Financial Incentives to Increase Canadian Organ Donation: Quick Fix or Fallacy?

Introducing Incentives and Reducing Disincentives in Enhancing Deceased Organ Donation and Transplantation

Despite the effectiveness of solid organ transplantation, progress to close the gap between donor organs and demand remains slow. An organ shortage increases the waiting time for transplant and involves significant costs including patient morbidity and mortality. Against the background of a low deceased organ donation rate, this article discusses the option of introducing incentives and removing disincentives to deceased organ donation. Perspectives from ethics, general public opinion, and the health care profession are examined to ensure a comprehensive appraisal and illustrate different facets of opinion on this complex area. Special cultural and psychosocial considerations in Asia, including the family based consent model, are discussed.

Ethical Challenges and the Donation Physician Specialist: A Scoping Review

Deceased donation medicine involves unique ethical challenges. Physicians who are focused on deceased donation medicine as part of their practice can expect to encounter these challenges. The goal of this review is to identify and describe these challenges, highlight existing guidelines and policy regarding the management of these challenges and to describe how the donation physician role might promote ethical practice in deceased donation medicine. Themes of discussion include: communication with families, interprofessional conflict, donation physician personal characteristics, donation clinical processes, health resource allocation, research and education, and remuneration. The information presented in this review can be used to inform development of recommendations and guidelines for the management of ethical challenges encountered by donation physicians.

Scarcity discourses and their impacts on renal care policy, practices, and everyday experiences in rural British Columbia

Drawing from a qualitative case study in rural British Columbia, Canada, this paper examines the discourse of kidney scarcity and its impact on renal care policies and practices. Our findings suggest that at different levels of care, there are different discourses and treatment foci. We have identified three distinct scarcity discourses at work. At the macro policy level, the scarcity of transplantable kidneys is the dominant discourse. At the meso health care institution level, we witnessed a discourse regarding the scarcity of health care and human resources. At the micro community level, there was a discourse of the scarcity of health and life-sustaining resources. For each form of scarcity, particular responses are encouraged. At the macro level, renal care and transplant organizations emphasize the benefits of kidney transplantation and procuring more donors. At the meso level, participants from the regional health care system increasingly encourage home hemodialysis and patient-led care. At the micro level, community health care professionals push for rural renal patients to attend dialysis and maintain their care plans. This work contributes to critical, interdisciplinary organ transfer discourse by contextualizing kidney scarcity. It reveals the tension between these discourses and the implications of pursuing kidney donations without addressing the conditions in which individuals experience kidney failure.

Paid Organ Donation: An Italian Perspective

The only countries that have allowed financial incentives for organ donation are Iran since 1988, and later on, Singapore and Saudi Arabia. In Europe, and of course in Italy, financial incentives for donors are prohibited. The author has completed extensive research via the Internet (PubMed) of worldwide scientific literature on paid organ donation, also researching studies concerning public opinion on organ commercialism and "regulated markets". Italian transplant laws also have been reported and analyzed.

The Canadian kidney paired donation program: a national program to increase living donor transplantation

BACKGROUND

Establishment of a national kidney paired donation (KPD) program represents a unique achievement in Canada's provincially organized health care system.

METHODS

Key factors enabling program implementation included consultation with international experts, formation of a unique organization with a mandate to facilitate interprovincial collaboration, and the volunteer efforts of members of the Canadian transplant community to overcome a variety of logistical barriers.

RESULTS

As of December 2013, the program had facilitated 240 transplantations including 10% with Calculated panel reactive antibody (cPRA) ≥97%. Unique features of the Canadian KPD program include participation of n = 55 nondirected donors, performance of only donor specific antibody negative transplants, the requirement for donor travel, and nonuse of bridge donors.

CONCLUSION

The national KPD program has helped maintain the volume of living kidney donor transplants in Canada over the past 5 years and serves as a model of inter-provincial collaboration to improve the delivery of health care to Canadians.

Focus group study of public opinion about paying living kidney donors in Australia

BACKGROUND AND OBJECTIVES

The unmet demand for kidney transplantation has generated intense controversy about introducing incentives for living kidney donors to increase donation rates. Such debates may affect public perception and acceptance of living kidney donation. This study aims to describe the range and depth of public opinion on financial reimbursement, compensation, and incentives for living kidney donors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Twelve focus groups were conducted with 113 participants recruited from the general public in three Australian states in February 2013. Thematic analysis was used to analyze the transcripts.

