Public attitudes toward incentives for organ donation: a national study of different racial/ethnic and income groups

The general public's attitude towards accepting payment for kidney donation

Introduction

Kidney transplantation has become the most cost-effective treatment for patients with end-stage kidney disease (ESKD) and offers them the highest quality of life. Yet, kidney donation is often inaccessible due to cultural and traditional beliefs about organ donation. The goal of our study is to assess the value of kidney donation using the Willingness to Accept (WTA) technique. We also aim to understand the factors influencing an individual's willingness to donate an organ.

Methods

A self-administered survey was completed by 985 participants from the general public. The quantitative method and survey design that were chosen used descriptive, correlational, nonparametric, and multivariate statistical tests.

Results

Most of the respondents, 895 (90.9%) are not willing to donate a kidney while alive. Four hundred and five (41.1%) of the respondents are not willing to donate a kidney after their death, while the rest are willing to donate their kidney after their death without financial compensation. The same attitude applies to the donation of a kidney from their relatives. Significant predictors from the results of the logistic regression model in predicting the lowest (minimal) amount that will encourage donation of one kidney after death were: Marital status; Nationality; Adi card holder; Knowing people who need a kidney donation; confidence in the medical staff; and consideration of the family's opinions regarding organ donation.

Discussion

Using cost benefit analysis (CBA), with the aim of evaluating the willingness of individuals to accept payment for innovative medical procedures, such as kidney donation, allows an assessment of the perceived value of the medical procedure and enables policymakers to decide whether to allocate funds or offer subsidies for kidney donation, given the limited healthcare resources available. During our research, we found that most participants did not support the commercialization of organs. Our recommendation for policymakers and health professionals is to continue providing adequate funding for kidney donations and to implement educational programs aimed at improving attitudes towards organ donation.

A regulated system of incentives for living kidney donation: Clearing the way for an informed assessment

The kidney shortage continues to be a crisis for our patients. Despite numerous attempts to increase living and deceased donation, annually in the United States, thousands of candidates are removed from the kidney transplant waiting list because of either death or becoming too sick to transplant. To increase living donation, trials of a regulated system of incentives for living donation have been proposed. Such trials may show: (1) a significant increase in donation, and (2) that informed, incentivized donors, making an autonomous decision to donate, have the same medical and psychosocial outcomes as our conventional donors. Given the stakes, the proposal warrants careful consideration. However, to date, much discussion of the proposal has been unproductive. Objections commonly leveled against it: fail to engage with it; conflate it with underground, unregulated markets; speculate without evidence; and reason fallaciously, favoring rhetorical impact over logic. The present paper is a corrective. It identifies these common errors so they are not repeated, thus allowing space for an assessment of the proposal on its merits.

Examining the Effect of Self-Determined Appeal Organ Donation Messages and Respective Underlying Mechanism

This study examined how intrinsic motivation and its respective underlying mechanism influence people's attitude and intentions of organ donation. The findings revealed the importance of meeting people's customized psychological needs. For the general population, especially non-organ donors, autonomous appeal message will be more effective in promoting their intention of becoming an organ donor. For registered organ donors, competence-based organ donation messages are more effective in increasing their promotion and seeking behavior of organ donation. This study also discovered underlying mechanisms of intrinsic motivation, such as self-integrity, pride, and sympathy. Pairing underlying mechanism with competence-based messages can maximize the message impact.

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.

Kidneys for Sale: Empirical Evidence From Iran

The kidney market in Iran is the only legal market of this sort globally. Yet, it has not been empirically studied based on real data. For the first time, we obtained data on donors and recipients from the Kidney Foundation in Mashhad, April 2011 up to March 2018, and assessed which individualistic characteristics contribute to a kidney’s price. Our findings indicate that each year of education for both donors and recipients increases the kidney price. Moreover, old patients are willing to make a higher payment to young vendors. We have also provided some policy implications to improve the efficiency of kidney allocations.

