For patients struggling to stay alive, organ donation serves as a new lease on life. According to the U.S. Department of Health and Human Services, there are 123,358 people waiting for life-saving organ transplantation, yet there are only 13,125 organ donors. While subtle, nominal changes such as changing the U.S. organ donor program from an opt-in to an opt-out program have been proven to increase rates of organ donation, the rising levels of organ demand and stagnating levels of donors indicate that the only way to completely bridge the gap is through tangible and pervasive policy change.
The most widely discussed and controversial policy suggested is instituting financial incentives to encourage organ donation. The current approach to acquiring organs for transplantation relies on the voluntarism of live donors and the altruism of deceased donor families. The Organ Procurement and Transplantation Network states “financial incentives will be considered as any material gain or valuable consideration obtained by those directly consenting to the process of organ procurement.”
Studies show financial incentives will increase organ procurement. In the past, after a small-scale implementation of a $300 payment to fund the funeral expenses for deceased donors, three million Pennsylvanians signed up to donate organs. According to a study by Mark Nadel of the Federal Communications Commission, in Georgia, a discounted-driver’s-license-for-organ-donors program increased donation rates by 33 percent. If we allow market forces to dictate the prices and economics of organ exchange, Gary Becker of the University of Chicago posits that kidney donations and transplants would increase by 44 percent, and liver donations and transplants would increase by 67 percent.
Furthermore, Sara Taub of the Journal of Transplantation even estimates that payment of $500 to $1,000 for cadaveric donation would increase donation rates sufficiently to nearly eliminate the kidney waiting list. Often lost within the slew of numbers is how much this would mean to individual lives. With survival rates being nearly twice as high for a kidney transplant recipient than one on dialysis, receiving an organ can substantially improve longevity and quality of life.
In addition to the obvious individual health benefits, a study by Benjamin Hippen of the CATO Institute also finds significant societal benefits, such as relief of Medicare entitlements for dialysis to treat end-stage renal disease which now cost taxpayers 21 billion dollars. This is money that could be saved with more transplantation. Quantifying the potential societal gains per transplant, Jake Linford of the the St. Louis Journal of Health Law and Policy finds that the more cost-effective transplantation encouraged by incentives could potentially save society more than a net 248,000 dollars per transplant. The overwhelming amount of studies makes it patently clear that when money talks, people listen. But does money really make everything better?
Financial incentives, while potentially increasing organ donation, may actually exacerbate the real root cause of why people don’t donate: mistrust of the medical system. Some people fear that agreeing to be an organ donor may create unnecessary conflicts of interest with doctors, causing the physician to potentially prioritize the procurement of organs, rather than the treatment of the patient.
Thus, an undercurrent of moral and ethical concerns seems to be the real problem, and financial incentives may actually increase these fears and corrupt other institutional factors. In fact, Margaret Byrne of the Journal of Health Economics models that a financial reward for registration distorts the signal that registration makes about the true decision to donate. Grieving families then utilize an implicit family veto over the deceased’s donation decision over an inability to tell whether the decision to donate was made willfully or because of monetary concerns.
Another potential moral question is the objectification of organs and the human body, and the slippery slope of problems that may result. The Hastings Center elaborates that being paid when donating is inseparable from the concept of buying and selling. Shockingly, Richard A. Demme of the Journal of the National Medical Association argues that when organs are worth some monetary value, other agents in the market have certain expectations. He states that debt collectors and society will immorally consider organs financial assets and collateral, implicitly adjusting contracts to require people to sell organs to pay off debt. This creates an impossible pressure upon certain individuals to donate an organ.
From an economic standpoint, allowing financial incentives and market forces to dictate organ donation has another harmful side-effect: disproportionately harming the poor. Andrew Hughes of the Vanderbilt Journal of Transnational Law sums up that because the impoverished respond disproportionately to monetary offers, financial incentives shift the donor pool to the exploited poor, which Will Harmon of Harvard Medical School finds comprise over 80 percent of transactions even in a regulated market. But Elizabeth NeSmith of the National Institute of Nursing Research reports low-level socioeconomic individuals are twice as likely to experience organ failure as higher-income individuals because chronic life stress leads to accelerated biologic organ aging via increased telomerase activity. However, U.S. Department of Health quality control screening only precludes those with certain severe and current infections from donating, failing to account for biological aging. In other words, although financial incentives may increase the quantity of organs, they may also decrease the quality, by shifting the donor pool.
To make things worse, an economic phenomenon known as crowding out could actually cause some people to stop donating. Gabriel Danovitch of UCLA explains that if there exists a perception that organs can be bought through financial incentives, the temptation to not expose the potential altruistic donor to the risk intrinsic to the process would be overwhelming, causing crowding out to occur. In Hong Kong and Israel, the institution of transplant tourism caused a drop in familial and altruistic donation from 50 percent to around 15 percent of the total kidney transplant pool.
It is easy to see why instituting financial incentives to encourage organ donation is a contentious and controversial issue. While proponents of the policy point to societal benefits in saving lives, the economic benefits to the health care system, and increasing rates of organ donation, opponents have equal ground to stand on in their concerns about moral questions, disproportionately hurting the poor, decreasing quality of organs, and crowding out altruistic donations. Ultimately there is no right answer to the many social and moral questions. Should you increase donation quantity, while decreasing quality? Despite the societal economic benefits, should we put such disproportionate pressure for organ procurement on the poor? Which matters more, the thousands of people waiting for an organ to save their lives, or the potential commodification of the human body? Although difficult issues, the medical community and public policy makers should address the problem sooner, rather than later, out of respect to the thousands of Americans whose lives depend on the answers to these questions.
Contributing Writer
Johns Hopkins University School of Medicine
Tejus Pradeep is a third year medical student at Johns Hopkins University, School of Medicine in Baltimore, Maryland. In 2016, he graduated from Rutgers University with a Bachelor of Arts in cell biology and neuroscience and a Bachelor of Arts in psychology. He enjoys basketball, football, and tennis in his free time. After graduating medical school, Tejus would like to pursue a career in the field of ophthalmology.