Attitudes toward financial incentives, donor authorization, and presumed consent among next-of-kin who consented vs. refused organ donation

Survey for the Opinion of Medical Students and Medical Staff on a Financial Incentive System for Deceased Organ Donation in an Asian Country

BACKGROUND

Financial incentives for deceased organ donation are associated with many controversial ethical issues. This study examines the perspectives of medical students and staff members on financial incentives for the families of brain-dead organ donors.

METHODOLOGY

A structured survey form was used between December 7, 2017 and January 28, 2018 to elicit opinions on financial incentives for the families of brain-dead organ donors. Forty-three medical staff members and 81 medical students participated in the survey voluntarily. The opinions on the financial incentive system and the relationship between willingness to give information about organ donation to families and a financial incentive system were assessed.

RESULTS

The majority of the participants (81.4%) had positive thoughts on organ donation. More than half of the participants (60.5%) thought that the financial incentive system did not erode the ethical purity of organ donation. As charge doctors, most respondents (84.6%) were willing to give information about organ donation to family members in the presence of financial incentives. However, the percentage decreased significantly to 60.5% when financial incentive was no longer factored into consideration (P < .001).

LIMITATION

The study population is small, and the participants are not representative of the general population.

CONCLUSION

The opinions of medical students and medical staff on financial incentives for deceased organ donation were generally positive. Financial incentives proved to be a potential influencing factor as an option of organ donation to be given to families.

Views on deceased organ donation in the Netherlands: A q-methodology study

In many countries, such as the US, Germany, France, and the Netherlands, governments are dealing with a great shortage of organ donors. Even though people generally show positive attitudes towards organ donation, they often do not actually register as organ donors themselves. This study's objective was to explore prevailing viewpoints among the Dutch population on deceased organ donation and the relation between aspects of the viewpoints potentially influencing the decision to register as an organ donor. Although substantive research about attitudes on organ donation has been conducted, this is the first study investigating people's viewpoints focusing on the relation between beliefs, tastes, preferences, motives, goals and other constituents underlying people's viewpoints on organ donation, such as the role of the media and public policies. This Q-methodology study revealed four viewpoints: "not donating your organs is a waste", "it does not go with my religion", "my family should decide"; and "it's a good deed, but I'm doubtful". These viewpoints convey information on potential reasons for the gap between people's favourable attitudes towards organ donation and the low number of actual registrations, and opportunities for policy makers to address certain target groups more adequately.

Canadian Guidelines for Controlled Pediatric Donation After Circulatory Determination of Death-Summary Report

OBJECTIVES

Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada.

METHODS

We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners.

RESULTS

We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report.

CONCLUSIONS

This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation.

Intention to Register as Organ Donors: A Survey of Adolescents

Background

Little is known about factors that influence the intention of adolescents to register as organ donors. The identification of such factors has important implications for the development and implementation of educational programs and subsequent donor registration rates.

Objective

To determine whether adolescents with an expressed commitment to becoming organ donor registrants differ significantly from nondonors on sociodemographic characteristics and factors influencing their decision.

Participants

Four hundred forty-five adolescents visiting a Department of Motor Vehicles office for a permit or license (n = 153) or attending a driver's education course (n = 292) completed a semistructured interview and questionnaire.

Results

Female (52.6%) and white (55.8%) adolescents were more likely to have favorable donation intentions relative to male (45.6%) and nonwhite (39.0%) adolescents (χ2 = 7.5, P = .02, and χ2 = 19.7, P = .003, respectively). Those with favorable donation intentions also endorsed significantly more positive factors (benevolence, need awareness, existentialism) as being more important in their decision. Adolescents who did not want to donate (58.7%) and those who were undecided (23.1%) were less likely to have discussed their decision with parents than were those who wanted to donate (67.7%, χ2 = 63.6, P = .0001). Finally, providing adolescents with a free driver's license in exchange for organ donor registration would have the greatest impact on registering undecided adolescents (29.8%, χ2 = 33.2, P = .0001).

Conclusions

There is a pressing need for more systematic and culturally sensitive organ donation education directed toward adolescents, and the Department of Motor Vehicles and driver's education courses may be appropriate venues. An educational program from the US Department of Health and Human Services, Decision: Donation, could be used in this context.

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.