The Magnitude of the Health and Economic Impact of Increased Organ Donation on Patients With End-Stage Renal Disease

Objectives. There are several approaches such as presumed consent and compensation for deceased donor organs that could reduce the gap between supply and demand for kidneys. Our objective is to evaluate the magnitude of the economic impact of policies to increase deceased donor organ donation in the United States. Methods. We built a Markov model and simulate an open cohort of end-stage renal disease patients awaiting kidney transplantation in the United States over 20 years. Model inputs were derived from the United States Renal Data System and published literature. We evaluate the magnitude of the health and economic impact of policies to increase deceased donor kidney donation in the United States. Results. Increasing deceased kidney donation by 5% would save $4.7 billion, and gain 30,870 quality-adjusted life years over the lifetime of an open cohort of patients on dialysis on the waitlist for kidney transplantation. With an increase in donations of 25%, the cost saved was $21 billion, and 145,136 quality-adjusted life years were gained. Policies increasing deceased kidney donation by 5% could pay donor estates $8000 or incur a onetime cost of up to $4 billion and still be cost-saving. Conclusions. Increasing deceased kidney donation could significantly impact national spending and health for end-stage renal disease patients.

Perceptions and Attitudes toward Brain Donation among the Chinese People

Postmortem human brain donation is crucial to both anatomy education and research. The China Human Brain Banking Consortium was established recently to foster brain donation in China. The purpose of this study was to gain information about the public perception of and attitudes toward brain donation and to identify factors that may impact the willingness to participate in brain donation among the Chinese people. A specifically designed questionnaire was delivered to community residents in Changsha (the capital city of Hunan province) with a total of 1,249 completed forms returned and statistically analyzed. The majority of the participants considered that brain donation would help medical research and education, and 32.0% of respondents agreed that the brain donation would help change the traditional Chinese funeral belief in keeping the body intact after death. However, participants aged over 60 years old were less supportive of this concept. Among all participants, 63.7% stated that they were not knowledgeable about brain donation, while 26.4% explicitly expressed a willingness to participate in brain donation. Age, gender, monthly household income, and knowledge about brain donation significantly affected the willingness. Compared with other age groups, a higher proportion of participants aged over 60 years old preferred to be informed by a medical college. To promote brain donation in China, especially among the elderly, better communication of its medical benefits and a reinterpretation of the Confucius view of the human body should be provided. Efforts are also needed to provide appropriate forums and sources of brain donation information to targeted communities and society in general.

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.

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.

Opinions of Health Care Personnel Regarding Disincentives and Incentives for Living Kidney Donation at a Single Center

BACKGROUND

Transplant societies continue to actively concentrate on increasing rates of living kidney donation (LKD) to bridge the gap between individuals awaiting transplantation and the number of kidneys available. A widely discussed strategy to increase living donation rates is the provision of incentives and removal of disincentives. Though opinions of the public regarding this strategy have been studied, the opinions of health care providers, including younger professionals, are less clear. We studied the opinions of medical students and other health care providers on strategies to increase LKD to determine if opinions were different among those < 25 or ≥ 25 years of age.

METHODS

A simple cross-sectional survey was conducted at an academic medical center. Participants included medical students and employees in Internal Medicine, General Surgery, and the Organ Transplantation Center. Pearson's χ² and Fisher's exact test were conducted on the responses regarding disincentives and incentives to determine whether opinions differed based on age.

RESULTS

Six hundred and twenty-four participants completed the survey. There was no statistical difference in opinions between groups on reimbursing transportation costs, loss of wages, or childcare costs, but those aged ≥ 25 were more agreeable with covering food/lodging costs compared to those < 25 (96.5% vs 90.7%, P = .009). Respondents < 25 years old were more willing to donate a kidney for a financial incentive (P = .0002) accepting a median amount of $25,000.

CONCLUSIONS

Health care personnel broadly support removing financial disincentives for living kidney donation, and those ≥ 25 were more in favor of covering food/lodging costs compared to those < 25. Those < 25 years old were more likely to accept financial incentives towards donating their kidney compared to those ≥ 25 years.

Effectiveness of informational decision aids and a live donor financial assistance program on pursuit of live kidney transplants in African American hemodialysis patients

BACKGROUND

African Americans have persistently poor access to living donor kidney transplants (LDKT). We conducted a small randomized trial to provide preliminary evidence of the effect of informational decision support and donor financial assistance interventions on African American hemodialysis patients' pursuit of LDKT.

METHODS

Study participants were randomly assigned to receive (1) Usual Care; (2) the Providing Resources to Enhance African American Patients' Readiness to Make Decisions about Kidney Disease (PREPARED); or (3) PREPARED plus a living kidney donor financial assistance program. Our primary outcome was patients' actions to pursue LDKT (discussions with family, friends, or doctor; initiation or completion of the recipient LDKT medical evaluation; or identification of a donor). We also measured participants' attitudes, concerns, and perceptions of interventions' usefulness.

