Ethical incentives--not payment--for organ donation

The Altruism Requirement as Moral Fiction

It is widely agreed that living kidney donation is permitted but living kidney sales are not. Call this the Received View. One way to support the Received View is to appeal to a particular understanding of the conditions under which living kidney transplantation is permissible. It is often claimed that donors must act altruistically, without the expectation of payment and for the sake of another. Call this the Altruism Requirement. On the conventional interpretation, the Altruism Requirement is a moral fact. It states a legitimate constraint on permissible transplantation and is accepted on the basis of cogent argument. The present paper offers an alternative interpretation. I suggest the Altruism Requirement is a moral fiction-a kind of motivated falsehood. It is false that transplantation requires altruism. But the Requirement serves a purpose. Accepting it allows kidney donation but not kidney sale. It, in short, rationalizes the Received View.

Organ Donation Organization Architecture: Recommendations From an International Consensus Forum

This report contains recommendations from 1 of 7 domains of the International Donation and Transplantation Legislative and Policy Forum (the Forum). The purpose is to provide expert guidance on the structure and function of Organ and Tissue Donation and Transplantation (OTDT) systems. The intended audience is OTDT stakeholders working to establish or improve existing systems.

Methods

The Forum was initiated by Transplant Québec and co-hosted by the Canadian Donation and Transplantation Program partnered with multiple national and international donation and transplantation organizations. This domain group included administrative, clinical, and academic experts in OTDT systems and 3 patient, family, and donor partners. We identified topic areas and recommendations through consensus, using the nominal group technique. Selected topics were informed by narrative literature reviews and vetted by the Forum's scientific committee. We presented these recommendations publicly, with delegate feedback being incorporated into the final report.

Results

This report has 33 recommendations grouped into 10 topic areas. Topic areas include the need for public and professional education, processes to assure timely referral of patients who are potential donors, and processes to ensure that standards are properly enforced.

Conclusions

The recommendations encompass the multiple roles organ donation organizations play in the donation and transplantation process. We recognize the diversity of local conditions but believe that they could be adapted and applied by organ donation organizations across the world to accomplish their fundamental objectives of assuring that everyone who desires to become an organ donor is given that opportunity in a safe, equitable, and transparent manner.

How a compensated kidney donation program facilitates the sale of human organs in a regulated market: the implications of Islam on organ donation and sale

BACKGROUND

Advocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales.

METHODS

This study reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation.

RESULTS AND DISCUSSION

According to Islamic law, organ donation is an act of sadaqatul jariyah, and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim eethaar, undermining donors of 'selfless' or 'altruistic' motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran's unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran's unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of 'buyer and seller', ensuring the philosophy of 'donor and recipient' is maintained.

CONCLUSIONS

Offering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors' health and reducing human suffering without legalizing the human organ trade.

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.

Public Perception of Organ Donation and Transplantation Policies in Southern Spain

BACKGROUND

This research explores how public awareness and attitudes toward donation and transplantation policies may contribute to Spain's success in cadaveric organ donation.

MATERIALS AND METHODS

A representative sample of 813 people residing in Andalusia (Southern Spain) were surveyed by telephone or via Internet between October and December 2018.

RESULTS

Most participants trust Spain's donation and transplantation system (93%) and wish to donate their organs after death (76%). Among donors, a majority have expressed their consent (59%), and few nondonors have expressed their refusal (14%). Only a minority are aware of the presumed consent system in force (28%) and feel sufficiently informed regarding the requirements needed to be an organ donor (16%). Participants mainly consider that relatives should represent the deceased's preferences and be consulted when the deceased's wishes are unknown, as is the case in Spain.

CONCLUSION

Public trust in the transplant system may contribute to Spain's high performance in organ donation. High levels of societal support toward organ donation and transplantation do not correspond with similar levels of public awareness of donation and transplantation policies in Spain.

Offering more without offering compensation: non-compensating benefits for living kidney donors

While different positions on the permissibility of organ markets enjoy support, there is widespread agreement that some benefits to living organ donors are acceptable and do not raise the same moral concerns associated with organ markets, such as exploitation and commodification. We argue on the basis of two distinctions that some benefit packages offered to donors can defensibly surpass conventional reimbursement while stopping short of controversial cash payouts. The first distinction is between benefits that defray the costs of donating an organ and benefits that incentivize donation by offering something in excess of defraying. The second distinction is between benefits that compensate donors and benefits that are non-compensating. We argue that non-compensating benefits are innocent of moral concerns typically associated with controversial cash payouts, and thus may be a morally promising avenue for increasing rates of kidney donation to address the tragic results of undersupply.