Understanding Australian Families’ Organ Donation Decisions

Numbers of deceased organ donors in Australia have increased, but rates of consent to donation remain at around 60%. Increasing family consent is a key target for the Australian Organ and Tissue Authority. Reasons for donation decisions have been reported in the international literature, but little is known of reasons for Australian families’ decisions. Potential organ donors in four Melbourne hospitals were identified and 49 participants from 40 families (23 consenting and 17 non-consenting) were interviewed to understand reasons for consent decisions. Themes for consent to organ donation included that: donation was consistent with the deceased's explicit wishes or known values, the desire to help others or self—including themes of altruism, pragmatism, preventing others from being in the same position, consolation received from donation and aspects of the donation conversation and care that led families to believe donation was right for them. Themes for non-consent included: lack of knowledge of wishes, social, cultural and religious beliefs; factors related to the donation process and family exhaustion; and conversation factors where negative events influenced decisions. While reasons for consent were similar to those described in international literature, reasons for non-consent differed in that there was little emphasis on lack of trust of the medical profession, concerns regarding level of care provided to the potential donor, preserving the deceased's body, fears of body invasion or organ allocation fairness.

Pro-donation behaviours of nursing students from the four countries of the UK

BACKGROUND

The effectiveness of the organ donation system depends on the health professionals involved in procurement and in dealing with donors and their families. Concerns about lack of knowledge and experience of organ donation have been expressed among such professionals but there is a paucity of literature to indicate the basis of such concerns and where knowledge may be lacking. Given that regional variations in organ donation rates exist in the UK, this study investigates knowledge about and attitudes towards organ donation among student nurses in different countries of the UK and examines regional variations.

METHODS

A questionnaire was distributed to 667 student nurses (female:male = 582∶85) aged 18 to 50 years (mean [SD] 25.4 [7.1] years) recruited from a total of five Universities (Scotland, Wales, Northern Ireland, England) during the period of January to September 2011.

RESULTS

Registration behaviour among participants was shown to vary depending upon many different factors that include birthplace, residency, fear of death and concerns of medical distrust.

CONCLUSIONS

Regional variations in organ donation behaviour in the UK were found in the cohorts of student nurses who participated in this study. These variations include willingness to register and to donate specific body parts and not others. The relationship between attitude and behaviour and how this may influence the decision making process of organ donation, as well as the underlying factors that result in regional variations, require further investigation.

Policy perspectives: international survey of nephrologists' perceptions of and attitudes towards rewards and compensation for kidney donation

The challenge to resolve the gap between supply and demand for organs is a global phenomenon. The possible solutions can invariably involve a range of ethical and moral dilemmas. This is certainly the case when considering rewards and compensation for kidney donation. In their thought provoking study, Ghahramami et al. provide the perspectives of medical professionals on these issues. The views of nephrologists concerning rewards and compensation chime with views of the public, which have been highlighted in many previous studies. Rewards and compensation for organ donation are perceived, by some, as barriers to successful organ donation transplant programmes; whereas others view them as potential facilitators to increasing organ donation rates. It is interesting to note that two-thirds of survey respondents believe that introducing some kind of reward or offering compensation would lead to an increase in organ donation. This finding is not unique to this study and is evident in many public surveys where respondents have expressed a belief that offering some form of incentive would have a positive impact on organ donation rates. Disappointingly, the debates concerning the type of reward or compensation and its potential impact on donation rates continue to take place in a relatively 'evidence base-free' vacuum. What is abundantly clear is that many lives continue to be lost in many countries due to a lack of suitable organs for transplant. What is less clear is which forms of reward and compensation actually have an impact on donation rates and whether they positively impact the life experiences of donors, recipients and their families. This level of evidence- base is urgently required.

Can education alter attitudes, behaviour and knowledge about organ donation? A pretest-post-test study

OBJECTIVE

The emergence of evidence suggests that student nurses commonly exhibit concerns about their lack of knowledge of organ donation and transplantation. Formal training about organ donation has been shown to positively influence attitude, encourage communication and registration behaviours and improve knowledge about donor eligibility and brain death. The focus of this study was to determine the attitude and behaviour of student nurses and to assess their level of knowledge about organ donation after a programme of study.

DESIGN

A quantitative questionnaire was completed before and after participation in a programme of study using a pretest-post-test design.

SETTING

Participants were recruited from a University based in Northern Ireland during the period from February to April 2011.