RESULTS

Of 329 screened, 92 patients were eligible and randomized to Usual Care (n = 31), PREPARED (n = 30), or PREPARED plus financial assistance (n = 31). Most participants reported interventions helped their decision making about renal replacement treatments (62%). However there were no statistically significant improvements in LDKT actions among groups over 6 months. Further, no participants utilized the living donor financial assistance benefit.

CONCLUSIONS

Findings suggest these interventions may need to be paired with personal support or navigation services to overcome key communication, logistical, and financial barriers to LDKT.

TRIAL REGISTRATION

ClinicalTrials.gov [ NCT01439516 ] [August 31, 2011].

Preferences for Policy Options for Deceased Organ Donation for Transplantation: A Discrete Choice Experiment

BACKGROUND

Despite broad public support for organ donation, there is a chronic shortage of deceased donor organs. We sought to identify community preferences for features of organ donation policies.

METHODS

A discrete choice study was conducted using an online panel of Australian community respondents older than 18 years. Respondents were presented with scenarios comparing a "new" policy to the current policy. Tradeoffs between 8 policy aspects were quantified using mixed logit and latent class models: registration system, extent of donor family involvement, ease of registration, frequency of confirmation of intent, direct payment, and funeral expense reimbursement, priority for donor's family, and formal recognition of donation.

RESULTS

There were 2005 respondents (mean, 44.6 years). We found a strong preference for a new policy. Overall, respondents favored a policy that included: some involvement of the donor's family in the final decision, simple registration processes, less frequent reconfirmation of donation intent, direct payment or funeral expense reimbursement, and formal recognition of donation. However, there was significant preference heterogeneity across respondents, with various respondent groups valuing policy mechanisms differently. Respondents who viewed policy change negatively were also those who would be unlikely to be organ donors anyway, because they tended to hold negative views toward organ donation.

CONCLUSIONS

Our results suggest that the Australian community are open to alternative organ donation policies including changes to: registration systems, family involvement, and financial and nonfinancial mechanisms. Future policy discussions should not be limited by preconceived notions of what is acceptable to the community, rather informed by actual community values and preferences.

From motivation to acceptability: a survey of public attitudes towards organ donation in Denmark

BACKGROUND

Over the past three decades, public attitudes to organ donation have been a subject of numerous studies focusing on donor motivation. Here, we present a fresh approach. We suggest focusing on public acceptability instead of motivation. The point is to understand public attitudes well enough to avoid risking public support for organ transplantation. We conducted the study in Denmark because there have been significant developments in public attitudes to organ donation in this country. In the 1990s, Denmark was a country with very low public support for organ donation and Denmark was the last country in Europe to introduce brain death as a legal criterion of death, whereas today Eurobarometer surveys rate Denmark as one of the European countries with the highest support for deceased organ donation from brain dead donors.

METHODS

We conducted a telephone survey in Denmark (N = 1195). A questionnaire was developed on the basis of preceding qualitative studies and pilot testing and included reuse of one item from earlier surveys to facilitate historical comparison. The analysis of the data was carried out using IBM SPSS Statistics 22 and focused on descriptive statistics.

RESULTS

A clear majority of 91.9 % are positive or very positive towards organ donation; 85.8 % like the idea of their body being used after their death, 85.0 % is willing to donate their own organs, 82.1 % to donate their tissue and only 2.3 % find that too much has been done to promote organ donation. There is limited support for monetary incentives for organ donation (5.8 %) and presumed consent (30.4 %), while a majority (63.9 %) supports making it mandatory to register a personal decision. Religious self-identification has limited impact on attitudes.

CONCLUSIONS

We can identify a shift over the past three decades from marked opposition to organ transplantation to strong support as well as a pattern in the contemporary public attitudes, which can help explain what is central to public acceptability: self-determination. Policies fostering choice are met with a majority of positive attitudes, while presumed consent and monetary incentives are met with more negative attitudes. Our approach calls for comparative studies in other countries to generate a better overall understanding of the conditions of acceptability, which need to be in place to ensure the long-term social robustness of organ donation and thereby safeguard this important medical technology.