RESULTS

Five themes were identified: creating ethical impasses (commodification of the body, quandary of kidney valuation, pushing moral boundaries), corrupting motivations (exposing the vulnerable, inevitable abuse, supplanting altruism), determining justifiable risk (compromising kidney quality, undue harm, accepting a confined risk, trusting protective mechanisms, right to autonomy), driving access (urgency of organ shortage, minimizing disadvantage, guaranteeing cost-efficiency, providing impetus, counteracting black markets), and honoring donor deservingness (fairness and reason, reassurance and rewards, merited recompense). Reimbursement and justifiable recompense are considered by the Australian public as a legitimate way of supporting donors and reducing disadvantage. Financial payment beyond reimbursement is regarded as morally reprehensible, with the potential for exploitative commercialism. Some contend that regulated compensation could be a defensible strategy to increased donation rates provided that mechanisms are in place to protect donors.

CONCLUSIONS

The perceived threat to community values of human dignity, goodwill, and fairness suggests that there could be strong public resistance to any form of financial inducements for living kidney donors. Policy priorities addressing the removal of disincentives may be more acceptable to the public.

The current status and future perspectives of organ donation in Japan: learning from the systems in other countries

The revised Organ Transplant Law came into effect in Japan in July 2010. The law allows for organ procurement from brain-dead individuals, including children, with family consent from subjects who had not previously rejected organ donation. Nevertheless, the number of cadaveric organ donations has not increased as expected. The Spanish Model is widely known as the most successful system in the field of organ donation. The system includes an earlier referral of possible donors to the transplant coordination teams, a new family-based approach and care methods, and the development of additional training courses aimed at specific groups of professionals, which are supported by their corresponding societies. South Korea, a country which neighbors Japan, has recently succeeded in increasing the rates of organ donation by introducing several systems, such as incentive programs, an organ procurement organization, a donor registry, and a system to facilitate potential donor referral. In this review, we present the current status of organ donation in Japan and also explore various factors that may help to improve the country's low donation rate based on the experiences of other developed countries.

Does financial compensation for living kidney donation change willingness to donate?

The potential use of financial compensation to increase living kidney donation rates remains controversial in potentially introducing undue inducement of vulnerable populations to donate. This cross-sectional study assessed amounts of financial compensation that would generate motivation and an undue inducement to donate to family/friends or strangers. Individuals leaving six Departments of Motor Vehicles were surveyed. Of the 210 participants who provided verbal consent (94% participation rate), respondents' willingness to donate would not change (70%), or would increase (29%) with compensation. Median lowest amounts of financial compensation for which participants would begin to consider donating a kidney were $5000 for family/friends, and $10,000 for strangers; respondents reporting $0 for family/friends (52%) or strangers (26%) were excluded from analysis. Median lowest amounts of financial compensation for which participants could no longer decline (perceive an undue inducement) were $50,000 for family/friends, and $100,000 for strangers; respondents reporting $0 for family/friends (44%) or strangers (23%) were excluded from analysis. The two most preferred forms of compensation included: direct payment of money (61%) and paid leave (21%). The two most preferred uses of compensation included: paying off debt (38%) and paying nonmedical expenses associated with the transplant (29%). Findings suggest tolerance for, but little practical impact of, financial compensation. Certain compensation amounts could motivate the public to donate without being perceived as an undue inducement.

Incentives and organ donation: what's (really) legal in Canada?

Purpose of review

To date, there has been little analysis of the degree to which emerging incentive initiatives are permissible under Canadian law. The purpose of this review is to examine the relevant law – including legislation and case law – in order to clarify the legality of existing proposed incentive schemes.

Sources of information

Legislation and case law.

Findings

Organ donation is governed by provincial legislation that, in general, bans the exchange of any “benefit” or any form of “valuable consideration” in return for an organ. As such, these laws are tremendously restrictive and could have significant implications for emerging and proposed procurement policy.

Implications

Given the need for innovative, ethically appropriate policies to increase donation rates, we suggest that the time is right to rethink the potentially restrictive nature of Canada’s organ donation laws.