PARTICIPANTS

100 preregistration nurses (female : male=96 : 4) aged 18-50 years (mean (SD) 24.3 (6.0) years) were recruited.

RESULTS

Participants' knowledge improved over the programme of study with regard to the suitability of organs that can be donated after death, methods available to register organ donation intentions, organ donation laws, concept of brain death and the likelihood of recovery after brain death. Changes in attitude postintervention were also observed in relation to participants' willingness to accept an informed system of consent and with regard to participants' actual discussion behaviour.

CONCLUSIONS

The results provide support for the introduction of a programme that helps inform student nurses about important aspects of organ donation.

Attitudes and acceptance of First Person Authorization: a national comparison of donor and nondonor families

BACKGROUND

First Person Authorization (i.e., donor designation) legislation makes indicating one's intent to be a posthumous organ donor legally binding, much like a living will or advance directive. Such legislation is the most recent in a long history of organ donation policies in the United States and has received little attention in the literature.

METHODS

This retrospective cohort study recruited nine US organ procurement organizations (OPOs) and their staff who make requests for organ donation as well as family decision makers approached by OPO staff about organ donation. Telephone interviews (N = 1,087) with family decision makers assessed the attitudes, perceptions, and behaviors regarding the request for organ donation of families of designated donors as compared with those of patients who did not formally designate themselves as donors.

RESULTS

Almost two thirds (65.7%) of the families of registered donors were aware of the decedent's decision to register as a posthumous donor. Family decision makers who authorized donation and those of designated donors exhibited greater knowledge of organ donation and more positive attitudes than decision makers who refused to donate. Families of designated donors had more favorable perceptions of the request for organ donation and were more satisfied with both the time spent discussing donation and the request process; fewer donor designation families were surprised at the request for donation.

CONCLUSION

The enactment of First Person Authorization legislation increases the likelihood of familial authorization and satisfaction with the final donation outcome. As compared with other families approached about the option of organ donation, families of designated donors report having a more positive experience with the organ donation request process overall and greater comfort and satisfaction with the donation decision.

LEVEL OF EVIDENCE

Epidemiologic study, level II.

Public attitudes to financial incentive models for organs: a literature review suggests that it is time to shift the focus from 'financial incentives' to 'reciprocity'

Waiting lists for organs have stimulated interest in the use of financial incentives for organ donation (FIs), but the literature does not contain an adequate overview of studies of public attitudes toward this mode of procurement. We conducted a literature review of international peer-reviewed research published between 2002 and 2012 on how members of the public position themselves toward FIs. We identified and analyzed 23 studies using MEDLINE, PsycINFO, Sociological Abstracts and cross-reference search. The search included whole organs, donation, quantitative and empirical qualitative social scientific studies on, public attitudes (excluding professionals and medical students). The review reveals a broad divergence of public opinions on financial incentives. However, quantitative studies showed a low overall level of acceptance of payment for organs in living donation (LD); only a slightly higher one for deceased donation (DD); and a general preference for alternative forms, such as removal of disincentives or expressions of social reciprocity. Across different national and methodological settings we observed a considerable preference of noncommercial forms. This does not preclude the opportunity to consider various types of acknowledgement of economic value given in return for the organ. This provides reason to shift the focus from incentives to reciprocity.

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.

In defense of a regulated system of compensation for living donation

PURPOSE OF REVIEW

The organ shortage is the major problem in kidney transplantation today. Despite aggressive organ procurement efforts, the supply of donated kidneys, living and deceased, has not matched the growing demand; as a consequence, more and more qualified candidates are suffering on dialysis and then dying before being transplanted. Herein, we provide justification for a regulated system of compensation for donation.

RECENT FINDINGS

The main argument in favor of compensation is simple-financial incentives will increase donation, so fewer transplant candidates will suffer and die while waiting. In addition, development of a regulated system of compensation is the most effective means of crippling the core economic support for transplant tourism. Because dialysis is so much more expensive than a transplant, compensated donation could be cost-neutral to the healthcare system. Importantly, opinion polls suggest that the public would support compensation. As uncompensated kidney donation is widely accepted, persuasive arguments against compensation must explain why such a system would be morally distinguishable from uncompensated donation.

SUMMARY

We suggest that the potential advantages of a regulated system of compensation for donation far outweigh any potential disadvantages. It is time to advocate for a change in the law so that trials can be done.