Gerundium: A Comprehensive Public Educational Program on Organ Donation and Transplantation and Civil Law in Hungary

BACKGROUND

Organ transplantation has become an organized, routine, widely used method in the treatment of several end-stage diseases. Kidney transplantation means the best life-quality and longest life expectancy for patients with end-stage renal diseases. Transplantation is the only available long-term medical treatment for patients with end-stage liver, heart, and lung diseases. Despite the number of transplantations increasing worldwide, the needs of the waiting lists remain below expectations.

METHODS

One of the few methods to increase the number of transplantations is public education. In cooperation with the University of Debrecen Institute for Surgery Department of Transplantation, the Hungarian National Blood Transfusion Service Organ Coordination Office, and the Local Committee Debrecen of Hungarian Medical Students' International Relations Committee (HuMSIRC), the Gerundium, a new educational program, has been established to serve this target. Gerundium is a special program designed especially for youth education. Peer education means that age-related medical student volunteers educate their peers during interactive unofficial sessions.

RESULTS

Volunteers were trained during specially designed training. Medical students were honored by HuMSIRC, depending on their activity on the basis of their own regulations. Uniform slides and brochures to share were designed. Every Hungarian secondary school was informed. The Local Committee Budapest of HuMSIRC also joined the program, which helps to expand our activity throughout Hungary. The aim of the program is public education to help disperse disapproval, if presented.

CONCLUSIONS

As a multiple effect, our program promotes medical students to have better skills in the field of transplantation, presentation, and communication skills. Our program is a voluntary program with strong professional support and is free of charge for the community.

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.

Between Scylla and Charybdis: charting an ethical course for research into financial incentives for living kidney donation

New approaches to address the kidney scarcity in the United States are urgently needed. The greatest potential source of kidneys is from living donors. Proposals to offer financial incentives to increase living kidney donation rates remain highly controversial. Despite repeated calls for a pilot study to assess the impact of financial compensation on living kidney donation rates, many fear that financial incentives will exploit vulnerable individuals and cast the field of transplantation in a negative public light, ultimately reducing donation rates. This paper provides an ethical justification for conducting a pilot study of a federally regulated approach to providing financial incentives to living kidney donors, with the goal of assessing donors' perceptions.

Transplantation as an abstract good: practising deliberate ignorance in deceased organ donation in Denmark

This article investigates valuations of organ transfers that are currently seen as legitimising increasingly aggressive procurement methods in Denmark. Based on interviews with registered donors and the intensive care unit staff responsible for managing organ donor patients we identify three types of valuation: the needs of recipients, respect for donors' autonomy and support of donors' relatives in their grieving process. Sometimes these modes of valuation conflict with each other, and we show how our informants then respond with a form of deliberate ignorance. We suggest that deliberate ignorance has a more general salience in the organ transplant field by way of facilitating a perception of organ transplantation as an abstract moral good rather than a specific good for specific people. Furthermore, we suggest that multiple forms of ignorance sustain each other: a desire for ignorance with respect to the prioritisation of recipients sustains pressure for more organs; this pressure necessitates more aggressive measures in organ procurement and these measures increase the need for ignorance in relation to the actual procedures as well as the actual recipients. These attempts to avoid knowledge are in remarkable contrast to the otherwise widespread policy emphasis on education and information in this medical domain.

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.

Concerns regarding the financial aspects of kidney transplantation: perspectives of pre-transplant patients and their family members

BACKGROUND

African American and non-African American pre-transplant patients' and their families' concerns about the financial costs of kidney transplantation have not been well studied.

METHODS

We conducted structured group interviews among pre-transplant patients (seven African American, five non-African American) and their family members (six African American, five non-African American) to identify their concerns about transplant health insurance coverage, out-of-pocket expenses, and living donor expenses. We reviewed transcribed group audio recordings and identified common discussion themes.

RESULTS

African American and non-African American patients and family members expressed uncertainty about which transplant-related costs were covered by health insurance and wanted information about how to choose insurance policies accordingly. Patients were particularly concerned about the impact of pre-existing illness on securing optimal health insurance, while family members wanted information about non-insurance-based financial resources. Both patients and family members expressed concern about paying for immunosuppressant medications and about gradual loss of insurance benefits after transplantation. Both patients and family members also expressed concern about potential financial hardships for living donors.

CONCLUSION

African American and non-African American pre-transplant patients and families expressed a broad range of concerns about transplant health insurance policies, out-of-pocket expenses, non-insurance-based financial resources, and resources to address donors' financial burden. Efforts to improve education and develop more comprehensive transplant insurance policies are needed to facilitate informed decision-making for potential transplant recipients and donors.

