over the Alyx™ whereby the DDRC collected by the MCS®+ were washed to reduce the risk of plasma associated TR. No serious DR from either BCS was observed. All donors had Hb >10 g/dL and Hct >30% after collection, as required by AABB. Serum ferritin reduction and iron depletion found in DDRC donors were not different from WB donors. All donors were satisfied with the DDRC collection process and would like to donate again. There was no evidence of acute or delayed TR in the patients. Hct increased significantly in 69.70% of the patients.

CONCLUSION

DDRC collection can be performed safely and efficiently from both BCS. The quality of DDRC from both BCSs met the AABB and FDA standards. Donor safety, transfusion safety, and effectiveness were observed. Even though the production cost of DDRC was slightly higher than that of whole blood derived filtered RBC, DDRC was better in terms of quality, risk reduction for infectious agents, and RBC alloimmunization. Production of DDRC can also be helpful supplying special RBC such as group O, Rh D negative, and phenotyped RBC.

'Because you can't live on love': living kidney donors' perspectives on compensation and payment for organ donation

CONTEXT AND OBJECTIVE

Living kidney donation accounts for approximately half of all kidney transplantation in many countries and is central to health policy focused on increasing organ supply. However, little examination of the economic consequences of living kidney donation has been undertaken from the perspective of donors themselves. This article documents living kidney donors' views regarding recompense and payment for organ donation, based on their experience.

PARTICIPANTS

Twenty-five living kidney donors from New Zealand participated in this study.

METHODS

This qualitative study, based on thematic analysis, uses semi-structured in-depth interviews to examine the experiences of living kidney donors. Themes were organized around altruism and the 'gift', perceptions of shared corporeality and identity, and donor support.

RESULTS

Most participants agreed the donation process was costly in terms of time and money. Many incurred personal costs, and some experienced financial hardship. All the participants viewed financial hardship as a barrier to organ donation and favoured recompense for direct and indirect costs. Most did not support payment for organs, and none supported commercialization.

DISCUSSION AND CONCLUSIONS

The findings show that framing organ donation as a 'gift' can stymie discussion about reciprocity, remuneration and exchange, making talk about financial recompense difficult. Financial well-being, nonetheless, has implications for the ability to care for self and others post-operatively. We conclude that the economic consequences for living kidney donors in jurisdictions where recompense for direct and indirect costs is insufficient are unfair. Review of financial assistance for live organ donors is therefore recommended.

Intra-hospital organ and tissue donation coordination project: cost-effectiveness and social benefits

OBJECTIVE To evaluate the viability of a professional specialist in intra-hospital committees of organ and tissue donation for transplantation.METHODS Epidemiological, retrospective and cross-sectional study (2003-2011 and 2008-2012), which was performed using organ donation for transplants data in the state of Sao Paulo, Southeastern Brazil. Nine hospitals were evaluated (hospitals 1 to 9). Logistic regression was used to evaluate the differences in the number of brain death referrals and actual donors (dependent variables) after the professional specialist started work (independent variable) at the intra-hospital committee of organ and tissue donation for transplantation. To evaluate the hospital invoicing, the hourly wage of the doctor and registered nurse, according to the legislation of the Consolidation of Labor Laws, were calculated, as were the investment return and the time elapsed to do so.RESULTS Following the nursing specialist commencement on the committee, brain death referrals and the number of actual donors increased at hospital 2 (4.17 and 1.52, respectively). At hospital 7, the number of actual donors also increased from 0.005 to 1.54. In addition, after the nurse started working, hospital revenues increased by 190.0% (ranging 40.0% to 1.955%). The monthly cost for the nurse working 20 hours was US$397.97 while the doctor would cost US$3,526.67. The return on investment was 275% over the short term (0.36 years).CONCLUSIONS This paper showed that including a professional specialist in intra-hospital committees for organ and tissue donation for transplantation proved to be cost-effective. Further economic research in the area could contribute to the efficient public policy implementation of this organ and tissue harvesting model.

Selling blood and gametes during tough economic times: insights from Google search

INTRODUCTION

To use Google Insights search volume and publicly available economic indicators to test the hypothesis that sperm, egg, and blood donations increase during economic downturns and to demonstrate the feasibility of using Google search volume data to predict national trends in actual sperm, egg, and blood donations rates.