Cognitive mapping as an approach to facilitate organ donation among African Americans

Making up 13.4% of the United States population, African Americans (AAs) account for 28.7% of candidates who are currently waiting for an organ donation. AAs are disproportionately affected by end-organ disease, particularly kidney disease, therefore, the need for transplantation among this population is high, and the high need is also observed for other solid organ transplantation. To this end, we worked with the AA community to derive an empirical framework of organ donation strategies that may facilitate AA decision-making. We used a cognitive mapping approach involving two distinct phases of primary data collection and a sequence of data analytic procedures to elicit and systematically organize strategies for facilitating organ donation. AA adults (n = 89) sorted 27 strategies identified from nominal group technique meetings in phase 1 based on their perceived similarities. Sorting data were aggregated and analyzed using Multidimensional scaling and hierarchical cluster analyses. Among 89 AA participants, 68.2% were female, 65.5% obtained > high school education, 69.5% reported annual household income ≤ $50,000. The average age was 47.4 years (SD = 14.5). Derived empirical framework consisted of five distinct clusters: fundamental knowledge, psychosocial support, community awareness, community engagement, and system accountability; and two dimensions: Approach, Donor-related Information. The derived empirical framework reflects an organization scheme that may facilitate AA decision-making about organ donation and suggests that targeted dissemination of donor-related information at both the individual-donor and community levels may be critical for increasing donation rates among AAs.

Prize, not price: reframing rewards for kidney donors

Worldwide 1.2 million people are dying from kidney failure each year, and in the USA alone, approximately 100 000 people are currently on the waiting list for a kidney transplant. One possible solution to the kidney shortage is for governments to pay donors for one of their healthy kidneys and distribute these kidneys according to need. There are, however, compelling objections to this government-monopsony model. To avoid these objections, I propose a small adjustment to the model. I suggest we reward kidney sellers with both money and a ceremony that celebrates their noble act. They should, in other words, receive a prize rather than a price.

Pure Altruistic Gift and the Ethics of Transplant Medicine

The article argues that altruistic giving based on anonymity, which is expected to promote social solidarity and block trade in human body parts, is conceptually defective and practically unproductive. It needs to be replaced by a more adequate notion which responds to the human practices of giving and receiving. The argument starts with identification of the main characteristics of the anonymous altruistic donation: social separation of the organ donor (or donor family) from the recipient, their mutual replaceability, non-obligatoriness of donation, and non-obligatoriness of reciprocation on the recipient's part. Since these characteristics are also central to typical market relations, anonymous altruistic donation not only cannot promote solidarity but may encourage proposals for (regulated) markets of transplantable organs. Thus, transplant ethics needs to be reframed. It needs to be rooted in, rather than promote, the practices of giving and receiving known to human societies. As the basis for such reframing, the idea of sharing in another's misfortune is proposed. It relies on the human practices of giving and receiving and, with appropriate regulatory safeguards, can provide a better conceptual basis for blocking commercial exchanges of human body parts.

Modeling Lay People's Ethical Attitudes to Organ Donation: A Q-Methodology Study

BACKGROUND

Organ donation is commonly evaluated by biomedical ethicists based largely on principlism with autonomy at the top of the "moral mountain." Lay people may differ in the way they invoke and balance the various ethical interests. We explored lay people's ethical attitudes to organ donation.

METHODS

Respondents (n=196) ranked 42 opinion-statements on organ donation according to a 9-category symmetrical distribution. Statements' scores were analyzed by averaging-analysis and Q-methodology.

RESULTS

Respondents' mean (SD) age was 34.5 (10.6) years, 53% were women, 69% Muslims (30% Christians), 29% Saudis (26% Filipinos), and 38% healthcare-related. The most-agreeable statements were "Acceptable if benefit to recipient large," "Explicit donor consent and family approval for live donation," "Acceptable if directed to family member," and "Explicit donor consent and family approval for postmortem donation." The most-disagreeable statements were "Donor consent and family approval not required for postmortem donation," "Acceptable with purely materialistic motivation," and "Only donor no-known objection for postmortem donation." Women, Christians, and healthcare respondents gave higher rank to "Explicit donor consent and family approval for live donation," "Only donor family consent required for postmortem donation," and "Acceptable if organ distribution equitable," respectively, and Muslims gave more weight to donor/family harm (p ≤0.001). Q-methodology identified various ethical resolution models that were associated with religious affiliation and included relatively "motives-concerned," "family-benefit-concerned," "familism-oriented," and "religious or non-religious altruism-concerned" models. Of 23 neutral statements on averaging-analysis, 48% and 65% received extreme ranks in ≥1 women and men Q-methodology models, respectively.

CONCLUSION

1) On average, recipient benefit, requirement of both explicit donor consent and family approval, donor-recipient relationship, and motives were predominant considerations; 2) ranking of some statements was associated with respondents' demographics; 3) Q-methodology identified various ethical resolution models that were partially masked by averaging-analysis; and 4) strong virtue and familism approaches in our respondents provide some empirical evidence against principlism adequacy.