Impact of gender and professional education on attitudes towards financial incentives for organ donation: results of a survey among 755 students of medicine and economics in Germany

Background

There is an ongoing expert debate with regard to financial incentives in order to increase organ supply. However, there is a lacuna of empirical studies on whether citizens would actually support financial incentives for organ donation.

Methods

Between October 2008 and February 2009 a quantitative survey was conducted among German students of medicine and economics to gain insights into their point of view regarding living and deceased organ donation and different forms of commercialization (n = 755).

Results

The average (passive) willingness to donate is 63.5% among medical students and 50.0% among students of economics (p = 0.001), while only 24.1% of the respondents were actually holding an organ donor card. 11.3% of students of economics had signed a donor card, however, the number is significantly higher among students of medicine (31.9%, p < 0.001). Women held donor cards significantly more often (28.6%) than men (19.4%, p = 0.004). The majority of students were against direct payments as incentives for deceased and living donations. Nevertheless, 37.5% of the respondents support the idea that the funeral expenses of deceased organ donors should be covered. Women voted significantly less often for the coverage of expenses than men (women 31.6%, men 44.0%, p = 0.003). The number of those in favor of allowing to sell one’s organs for money (living organ donation) was highest among students of economics (p = 0.034).

Conclusion

Despite a generally positive view on organ donation the respondents refuse to consent to commercialization, but are in favor of removing disincentives or are in favor of indirect models of reward.

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.

Public awareness and attitudes to living organ donation: systematic review and integrative synthesis

BACKGROUND

The deceased-donor organ shortage has driven widespread adoption of living-donor transplantation. Yet, public views on living donation are not well understood. This study aims to synthesize studies on public awareness and attitudes toward living organ donation.

METHODS

Electronic databases and reference lists were searched to September 2012. Summary estimates from survey data were obtained by random effects meta-analysis. Qualitative descriptive synthesis of each study was performed.

RESULTS

Forty-seven studies involving 34,610 respondents were included. The proportion of respondents aware of living organ donation was 76.7% (4 studies, n=3248; 95% confidence interval, 46.2%-97.0%; I=99.7%). The majority were in favor of living directed donation (85.5% (11 studies, n=15,836; 95% confidence interval, 81.6%-89.6%; I=98%), with recipient and community benefit as the rationale provided. However, barriers included fear of surgical and health risks, lack of knowledge, respect for cultural norms, financial loss, distrust in hospitals, and avoiding recipient indebtedness. The public voiced concern about possible risks or an obligatory pressure exerted on the donor. Many supported reimbursement for out-of-pocket expenses, paid leave, wait-listing priority, health insurance, and donor acknowledgment. There was strong opposition to financial incentives, which they believed risked exploitation and inequity and diminished voluntary altruistic donation.

CONCLUSIONS

The public is generally supportive of living donation and articulated important equity and ethical considerations for protecting the health and safety of living donors. This supports increased public engagement and strengthening of a shared view among professionals and the public in living donation practice and policy.

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.

Priority in Organ Allocation to Previously Registered Donors: Public Perceptions of the Fairness and Effectiveness of Priority Systems

A priority system is one in which previously registered donors receive a preference in the allocation of organs for transplant ahead of those who have not registered. Supporters justify these systems on the basis that they are fair and will encourage donor registration. This article reviews existing studies of public reactions to priority systems, as well as studies of the extent to which the moral principle of reciprocity affects decision making in organ donation. The role of reciprocity in the public discourse surrounding the enactment of priority systems in Singapore and Israel is described. One factor that seems to have been relevant in these countries is the existence of a religious minority that is perceived as willing to take an organ but not to donate one. Although this perception may have fueled a resentment of perceived “free-riders,” concerns were raised about the social divisiveness of priority systems. In sum, people appear to be sensitive to the principle of reciprocity in the context of organ donation, but this sensitivity does not always translate into support for priority systems. Further research into whether public messaging about organ donation could be modified to encourage registration by appeal to the golden rule would be worthwhile.

The providing resources to enhance African American patients' readiness to make decisions about kidney disease (PREPARED) study: protocol of a randomized controlled trial

Background

Living related kidney transplantation (LRT) is underutilized, particularly among African Americans. The effectiveness of informational and financial interventions to enhance informed decision-making among African Americans with end stage renal disease (ESRD) and improve rates of LRT is unknown.