MATERIALS AND METHODS

Cross-correlation statistical analysis comparing Google search data for terms relating to blood, egg, and sperm donations with various economic indicators including the S&P 500 closing values, gross domestic product (GDP), the U.S. Index of Leading Indicators (U.S. Leading Index), gross savings rate, mortgage interest rates, unemployment rate, and consumer price index (CPI) from 2004-2011. A secondary analysis determined the Pearson correlation coefficient between Google search data with actual sperm, egg, and blood donation volume in the U.S. as measured by California Cryobank, the National Assisted Reproductive Technology Surveillance System, and the National Blood Collection and Utilization Survey, respectively. Significance of cross-correlation and Pearson correlation analysis as indicated by p value.

RESULTS

There were several highly significant cross-correlation relationships between search volume and various economic indicators. Correlation between Google search volume for the term 'sperm donation,' 'egg donation,' and 'blood donation' with actual number of sperm, egg and blood donations in the United States demonstrated Pearson correlation coefficients of 0.2 (p > 0.10), -0.1 (p > 0.10), and 0.07 (p > 0.10), respectively. Temporal analysis showed an improved correlation coefficient of 0.9 (p < 0.05) for blood donation when shifted 12 months later relative to Google search volume.

CONCLUSION

Google search volume data for search terms relating to sperm, egg, and blood donation increase during economic downturns. This finding suggests gamete and bodily fluid donations are influenced by market forces like other commodities. Google search may be useful for predicting blood donation trends but is more limited in predicting actual semen and oocyte donation patterns.

Challenging the Sanctity of Donorism: Patient Tissue Providers as Payment-Worthy Contributors

Many research projects rely on human biological materials and some of these projects generate revenue. Recently, it has been argued that investigators have a moral claim to share in the revenue generated by these projects, whereas persons who provide the biological material have no such claim (Truog, Kesselheim, and Joffe 2012). In this paper, we critically analyze this view and offer a positive proposal for why tissue providers have a moral claim to benefit. Focusing on payment as a form of benefit, we argue that research is a joint project and propose a contribution principle for paying participants in those joint projects. We distinguish between contributions that shape a project's revenue generating properties, grounding a claim to payment, and contributions that fail to ground such a claim. We conclude, contrary to existing arguments and practices, that some tissue providers have a moral claim to payment beyond compensation for risk and burden. This conclusion suggests that investigators, institutions, and sponsors should reconsider the fairness of their current practices.

From blood donation to kidney sales: the gift relationship and transplant commercialism

In The Gift Relationship, Richard Titmuss argued that the practice of altruistic blood donation fosters social solidarity while markets in blood erode it. This paper considers the implications of this line of argument for the organ market debate. I defend Titmuss' arguments against a number of criticisms and respond to claims that Titmuss' work is not relevant to the context of live donor organ transplantation. I conclude that Titmuss' arguments are more resilient than many advocates of organ markets suggest, and more relevant to the debate than is commonly appreciated.

Ethical problems in ex vivo or cadaver organ transplantation: should the donation be paid?

Financial incentives for organ donation (from living or cadaveric donors) have been considered ethically acceptable by some bioethicists, and recently, according to the media, by Prof. Gary Becker, Nobel Laureate for Economy. However, the only countries to have approved a law allowing financial incentives for organ donation are Iran in 1988 and, in some way and much later, Singapore and Saudi Arabia. In Europe financial incentives for donors are prohibited, except maybe in Austria. In Germany, it is forbidden to purchase organs not only in the home country, but all over the world. The author was involved, as peer reviewer of a major international Transplant journal, in the evaluation of some papers concerning paid kidney living donors in Iran, and therefore made an extensive literature search on this topic and more generally on paid kidney living donation all over the world. The situation in Italy will also be reported and analysed.

Why and how to compensate living organ donors: ethical implications of the new Australian scheme

The Australian Federal Government has announced a two-year trial scheme to compensate living organ donors. The compensation will be the equivalent of six weeks paid leave at the rate of the national minimum wage. In this article I analyse the ethics of compensating living organ donors taking the Australian scheme as a reference point. Considering the long waiting lists for organ transplantations and the related costs on the healthcare system of treating patients waiting for an organ, the 1.3 million AUD the Australian Government has committed might represent a very worthwhile investment. I argue that a scheme like the Australian one is sufficiently well designed to avoid all the ethical problems traditionally associated with attaching a monetary value to the human body or to parts of it, namely commodification, inducement, exploitation, and equality issues. Therefore, I suggest that the Australian scheme, if cost-effective, should represent a model for other countries to follow. Nonetheless, although I endorse this scheme, I will also argue that this kind of scheme raises issues of justice in regard to the distribution of organs. Thus, I propose that other policies would be needed to supplement the scheme in order to guarantee not only a higher number of organs available, but also a fair distribution.