What constitutes a reasonable compensation for non-commercial oocyte donors: an analogy with living organ donation and medical research participation

There is a growing consensus that the offer of a reasonable compensation for oocyte donation for reproductive treatment is acceptable if it does not compromise voluntary and altruistically motivated donation. However, how to translate this 'reasonable compensation' in practice remains unclear as compensation rates offered to oocyte donors between different European Union countries vary significantly. Clinics involved in oocyte donation, as well as those in other medical contexts, might be encouraged in calculating a more consistent and transparent compensation for donors if the elements that constitute a reasonable compensation are explicated. In doing so, lessons can be learnt from living organ donation and medical research participation. Practices in which the elements of a reasonable compensation for the individuals involved have already been more defined in the literature. By means of analogical reasoning, we will outline the different components of a reasonable compensation and subsequently apply these to the context of oocyte donation. We will argue that oocyte donors should first of all be reasonably reimbursed direct expenses related to the donation, without standard remuneration of lost wages. Second, donating oocytes requests a serious time investment, therefore donors are entitled to suitable compensation for their time spent and efforts made. Finally, we will explain that a reasonable compensation consisting of these two components allows for altruism to remain the key value of oocyte donation for reproductive treatment. However, if we acknowledge that donors' motives are more complex and often include reasons from self-interest, the reasonable compensation may be complemented with modest (non)monetary benefits.

The present and future of transplant organ shortage: some potential remedies

Transplantation remains the modality of choice for patients with end stage renal disease (ESRD). However, while there has been a steady rise in the number of patients with ESRD the supply of donors (combine living and deceased) has fallen far behind the need, resulting in an increasing number of qualified patients remaining on the wait-list, and thousands being removed from the list every year because of death or becoming too sick for transplantation. This has also fed to transplant tourism around the world. Several countries have implemented a variety of policies to overcome their organ shortage that are presented in this article. There is an urgent need for developing policies geared to the cultural norms of different societies and universally accepted ethical principles to remedy this public health issue.

Transformation of the Doctor-Patient Relationship: Big Data, Accountable Care, and Predictive Health Analytics

The medical profession is steeped in traditions that guide its practice. These traditions were developed to preserve the well-being of patients. Transformations in science, technology, and society, while maintaining a self-governance structure that drives the goal of care provision, have remained hallmarks of the profession. The purpose of this paper is to examine ethical challenges in health care as it relates to Big Data, Accountable Care Organizations, and Health Care Predictive Analytics using the principles of biomedical ethics laid out by Beauchamp and Childress (autonomy, beneficence, non-maleficence, and justice). Among these are the use of Electronic Health Records within stipulations of the Health Insurance Portability and Accountability Act. Clinicians are well-positioned to impact health policy development to address ethical issues associated with the use of Big Data, Accountable Care, and Health Care Predictive Analytics as we work to transform the doctor-patient relationship towards improving population health outcomes and creating a healthier society.

What Money Cannot Buy and What Money Ought Not Buy: Dignity, Motives, and Markets in Human Organ Procurement Debates

Given the current organ shortage, a prevalent alternative to the altruism-based policy is a market-based solution: pay people for their organs. Receiving much popular and scholarly attention, a salient normative argument against neoliberal pressures is the preservation of human dignity. This article examines how advocates of both the altruistic status quo and market challengers reason and weigh the central normative concept of dignity, meant as inherent worth and/or rank. Key rhetorical strategies, including motivations and broader social visions, of the two positions are analyzed and evaluated, and the separation of morally normative understandings of dignity from market encroachment is defended.

Altruism, solidarity and affect in live kidney donation and breastmilk sharing

Social scientists have recently diverged from mainstream bioethical discussion on the topic of the medical use of human biological materials for therapeutic, reproductive and research purposes. Rather than justifying the donation and provision of biological materials solely in terms of alleviating physical, psychological and social suffering, saving or enhancing life, and advancing biomedical knowledge, this work looks beyond humanist bioethics to take a social justice approach to questions of the life sciences. In this article, I draw insight from these accounts to propose an approach to the sociology of live kidney and breastmilk donation that is situated at the interface of the new sociology of morality and affect studies. To do so, I examine the moral economy of tissue provision with respect to its organisation around the discourse of altruism and the gift. I then turn to recent work on tissue economies, which are in the business of creating and producing biovalue, to discuss the manipulation of affect and the entanglement of new forms of bio-intimacy in the production and reproduction of somatic life. The aim of the article was to contribute to the study of the sociology of donation as a substantive field of specialisation within sociology.

Ethically Acceptable Compensation for Living Donations of Organs, Tissues, and Cells: An Unexploited Potential?

The number of living donations of human organs, tissues, and cells falls far short of the need. Market-like arrangements to increase donation rates have been proposed, but they are broadly considered unacceptable due to ethical concerns and are therefore not policy relevant in most countries. The purpose of this paper is to explore a different approach to increasing living donations, namely through the use of ethically acceptable compensation of donors. We review the compensation practices in Europe and find a lack of reimbursement of incurred costs and lack of compensation for non-monetary losses, which create disincentives for donation. We draw on a well-known philosophical theory to explain why donors are rarely fully compensated and why many existing proposals to raise donation rates are seen as controversial or even unethical. We present and discuss three categories of compensation with the potential to increase donation rates in an ethically acceptable way.