Methods/design

We report the protocol of the Providing Resources to Enhance African American Patients’ Readiness to Make Decisions about Kidney Disease (PREPARED) Study, a two-phase study utilizing qualitative and quantitative research methods to design and test the effectiveness of informational (focused on shared decision-making) and financial interventions to overcome barriers to pursuit of LRT among African American patients and their families. Study Phase I involved the evidence-based development of informational materials as well as a financial intervention to enhance African American patients’ and families’ proficiency in shared decision-making regarding LRT. In Study Phase 2, we are currently conducting a randomized controlled trial in which patients with new-onset ESRD receive 1) usual dialysis care by their nephrologists, 2) the informational intervention (educational video and handbook), or 3) the informational intervention in addition to the option of participating in a live kidney donor financial assistance program. The primary outcome of the randomized controlled trial will include patients’ self-reported rates of consideration of LRT (including family discussions of LRT, patient-physician discussions of LRT, and identification of a LRT donor).

Discussion

Results from the PREPARED study will provide needed evidence on ways to enhance the decision to pursue LRT among African American patients with ESRD.

Trial registration

ClinicalTrials.gov NCT01439516

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.

The impact of tax policies on living organ donations in the United States

In an effort to increase living organ donation, fifteen states passed tax deductions and one a tax credit to help defray potential medical, lodging and wage loss costs between 2004 and 2008. To assess the impact of these policies on living donation rates, we used a differences-in-differences strategy that compares the pre- and postlegislation change in living donations in states that passed legislation against the same change in those states that did not. We found no statistically significant effect of these tax policies on donation rates. Furthermore, we found no evidence of any lagged effects, differential impacts by gender, race or donor relationship, or impacts on deceased donation. Possible hypotheses to explain our findings are: the cash value of the tax deduction may be too low to defray costs faced by donors, lack of public awareness about the existence of these policies, and that states that were proactive enough to pass tax policy laws may have already depleted donor pools with previous interventions.

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.

Distrust in the healthcare system and organ donation intentions among African Americans

The purpose of this study is to further understanding of the association between distrust in the healthcare system and written and verbal expressions of donation intentions among African Americans. We hypothesize that distrust in the healthcare system will be significantly, positively associated with both verbal and written donation intentions. Five hundred and eighty five participants completed a 98-item survey that included scales on distrust in the healthcare system and donation intentions. Bivariate analyses (t-tests, ANOVA, chi-square tests and odds ratios) were used to explore the extent to which donation intentions and distrust in the healthcare system varied by demographic characteristics and the association between the distrust in the healthcare system scale and verbal and written donation intentions. Separate logistic regressions were performed with each of the dependent variables to see if significant associations remained while controlling for confounders. Findings based on the multiple regression indicate that when controlling the participant's education level, distrust in the healthcare system was not significantly related to written donation intentions (OR = 1.04; P = .12). When controlling for education level, health insurance status, Community Health Advocates group and marital status, distrust in the healthcare system was significantly associated with verbal donation intentions (OR = 1.08; P < 0.05). Our results suggest that distrust in the healthcare system varies in the way that it is associated with donation intentions. Future organ donation studies should be conducted to determine the pathways through which distrust in the healthcare system impacts different types of organ donation intentions.

Donor designation: racial and ethnic differences in US nondesignators' preferred methods for disclosing intent to donate organs

Little is known about racial/ethnic differences in preferred methods of disclosing deceased organ donation intentions among persons not previously designating their organ donation preferences publicly or the association of medical mistrust with preferences. We surveyed 307 United States (US) adults who had not yet designated their donation intentions via drivers' licenses or organ donor cards (nondesignators) to identify their preferred disclosure methods (personal discussions with family, physicians, or religious representatives or public registration via mail/telephone/computer, workplace, place of religious worship, or grocery store/bank/post office) and to assess the association of mistrust with preferences. In multivariable models, we assessed racial/ethnic differences in preferences and the influence of medical mistrust on preferences. Nondesignators most preferred discussions with physicians (65%) or family members (63%). After adjustment, African Americans (AAs) were more likely than Whites to prefer discussion with religious representatives. In contrast, AAs and Hispanics were less likely than Whites to prefer registration at a workplace or through mail/telephone/computer. Medical mistrust was common and associated with less willingness to disclose via several methods. Encouraging donation intention disclosure via discussions with physicians, family, and religious representatives and addressing medical mistrust could enhance strategies to improve nondesignators' donation rates.