Altruism and reward: motivational compatibility in deceased organ donation

Acts of helping others are often based on mixed motivations. Based on this claim, it has been argued that the use of a financial reward to incentivize organ donation is compatible with promoting altruism in organ donation. In its report Human Bodies: Donation for Medicine and Research, the Nuffield Council on Bioethics uses this argument to justify its suggestion to pilot a funeral payment scheme to incentivize people to register for deceased organ donation in the UK. In this article, I cast a sceptical eye on the above Nuffield report's argument that its proposed funeral payment scheme would prompt deceased organ donations that remain altruistic (as defined by and valued the report). Specifically, I illustrate how this scheme may prompt various forms of mixed motivations which would not satisfy the report's definition of altruism. Insofar as the scheme produces an expectation of the reward, it stands diametrical to promoting an 'altruistic perspective'. My minimal goal in this article is to argue that altruism is not motivationally compatible with reward as an incentive for donation. My broader goal is to argue that if a financial reward is used to incentivize organ donation, then we should recognize that the donation system is no longer aiming to promote altruism. Rewarded donation would not be altruistic but it may be ethical given a persistent organ shortage situation.

Should we perform kidney transplants on foreign nationals?

In Canada, there are currently no guidelines at either the federal or provincial level regarding the provision of kidney transplantation services to foreign nationals (FN). Renal transplant centres have, in the past, agreed to put refugee claimants and other FNs on the renal transplant waiting list, in part, because these patients (refugee claimants) had health insurance through the Interim Federal Health Programme to cover the costs of medication and hospital care. However, severe cuts recently made to this programme have forced clinicians to question whether they should continue with transplants for FNs, for financial and ethical reasons. This paper first examines different national policies (eg, in Canada, USA, France and the UK) to map the diversity of approaches regarding transplantation for FNs, and then works through different considerations commonly used to support or oppose the provision of organs to these patients: (1) the organ shortage; (2) the free-rider problem; (3) the risk of becoming a transplant destination; (4) the impact on organ donation rates; (5) physicians' duties; (6) economic concerns; (7) vulnerability. Using a Canadian case as a focus, and generalising through a review of various national policies, we analyse the arguments for and against transplantation for FNs with a view to bringing clarity to what is a sensitive political and clinical management issue. Our aim is to help transplant centres, clinicians and ethicists reflect on the merits of possible options, and the rationales behind them.

Independent organ donor facilities: The future of organ donation?