Kidney Paired Donation and the "Valuable Consideration" Problem: The Experiences of Australia, Canada, and the United States

As organ donation rates remain unable to meet the needs of individuals waiting for transplants, it is necessary to identify reasons for this shortage and develop solutions to address it. The introduction of kidney paired donation (KPD) programs represents one such innovation that has become a valuable tool in donation systems around the world. Although KPD has been successful in increasing kidney donation and transplantation, there are lingering questions about its legality. Donation through KPD is done in exchange for-and with the expectation of-a reciprocal kidney donation and transplantation. It is this reciprocity that has caused concern about whether KPD complies with existing law. Organ donation systems around the world are almost universally structured to legally prohibit the commercial exchange of organs. Australia, Canada, and the United States have accomplished this goal by prohibiting the exchange of an organ for "valuable consideration," which is a legal term that has not historically been limited to monetary exchange. Whether or not KPD programs violate this legislative prohibition will depend on the specific legislative provision being considered, and the legal system and case law of the particular jurisdiction in question. This article compares the experiences of Australia, Canada, and the United States in determining the legality of KPD and highlights the need for legal clarity and flexibility as donation and transplantation systems continue to evolve.

The Ethics of Organ Tourism: Role Morality and Organ Transplantation

Organ tourism occurs when individuals in countries with existing organ transplant procedures, such as the United States, are unable to procure an organ by using those transplant procedures in enough time to save their life. In this paper, I am concerned with the following question: When organ tourists return to the United States and need another transplant, do US transplant physicians have an obligation to place them on a transplant list? I argue that transplant physicians have a duty not to relist organ tourists. Specifically, I contend that we should locate physicians' duties in these cases within the new role of "transplant physician." This role results from transplant physicians' participation in a system that depends on organ donors' voluntary act of donation.

Financial Considerations in Living Organ Donation

The shortage of cadaveric organs and increased success of living donor transplantation support the use of living organ donors. Clinical social workers have the opportunity to explore a variety of donor-specific issues when performing psychosocial evaluations of living donors, including motivation, psychological stability, and personal and family consequences of donation, as well as the direct and indirect financial consequences faced by living donors. Although most donor-related medical costs are covered, other associated expenses are not reimbursable and may put donors at risk for financial hardship. Out-of-pocket expenses also serve as a disincentive to donate for some volunteers. During the evaluation process, healthcare professionals should openly discuss how surgery, recovery, and any potential complications might impact prospective donors' financial situation. Donors can then decide whether they are able to realistically handle the costs of donation. We present the financial dilemmas experienced by many living donors and highlight efforts that have been made to deal with them.

For and against Organ Donation and Transplantation: Intricate Facilitators and Barriers in Organ Donation Perceived by German Nurses and Doctors

Background. Significant facilitators and barriers to organ donation and transplantation remain in the general public and even in health professionals. Negative attitudes of HPs have been identified as the most significant barrier to actual ODT. The purpose of this paper was hence to investigate to what extent HPs (physicians and nurses) experience such facilitators and barriers in ODT and to what extent they are intercorrelated. We thus combined single causes to circumscribed factors of respective barriers and facilitators and analyzed them for differences regarding profession, gender, spiritual/religious self-categorization, and self-estimated knowledge of ODT and their mutual interaction. Methods. By the use of questionnaires we investigated intricate facilitators and barriers to organ donation experienced by HPs (n = 175; 73% nurses, 27% physicians) in around ten wards at the University Hospital of Munich. Results. Our study confirms a general high agreement with the importance of ODT. Nevertheless, we identified both facilitators and barriers in the following fields: (1) knowledge of ODT and willingness to donate own organs, (2) ethical delicacies in ODT, (3) stressors to handle ODT in the hospital, and (4) individual beliefs and self-estimated religion/spirituality. Conclusion. Attention to the intricacy of stressors and barriers in HPs continues to be a high priority focus for the availability of donor organs.

Attitude of medical professionals regarding controversial issues in kidney donation/transplantation

There is a dire need to evaluate new strategies to bridge the wide kidney demand-supply gap. The current study examined the attitude of medical professionals regarding controversial issues pertaining to transplantation. A questionnaire, presenting controversial issues related to kidney transplantation, in an agree-disagree format with supporting reasons, was employed. The research was exploratory. Data were analyzed quantitatively and qualitatively. The sample comprised 140 doctors from Mumbai (mean = 38.1 years, standard deviation = 17.95; Males = 44.3%, Females = 55.7%). Whereas 47.1% of the participants felt that live donors should be given incentives for kidney donation, others (52.9%) disagreed, fearing commercialization and illegal activities. The eligibility of patients with HIV/hepatitis for a transplant was denied by 52.9% because of poor outcomes, with the others (47.1%) maintaining that these individuals too had a right to live. A substantial majority (90.7%) of the participants maintained that organ donors should be given priority in the event of a future need for an organ because their previous humane act should be rewarded (47.1%). Most of the participants (91.4%) felt that individuals from the higher socioeconomic strata should not receive preference for kidney transplantation. A majority (77.1%) of them were also against kidney selling getting legalized. Compulsory possession of a donor card elicited mixed responses, with some accepting (56.4%), but others rejecting (43.6%) this idea as donation was perceived to be a voluntary act (33.6%). While compulsory kidney donation found favor with 44.3%, it found disfavor with others (55.7%). This study will benefit transplant healthcare personnel to formulate new policies in relation to kidney donation/transplantation.