Community Preferences for the Allocation & Donation of Organs--the PAraDOx Study

BACKGROUND

Transplantation is the treatment of choice for people with severe organ failure. However, demand substantially exceeds supply of suitable organs; consequently many people wait months, or years to receive an organ. Reasons for the chronic shortage of deceased organ donations are unclear; there appears to be no lack of 'in principle' public support for organ donation.

METHODS/DESIGN

The PAraDOx Study examines community preferences for organ donation policy in Australia. The aims are to 1) determine which factors influence decisions by individuals to offer their organs for donation and 2) determine the criteria by which the community deems the allocation of donor organs to be fair and equitable. Qualitative and quantitative methods will be used to assess community preferences for organ donation and allocation.Focus group participants from the general community, aged between 18-80, will be purposively sampled to ensure a variety of cultural backgrounds and views on organ donation. Each focus group will include a ranking exercise using a modified nominal group technique. Focus groups of organ recipients, their families, and individuals on a transplant waiting list will also be conducted.Using the qualitative work, a discrete choice study will be designed to quantitatively assess community preferences. Discrete choice methods are based on the premise that goods and services can be described in terms of a number of separate attributes. Respondents are presented with a series of choices where levels of attributes are varied, and a mathematical function is estimated to describe numerically the value respondents attach to different options. Two community surveys will be conducted in approximately 1000 respondents each to assess community preferences for organ donation and allocation. A mixed logit model will be used; model results will be expressed as parameter estimates (β) and the odds of choosing one option over an alternative. Trade-offs between attributes will also be calculated.

DISCUSSION

By providing a better understanding of current community preferences in relation to organ donation and allocation, the PAraDOx study will highlight options for firstly, increasing the rate of organ donation and secondly, allow for more transparent and equitable policies in relation to organ allocation.

For love or money? Attitudes toward financial incentives among actual living kidney donors

Due to lengthening waiting lists for kidney transplantation, a debate has emerged as to whether financial incentives should be used to stimulate living kidney donation. In recent surveys among the general public approximately 25% was in favor of financial incentives while the majority was opposed or undecided. In the present study, we investigated the opinion of living kidney donors regarding financial incentives for living kidney donation. We asked 250 living kidney donors whether they, in retrospect, would have wanted a financial reward for their donation. We also investigated whether they were in favor of using financial incentives in a government-controlled system to stimulate living anonymous donation. Additionally, the type of incentive deemed most appropriate was also investigated. In general almost half (46%) of the study population were positive toward introducing financial incentives for living donors. The majority (78%) was not in favor of any kind of reward for themselves as they had donated out of love for the recipient or out of altruistic principles. Remarkably, 60% of the donors were in favor of a financial incentive for individuals donating anonymously. A reduced premium or free health insurance was the preferred incentive.

Addressing racial and ethnic disparities in live donor kidney transplantation: priorities for research and intervention

One potential mechanism for reducing racial/ethnic disparities in the receipt of kidney transplants is to enhance minorities' pursuit of living donor kidney transplantation (LDKT). Pursuit of LDKT is influenced by patients' personal values, their extended social networks, the health care system, and the community at large. This review discusses research and interventions promoting LDKT, especially for minorities, including improving education for patients, donors, and providers, using LDKT kidneys more efficiently, and reducing surgical and financial barriers to transplant. Future directions to increase awareness of LDKT for more racial/ethnic minorities also are discussed including developing culturally tailored transplant education, clarifying transplant-eligibility practice guidelines, strengthening partnerships between community kidney providers and transplant centers, and conducting general media campaigns and community outreach.

Kidneys for sale: who disapproves, and why?

The shortage of transplant kidneys has spurred debate about legalizing monetary payments to donors to increase the number of available kidneys. However, buying and selling organs faces widespread disapproval. We survey a representative sample of Americans to assess disapproval for several forms of kidney market, and to understand why individuals disapprove by identifying factors that predict disapproval, including disapproval of markets for other body parts, dislike of increased scope for markets and distrust of markets generally. Our results suggest that while the public is potentially receptive to compensating kidney donors, among those who oppose it, general disapproval toward certain kinds of transactions is at least as important as concern about specific policy details. Between 51% and 63% of respondents approve of the various potential kidney markets we investigate, and between 42% and 58% want such markets to be legal. A total of 38% of respondents disapprove of at least one market. Respondents who distrust markets generally are not more disapproving of kidney markets; however we find significant correlations between kidney market disapproval and attitudes reflecting disapproval toward certain transactions-including both other body markets and market encroachment into traditionally nonmarket exchanges, such as food preparation.