Addressing the Unintended Adverse Consequences of First-Person Consent and Donor Registries

One of the most common reasons given for the refusal to donate in both the United States and the United Kingdom is that the potential donor, in his lifetime, said he did not want to be a donor. This objection has not always been given by families refusing to donate and appears to be an unintended consequence of donation strategies based on public education, donor registries, and first-person consents. A history of the objection is given, possible meanings are explored, and strategies for dealing with it are suggested.

Stimulus for organ donation: a survey of the American Society of Transplant Surgeons membership

Federal legislation has been proposed to modify the National Organ Transplant Act in a way that would permit government-regulated strategies, including financial incentives, to be implemented and evaluated. The Council and Ethics Committee of the American Society of Transplant Surgeons conducted a brief web-based survey of its members' (n = 449, 41.6% response rate) views on acceptable or unacceptable strategies to increase organ donation. The majority of the membership supports reimbursement for funeral expenses, an income tax credit on the final return of a deceased donor and an income tax credit for registering as an organ donor as strategies for increasing deceased donation. Payment for lost wages, guaranteed health insurance and an income tax credit are strategies most strongly supported by the membership to increase living donation. For both deceased and living donation, the membership is mostly opposed to cash payments to donors, their estates or to next-of-kin. There is strong support for a government-regulated trial to evaluate the potential benefits and harms of financial incentives for both deceased and living donation. Overall, there is strong support within the ASTS membership for changes to NOTA that would permit the implementation and careful evaluation of indirect, government-regulated strategies to increase organ donation.

Obtaining consent for future research with induced pluripotent cells: opportunities and challenges

Human induced pluripotent stem cells have revolutionized stem cell research. However, their great potential also raises important concerns about consent for future research.

What is presumed when we presume consent?

BACKGROUND

The organ donor shortfall in the UK has prompted calls to introduce legislation to allow for presumed consent: if there is no explicit objection to donation of an organ, consent should be presumed. The current debate has not taken in account accepted meanings of presumption in law and science and the consequences for rights of ownership that would arise should presumed consent become law. In addition, arguments revolve around the rights of the competent autonomous adult but do not always consider the more serious implications for children or the disabled.

DISCUSSION

Any action or decision made on a presumption is accepted in law and science as one based on judgement of a provisional situation. It should therefore allow the possibility of reversing the action or decision. Presumed consent to organ donation will not permit such reversal. Placing prime importance on the functionality of body organs and their capacity to sustain life rather than on explicit consent of the individual will lead to further debate about rights of ownership and potentially to questions about financial incentives and to whom benefits should accrue. Factors that influence donor rates are not fully understood and attitudes of the public to presumed consent require further investigation. Presuming consent will also necessitate considering how such a measure would be applied in situations involving children and mentally incompetent adults.

SUMMARY

The presumption of consent to organ donation cannot be understood in the same way as is presumption when applied to science or law. Consideration should be given to the consequences of presuming consent and to the questions of ownership and organ monetary value as these questions are likely to arise should presumed consent be permitted. In addition, the implications of presumed consent on children and adults who are unable to object to organ donation, requires serious contemplation if these most vulnerable members of society are to be protected.

Opportunities not taken: Successes and shortcomings in the Institute of Medicine's report on organ donation

The Institute of Medicine's recent report, Organ Donation: Opportunities for Action, studies the current problems facing organ donation in the USA, making suggestions for quality improvement and analyzing various proposals of incentivized donation and presumed consent (PC). Although the report deals with the donation of several solid organs, this mini review examines the findings from the perspective of kidney transplantation. The committee's recommendations to move from circulatory to neurologic criteria for cadaveric donation and to increase opportunities for donor decision making are prudent. We agree with the committee's arguments against providing incentives for donation because of the inherent distributional inequalities and imperfect information; the intrinsic difficulties in establishing market equilibrium for such heterogeneous and perishable goods; the implied commoditization of the human body; and the inadequate data regarding the long-term risks of living donation. However, we question the committee's firm opposition to PC, especially given recent data from 22 European countries showing a 25-30% increase in organ supply attributable to a PC policy. If this simple change in the default position on donation has the potential to increase organ supply, decrease the need for living donation, reduce the burden on grieving families, maintain familial authority over the deceased, and respect patient autonomy, at least a pilot program of PC seems warranted.