BARTERING FOR A COMPATIBLE KIDNEY USING YOUR INCOMPATIBLE, LIVE KIDNEY DONOR: LEGAL AND ETHICAL ISSUES RELATED TO KIDNEY CHAINS

Kidney chains are a recent and novel method of increasing the number of available kidneys for transplantation and have the potential to save thousands of lives. However, because they are novel, kidney chains do not fit neatly within existing legal and ethicalframeworks, raising potential barriers to their full implementation. Kidney chains are an extension of paired kidney donation, which began in the United States in 2000. Paired kidney donations allow kidney patients with willing, but incompatible, donors to swap donors to increase the number of donor/recipient pairs and consequently, the number of transplants. More recently, transplant centers have been using non-simultaneous, extended, altruistic donor ("NEAD") kidney chains--which consist of a sequence of donations by incompatible donors--to further expand the number of donations. This Article fully explains paired kidney donation and kidney chains and focuses on whether NEAD chains are more coercive than traditional kidney donation to a family member or close friend and whether NEAD chains violate the National Organ Transplant Act's prohibition on the transfer of organs for valuable consideration.

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.

Reporting Organ Trafficking Networks: A Survey-Based Plea to Breach the Secrecy Oath

Patients travel worldwide to purchase kidneys. Transplant professionals can play a role in identifying kidney purchase. However, due to the tension between their rights and obligations, a lack of understanding and knowledge exists on how to prevent and report purchase. We present the results of a national survey that describes transplant professionals' experiences, attitudes, behaviors, conflicts of duties, legal knowledge and needs for guidelines toward patients who purchase kidneys abroad. Second, we clarify professionals' rights and obligations regarding organ purchase and propose actions that they can take to report purchase. Of the 100/241 (42%) professionals who treated patients who traveled to a country outside the European Union for a kidney transplant, 31 (31%) were certain that patients purchased kidneys. Sixty-five (65%) had suspicions that patients had bought kidneys. The majority reported a conflict of duties. Eighty percent reported a need for guidelines. Professionals can help prevent organ purchase by disclosing information about organ trafficking networks to law enforcement. Such disclosure can support the investigation and prosecution of networks. We offer key components for guidelines on disclosure of these networks.

Markets and morals: an experimental survey study

Most societies prohibit some market transactions based on moral concerns, even when the exchanges would benefit the parties involved and would not create negative externalities. A prominent example is given by payments for human organs for transplantation, banned virtually everywhere despite long waiting lists and many deaths of patients who cannot find a donor. Recent research, however, has shown that individuals significantly increase their stated support for a regulated market for human organs when provided with information about the organ shortage and the potential beneficial effects a price mechanism. In this study we focused on payments for human organs and on another “repugnant” transaction, indoor prostitution, to address two questions: (A) Does providing general information on the welfare properties of prices and markets modify attitudes toward repugnant trades? (B) Does additional knowledge on the benefits of a price mechanism in a specific context affect attitudes toward price-based transactions in another context? By answering these questions, we can assess whether eliciting a market-oriented approach may lead to a relaxation of moral opposition to markets, and whether there is a cross-effect of information, in particular for morally controversial activities that, although different, share a reference to the “commercialization” of the human body. Relying on an online survey experiment with 5,324 U.S. residents, we found no effect of general information about market efficiency, consistent with morally controversial markets being accepted only when they are seen as a solution to a specific problem. We also found some cross-effects of information about a transaction on the acceptance of the other; however, the responses were mediated by the gender and (to a lesser extent) religiosity of the respondent—in particular, women exposed to information about legalizing prostitution reduced their stated support for regulated organ payments. We relate these findings to prior research and discuss implications for public policy.

A perpetual source of DNA or something really different: ethical issues in the creation of cell lines for African genomics research

Background

The rise of genomic studies in Africa – not least due to projects funded under H3Africa – is associated with the development of a small number of biorepositories across Africa. For the ultimate success of these biorepositories, the creation of cell lines including those from selected H3Africa samples would be beneficial. In this paper, we map ethical challenges in the creation of cell lines.