Regulated payments for living kidney donation: an empirical assessment of the ethical concerns

BACKGROUND

Although regulated payments to encourage living kidney donation could reduce morbidity and mortality among patients waiting for a kidney transplant, doing so raises several ethical concerns.

OBJECTIVE

To determine the extent to which the 3 main concerns with paying kidney donors might manifest if a regulated market were created.

DESIGN

Cross-sectional study of participants' willingness to donate a kidney in 12 scenarios.

SETTING

Regional rail and urban trolley lines in Philadelphia County, Philadelphia, Pennsylvania.

PARTICIPANTS

Of 550 potential participants, 409 completed the questionnaire (response rate, 74.4%); 342 of these participants were medically eligible to donate.

INTERVENTION

Across scenarios, researchers experimentally manipulated the amount of money that participants would receive, the participants' risk for subsequently developing kidney failure themselves, and who would receive the donated kidney.

MEASUREMENTS

The researchers determined whether payment represents an undue inducement by evaluating participants' sensitivity to risk in relation to the payment offered or an unjust inducement by evaluating participants' sensitivity to payment as a function of their annual income. The researchers also evaluated whether introducing payment would hinder altruistic donations by comparing participants' willingness to donate altruistically before versus after the introduction of payments.

RESULTS

Generalized estimating equation models revealed that participants' willingness to donate increased significantly as their risk for kidney failure decreased, as the payment offered increased, and when the kidney recipient was a family member rather than a patient on a public waiting list (P < 0.001 for each). No statistical interactions were identified between payment and risk (odds ratio, 1.00 [95% CI, 0.96 to 1.03]) or between payment and income (odds ratio, 1.01 [CI, 0.99 to 1.03]). The proximity of these estimates to 1.0 and narrowness of the CIs suggest that payment is neither an undue nor an unjust inducement, respectively. Alerting participants to the possibility of payment did not alter their willingness to donate for altruistic reasons (P = 0.40).

LIMITATION

Choices revealed in hypothetical scenarios may not reflect real-world behaviors.

CONCLUSION

Theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence. A real-world test of regulated payments for kidney donation is needed to definitively show whether payment provides a viable and ethical method to increase the supply of kidneys available for transplantation.

PRIMARY FUNDING SOURCE

None.

Incentivizing living organ donation

PURPOSE OF REVIEW

The number of organs available for the patients on the transplant waitlist remains at a disproportionate low. All possible methods to curtail this shortage, including providing donors with incentives, have been proposed. This article reviews recent publications addressing the benefits and risks involved in incentivizing living donation.

RECENT FINDINGS

The debate about the ethics, feasibility, and possible models for compensating organ donors has been prominent in recent literature. As certain countries take lead on this initiative, others are cautiously weighing in on the impact implementations of such policies may have on the society, especially on the underprivileged.

SUMMARY

The shortage of organs has resulted in proposal of strategies that encroach on certain moral and ethical principles. Providing incentives to donors is one such strategy that is likely to receive a lot of attention in the next few years.

Transplant tourism to China: the impact on domestic patient-care decisions

Organ procurement in China has been criticized because of its reliance on executed prisoners as donors. We aimed to assess the influence of perceptions about organ procurement practices in China on domestic patient-care decisions.

METHODS

An anonymous internet administered case-based questionnaire was used to survey a sample of healthcare professionals with affiliations to hepatology and transplantation professional societies.

RESULTS

Of 674 completed surveys, the vast majority (93%) of the respondents were physicians, surgeons or allied transplant professionals actively caring for liver transplant patients and 81% practiced in the US. A strong majority believed procurement practices were ethically sound in the US and Europe (87% and 73%) but fare fewer believed that procurement practices were ethically sound in China (4%, p < 0.001). In case-based questions, lack of confidence in the ethical standards of organ procurement in China predicted patient-care decisions. The majority would provide post-transplantation care for patients who underwent liver transplantation at another domestic center, in a foreign country and in China (90%, 78%, and 63%, respectively, p < 0.001) yet respondents who suspected unethical procurement practices in China were more reluctant to do so (p < 0.001).

CONCLUSIONS

Transplant professionals expressed concern about organ procurement practices in China which influenced their patient-care decision-making.