A group of medical, legal, economics and ethics specialists has entered the debate over the propriety of paying people to donate one of their kidneys for transplantation, as a solution to the national organ shortage. The current system of organ donation expressly forbids the offer of “valuable consideration” for a human organ.

“While offering a financial incentive may be unacceptable, at least we can limit financial disincentives that inhibit many people’s altruistic tendencies to help a friend or relative by donating a kidney,” said Robert S. Gaston, MD, director of medical evaluation and patient treatment for the large kidney transplant program at the University of Alabama at Birmingham (UAB).

Gaston is lead author of the proposal published in the American Journal of Transplantation (Am J Transplant 6(11):2548-2555, 2006). They propose a package of benefits for a live donor that would cost the government between $23,525 and $32,800 per donor and include:

• One year, $1 million term life insurance policy;
• long-term health insurance to be integrated with other forms of coverage individuals may possess;
• reimbursement of travel expenses and lost wages from missed work, during both evaluation and perioperative phases; and
• either a tax deduction of $10,000 or a nontaxable lump-sum payment of $5,000.

“The current debate over paying for organs as a possible solution to the shortage is heated and polarized,” Gaston said. “Our group offers a compromise that we acknowledge is unlikely to please advocates on either side of the debate, but which we hope will spark much needed discussion of the issue.”

He said, “Our proposal would expand compensation beyond what is currently acceptable by many, but we also would cap the total amount at levels far below what ‘open market’ advocates would prefer. By directly linking compensation to risk, we believe our proposal preserves the essence of kidney donation as a gift – and would be implementable in the United States without altering current legal statutes.”

Increased costs of delivering these benefits would be more than offset by savings from decreased use of long-term dialysis, the article stated.

This package would minimize hazard and ensure donor interests are protected after, as well as before, their kidney is removed. “Similar programs are now being developed piecemeal is some states, but we maintain that the program should be universal and national in scope, with costs to be assumed by the federal Center for Medicare and Medicaid Services (CMS),” Gaston said. The proposal also would fund medical follow-up and enable data collection so that long-term risk, up until now only estimated, could be accurately assessed. Most donors look back favorably on their choice to donate, Gaston said, but some do not, especially in cases of perioperative complications or bad clinical outcomes.

The journal article cites one study that found that 70% of a sample of living donors expressed concerns about financial ramifications of lost time from work, childcare, job security and future health insurance coverage. It is estimated that out-of-pocket expenses associated with living donation range from $550 to $20,000. A recent survey indicates that as many as 40% of potential kidney donors ultimately decide not to donate due to financial concerns, the article states.

The number of deceased donors has not changed significantly in many years, Gaston said, and the system is increasingly relying on living donors for kidneys to transplant. Yet the waiting list for kidney transplantation has increased dramatically and waiting times now are 5-to-10 years in some parts of the country. Mortality rates of those waiting increased almost by one quarter in a recent 4-year period, Gaston said.

Gaston’s co-authors are G. M. Danovitch of UCLA’s Geffen School of Medicine; R.A. Epstein of the University of Chicago Law School, J. P. Kahn and A. J. Matas of the University of Minnesota School of Medicine and M. A. Schnitzler of St. Louis University School of Medicine.