Discussion

The first challenge we identified relates to the moral status of cells living in culture. There is no doubt that cells in culture are alive, and the question is how this characteristic is relevant to ethical decision-making. The second challenge relates to the fact that cells in culture are a source of cell products and mitochondrial DNA. In combination with other technologies, cells in culture could also be used to grow human tissue. Whilst on the one hand, this feature increases the potential utility of the sample and promotes science, on the other it also enables further scientific work that may not have been specifically consented to or approved. The third challenge relates to ownership over samples, particularly in cases where cell lines are created by a biobank, and in a different country than where samples were collected. Relevant questions here concern the export of samples, approval of secondary use and the acceptability of commercialisation. A fourth challenge relates to perceptions of blood and bodily integrity, which may be particularly relevant for African research participants from certain cultures or backgrounds. Finally, we discuss challenges around informed consent and ethical review.

Summary

In this paper, we sought to map the myriad of ethical challenges that need to be considered prior to making cell line creation a reality in the H3Africa project. Considering the relative novelty of this practice in Africa, such challenges will need to be considered, discussed and potentially be resolved before cell line creation in Africa becomes financially feasible and sustainable. We suggest that discussions need to be undertaken between stakeholders internationally, considering the international character of the H3Africa project. We also map out avenues for empirical research.

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.

Altruism, gift giving and reciprocity in organ donation: a review of cultural perspectives and challenges of the concepts

Living and deceased organ donation are couched in altruism and gift discourse and this article reviews explores cultural views towards these concepts. Altruism and egoism theories and gift and reciprocity theories are outlined from a social exchange theory perspective to highlight the key differences between altruism and the gift and the wider implications of reciprocation. The notion of altruism as a selfless act without expectation or want for repayment juxtaposed with the Maussian gift where there are the obligations to give, receive and reciprocate. Lay perspectives of altruism and the gift in organ donation are outlined and illustrate that there are differences in motivations to donate in different programmes of living donation and for families who decide to donate their relative's organs. These motivations reflect cultural views of altruism and the gift and perceptions of the body and death.

The cost-effectiveness of using payment to increase living donor kidneys for transplantation

BACKGROUND AND OBJECTIVES

For eligible candidates, transplantation is considered the optimal treatment compared with dialysis for patients with ESRD. The growing number of patients with ESRD requires new strategies to increase the pool of potential donors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using decision analysis modeling, this study compared a strategy of paying living kidney donors to waitlisted recipients on dialysis with the current organ donation system. In the base case estimate, this study assumed that the number of donors would increase by 5% with a payment of $10,000. Quality of life estimates, resource use, and costs (2010 Canadian dollars) were based on the best available published data.

RESULTS

Compared with the current organ donation system, a strategy of increasing the number of kidneys for transplantation by 5% by paying living donors $10,000 has an incremental cost-savings of $340 and a gain of 0.11 quality-adjusted life years. Increasing the number of kidneys for transplantation by 10% and 20% would translate into incremental cost-savings of $1640 and $4030 and incremental quality-adjusted life years gain of 0.21 and 0.39, respectively.

CONCLUSION

Although the impact is uncertain, this model suggests that a strategy of paying living donors to increase the number of kidneys available for transplantation could be cost-effective, even with a transplant rate increase of only 5%. Future work needs to examine the feasibility, legal policy, ethics, and public perception of a strategy to pay living donors.

Organ donation as transition work: Policy discourse and clinical practice in The Netherlands

An increasing number of patients become eligible for organ transplants. In the Netherlands, at the level of policy discourse, growing waiting lists are often referred to as a persistent “shortage” of organs, producing a “public health crisis.” In this way, organ donation is presented as an ethical, social, and medical necessity. Likewise, policy discourse offers a range of seemingly unambiguous solutions: improving logistical infrastructure at the level of hospitals, developing organizational and legal protocols, as well as public information campaigns. Instead of taking these problem and solution definitions as given, we critically examine the relationship between policy discourse and clinical practice. Based on a historical review, first, we trace the key moments of transformation where organ donation became naturalized in Dutch policy discourse, particularly in its altruistic connotation. Second, based on in-depth interviews with medical professionals, we show how those involved in organ donation continue to struggle with the controversial nature of their clinical practice. More specifically, we highlight their use of different forms of knowledge that underlie clinicians’ “transition work”: from losing a patient to “gaining” a donor.

Honoring Deceased Donors with a Unique Family-Designed Statement Followed by a Moment of Silence: Effect on Donation Outcomes

Context

Studies indicate that donor families and hospital staff, particularly operating room staff, fear that organ donors will not be treated with dignity, honor, and respect.

Objective

The ritual of a unique, family-designed statement of honor followed by a 15-second moment of silence in the operating room before organ recovery was implemented to honor organ donors and their families. The purpose of this study was to describe the development of the ritual and to investigate its impact on donation rates in the California Transplant Donor Network's service area.

Design

Cross-sectional observational study.

Setting

The California Transplant Donor Network, an organ procurement organization.

Participants

58 organ donors and families in 39 donor hospitals.

Main Outcome Measures

Variables of interest included hospital rate of referral and of timely referral to their organ procurement organization, collaborative conversion rates, and donor families' response to implementation of the new ritual.