Since 2001 independent Organ Donor Facilities(OFOs) have been proposed within Organ Procurement Organizations (OPOs) with the aim of reducing organ procurement costs 1, cold ischemia time of donor organs and the flight-related risk 2 for donor surgeons, perfusionists and coordinators. An independent OFO has been established in 2001 in St. Louis 3, half away between the 2 Transplant Centers (TCs) (Washington University School of Medicine and St. Louis University) and now includes a two-bed intensive care facility, a complete laboratory, a cardiac catheterization facility, a Computed Tomography (CT) scanner and an operating room. All brain-dead (BD) patients within OPO (Mid-America Transplant Services), after family's informed consent, are transferred, if necessary by an OPO owned and operated airplane, to this facility, where undergo multiorgan harvesting. By doing so the organ acquisition charges (OACs) apparently decreased, as well as delay in recovery, which can affect organ viability and move families to withdraw consent; also risks and tiring of transplant surgeons were reduced. This independent OFO successfully procured in 2001 not only livers, but also pancreas, kidneys, hearts and lungs 4-6. Cold ischemia time was reduced and there was no Primary Non Function (PNF) of harvested organs, but only kidney delayed graft function (DGF). In the past, heart donors were moved to the recipient's hospital. With the development of multiorgan harvesting, usually donor surgeons are sent by the TCs in order to evaluate liver, pancreas, heart and lungs, while the only local surgeons is the "nephrectomist", that in local hospital is not a transplant surgeon. To move a donor, although hemodinamically stable, is always a risk. Finally, the decrease of OAC must balance the extra expenses to create and operate independent OFOs. In all the papers published by the members of this OFO, the control group of the retrospective analysis consisted of less selected BD donors, requiring more vasosuppressor support, which can be a study bias. It has been proposed that OPOs should organize "recovery teams" for multiple TCs but most transplant surgeons, in case of marginal donors, would like to inspect the organ prior to starting recipient surgery or would send their own team to harvest organs. According to literature, there are no other independent OFOs in US, probably because there is no need for them, and increasing their numbers would not increase organ donation rate. Considering Europe, we do not have information about the existence of independent OFOs: this may be a consequence of logistical organization and minor distances, as well as the higher concentration of TCs. However, the acceptance of such a procedure from donors' families may be less enthusiastic in Europe than in USA, particularly from minorities. In Italy would not be acceptable that the maintenance of BD donors and more generally the operation of independent OFO would rely on non-physicians, to save costs. Finally it is not clear from the reviewed papers who pay for transportation of the donor's body from the independent OFO back to home, but donor's family should not be charged for these expenses. At least 5 donors were lost during transportation, confirming that moving of BD donors remains a risky procedure. The potential economical and organizative benefits of independent OFOs could be counterweighted by the perceived (by relatives and public opinion) commodification/ reification of BD patients. Anyway, the authors of these papers should be congratulated for their innovative proposal. However, a prospective randomized trial would be needed to draw more definitive conclusions on the real benefits of independent OFOs.

Egg donation brokers: an analysis of agency versus in vitro fertilization clinic websites

OBJECTIVE

To compare websites of agencies that broker the services of women who provide human eggs for in vitro fertilization versus clinics that recruit egg providers.

STUDY DESIGN

We examined 207 websites, of which 128 were egg provider agency 40%) or clinic (60%) websites that recruited providers online. We compared them regarding several variables related to adherence to American Society for Reproductive Medicine (ASRM) guidelines.

RESULTS

According to their respective websites, agencies were more likely than clinics to mention ASRM guidelines, be located in the West/Pacific, indicate compensation, offer a fee range, set their minimum > $5,000, specify preferable traits, cap provider age at 31, require an education minimum, allow both parties to meet, discuss short-term risks, and not acknowledge a possible cancer risk. Only 25.5% of agencies and 19.5% of clinics mention psychological/emotional risks, and 11.8% and 5.2%, respectively, mention risk to future fertility.

CONCLUSION

This research, the first to systematically compare several key aspects of egg provider agencies versus clinics, suggests it significant differences in adherence to guidelines, raising several concerns and suggesting needs for consideration of improved monitoring and regulation by ASRM or others.

Problem of living liver donation in the absence of deceased liver transplantation program: Mansoura experience

We report our experience with potential donors for living donor liver transplantation (LDLT), which is the first report from an area where there is no legalized deceased donation program. This is a single center retrospective analysis of potential living donors (n = 1004) between May 2004 and December 2012. This report focuses on the analysis of causes, duration, cost, and various implications of donor exclusion (n = 792). Most of the transplant candidates (82.3%) had an experience with more than one excluded donor (median = 3). Some recipients travelled abroad for a deceased donor transplant (n = 12) and some died before finding a suitable donor (n = 14). The evaluation of an excluded donor is a time-consuming process (median = 3 d, range 1 d to 47 d). It is also a costly process with a median cost of approximately 70 USD (range 35 USD to 885 USD). From these results, living donor exclusion has negative implications on the patients and transplant program with ethical dilemmas and an economic impact. Many strategies are adopted by other centers to expand the donor pool; however, they are not all applicable in our locality. We conclude that an active legalized deceased donor transplantation program is necessary to overcome the shortage of available liver grafts in Egypt.

Human organ markets and inherent human dignity

It has been suggested that human organs should be bought and sold on a regulated market as any other material property belongingto an individual. This would have the advantage of both addressing the grave shortage of organs available for transplantation and respecting the freedom of individuals to choose to do whatever they want with their body parts. The old arguments against such a market in human organs are, therefore, being brought back into question. The article examines the different arguments both in favour and against the sale of human organs. It concludes that the body and any of its elements is a full expression of the whole person. As such, they cannot have a price if the individual is to retain his or her full inherent dignity and if society is to retain and protect this very important concept.