Results

The ritual was implemented in 2011 in several randomly selected hospitals locally. Seventy-one unique rituals were performed in 22 local hospitals in the trial period. No families or health care providers declined to participate. Families reported that the ritual honored their loved ones. Although the collaborative conversion rates were similar in hospitals before implementation (2010), implementation of the ritual affected donation rates in 2011.

Conclusions

The 15-second moment of silence honors deceased donors and their families and improves donation rates in donor hospitals.

Consenting options for posthumous organ donation: presumed consent and incentives are not favored

BACKGROUND

Posthumous organ procurement is hindered by the consenting process. Several consenting systems have been proposed. There is limited information on public relative attitudes towards various consenting systems, especially in Middle Eastern/Islamic countries.

METHODS

We surveyed 698 Saudi Adults attending outpatient clinics at a tertiary care hospital. Preference and perception of norm regarding consenting options for posthumous organ donation were explored. Participants ranked (1, most agreeable) the following, randomly-presented, options from 1 to 11: no-organ-donation, presumed consent, informed consent by donor-only, informed consent by donor-or-surrogate, and mandatory choice; the last three options ± medical or financial incentive.

RESULTS

Mean(SD) age was 32(9) year, 27% were males, 50% were patients' companions, 60% had ≥ college education, and 20% and 32%, respectively, knew an organ donor or recipient. Mandated choice was among the top three choices for preference of 54% of respondents, with an overall median[25%,75%] ranking score of 3[2,6], and was preferred over donor-or-surrogate informed consent (4[2,7], p < 0.001), donor-only informed consent (5[3,7], p < 0.001), and presumed consent (7[3,10], p < 0.001). The addition of a financial or medical incentive, respectively, reduced ranking of mandated choice to 7[4,9], p < 0.001, and 5[3,8], p < 0.001; for donor-or-surrogate informed consent to 7[5,9], p < 0.001, and 5[3,7], p = 0.004; and for donor-only informed consent to 8[6,10], p < 0.001, and 5[3,7], p = 0.56. Distribution of ranking score of perception of norm and preference were similar except for no-organ donation (11[7,11] vs. 11[6,11], respectively, p = 0.002). Compared to females, males more perceived donor-or-surrogate informed consent as the norm (3[1,6] vs. 5[3,7], p < 0.001), more preferred mandated choice with financial incentive option (6[3,8] vs. 8[4,9], p < 0.001), and less preferred mandated choice with medical incentive option (7[4,9] vs. 5[2,7], p < 0.001). There was no association between consenting options ranking scores and age, health status, education level, or knowing an organ donor or recipient.

CONCLUSIONS

We conclude that: 1) most respondents were in favor of posthumous organ donation, 2) mandated choice system was the most preferred and presumed consent system was the least preferred, 3) there was no difference between preference and perception of norm in consenting systems ranking, and 4) financial (especially in females) and medical (especially in males) incentives reduced preference.

Attitudes toward strategies to increase organ donation: views of the general public and health professionals

BACKGROUND AND OBJECTIVE

The acceptability of financial incentives for organ donation is contentious. This study sought to determine (1) the acceptability of expense reimbursement or financial incentives by the general public, health professionals involved with organ donation and transplantation, and those with or affected by kidney disease and (2) for the public, whether financial incentives would alter their willingness to consider donation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Web-based survey administered to members of the Canadian public, health professionals, and people with or affected by kidney disease asking questions regarding acceptability of strategies to increase living and deceased kidney donation and willingness to donate a kidney under various financial incentives.

RESULTS

Responses were collected from 2004 members of the Canadian public October 11-18, 2011; responses from health professionals (n=339) and people with or affected by kidney disease (n=268) were collected during a 4-week period commencing October 11, 2011. Acceptability of one or more financial incentives to increase deceased and living donation was noted in >70% and 40% of all groups, respectively. Support for monetary payment for living donors was 45%, 14%, and 27% for the public, health professionals, and people with or affected by kidney disease, respectively. Overall, reimbursement of funeral expenses for deceased donors and a tax break for living donors were the most acceptable.

CONCLUSION

The general public views regulated financial incentives for living and deceased donation to be acceptable. Future research needs to examine the impact of financial incentives on rates of deceased and living donors.

Organ donation and priority points in Israel: an ethical analysis

Israel's rates of organ donation have been one of the lowest among developed countries. An attempt to change this has led to the introduction of a pioneering new law, the Organ Transplant Act 2008, which came into effect in January 2010 and sets out principles underlying a new policy in relation to the allocation of organs for transplantation. According to this policy, a person can gain priority points by signing a donor card, making a nondirected organ donation during their lifetime, or as a result of a first-degree relative signing a donor card, or consenting to procurement of organs after death. In this opinion piece, we argue that although this approach merits attention for its innovative aspects and its potential benefits, it raises some ethical difficulties. In particular, we discuss some problems of justice and fairness inherent in the system, focusing on inequalities because of the (a) number of relatives one might have, (b) the type of living donation one makes, (c) the potential for strategic behavior, and (d) problems regarding the consent of family members.

Laypeople's ethical concerns about a New Israeli organ transplantation prioritization policy aimed to encourage organ donor registration among the public

A new policy recently enacted in Israel promises preferred status in receiving organs for transplantation to individuals who register to be organ donors and to their close family members. Proponents believe it will increase the supply of organs for transplantation from the deceased. Ethical issues were raised in government committees appointed to discuss the policy before its approval, but discussions among laypeople were not solicited. This study aimed to elicit laypeople's views about the policy by conducting thirteen group interviews and thirty-six individual interviews. Participants included religious and nonreligious people, immigrants, and Arabs. Some participants thought the law would contribute to fairness by prioritizing those willing to give, but others articulated ethical concerns that were not emphasized by scholars, in particular that the policy would add to the erosion of social solidarity, increase divisiveness, and enable people to abuse the system. Mistrust in the health care system emerged as a prominent reason for not registering as an organ donor. Implications about the importance of transparency in the organ transplantation system as a basis for an information campaign, social norms regarding organ donation, and the public's involvement in policy issues on organ donation are discussed.

Legal and ethical aspects of organ donation and transplantation

The legislation called the Transplantation of Human Organ Act (THO) was passed in India in 1994 to streamline organ donation and transplantation activities. Broadly, the act accepted brain death as a form of death and made the sale of organs a punishable offence. With the acceptance of brain death, it became possible to not only undertake kidney transplantations but also start other solid organ transplants like liver, heart, lungs, and pancreas. Despite the THO legislation, organ commerce and kidney scandals are regularly reported in the Indian media. In most instances, the implementation of the law has been flawed and more often than once its provisions have been abused. Parallel to the living related and unrelated donation program, the deceased donation program has slowly evolved in a few states. In approximately one-third of all liver transplants, the organs have come from the deceased donor program as have all the hearts and pancreas transplants. In these states, a few hospitals along with committed NGOs have kept the momentum of the deceased donor program. The MOHAN Foundation (NGO based in Tamil Nadu and Andhra Pradesh) has facilitated 400 of the 1,300 deceased organ transplants performed in the country over the last 14 years. To overcome organ shortage, developed countries are re-looking at the ethics of unrelated programs and there seems to be a move towards making this an acceptable legal alternative. The supply of deceased donors in these countries has peaked and there has been no further increase over the last few years. India is currently having a deceased donation rate of 0.05 to 0.08 per million population. We need to find a solution on how we can utilize the potentially large pool of trauma-related brain deaths for organ donation. This year in the state of Tamil Nadu, the Government has passed seven special orders. These orders are expected to streamline the activity of deceased donors and help increase their numbers. Recently, on July 30, 2008, the Government brought in a few new amendments as a Gazette with the purpose of putting a stop to organ commerce. The ethics of commerce in organ donation and transplant tourism has been widely criticized by international bodies. The legal and ethical principles that we follow universally with organ donation and transplantation are also important for the future as these may be used to resolve our conflicts related to emerging sciences such as cloning, tissue engineering, and stem cells.

Legal and ethical aspects of organ donation and transplantation

The legislation called the Transplantation of Human Organ Act (THO) was passed in India in 1994 to streamline organ donation and transplantation activities. Broadly, the act accepted brain death as a form of death and made the sale of organs a punishable offence. With the acceptance of brain death, it became possible to not only undertake kidney transplantations but also start other solid organ transplants like liver, heart, lungs, and pancreas. Despite the THO legislation, organ commerce and kidney scandals are regularly reported in the Indian media. In most instances, the implementation of the law has been flawed and more often than once its provisions have been abused. Parallel to the living related and unrelated donation program, the deceased donation program has slowly evolved in a few states. In approximately one-third of all liver transplants, the organs have come from the deceased donor program as have all the hearts and pancreas transplants. In these states, a few hospitals along with committed NGOs have kept the momentum of the deceased donor program. The MOHAN Foundation (NGO based in Tamil Nadu and Andhra Pradesh) has facilitated 400 of the 1,300 deceased organ transplants performed in the country over the last 14 years. To overcome organ shortage, developed countries are re-looking at the ethics of unrelated programs and there seems to be a move towards making this an acceptable legal alternative. The supply of deceased donors in these countries has peaked and there has been no further increase over the last few years. India is currently having a deceased donation rate of 0.05 to 0.08 per million population. We need to find a solution on how we can utilize the potentially large pool of trauma-related brain deaths for organ donation. This year in the state of Tamil Nadu, the Government has passed seven special orders. These orders are expected to streamline the activity of deceased donors and help increase their numbers. Recently, on July 30, 2008, the Government brought in a few new amendments as a Gazette with the purpose of putting a stop to organ commerce. The ethics of commerce in organ donation and transplant tourism has been widely criticized by international bodies. The legal and ethical principles that we follow universally with organ donation and transplantation are also important for the future as these may be used to resolve our conflicts related to emerging sciences such as cloning, tissue engineering, and stem cells.