Organ Donation Opportunities for Action (2006) / Chapter Skim
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8 Incentives for Deceased Donation
8 Incentives for Deceased Donation
Pages 229-262
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From page 229... ...
Nonfinancial incentives to donate could take the form of community recognition or preferential access to donated organs. Community recognition might be a public appreciation ceremony or a medal of nominal material value provided to individuals who register as potential organ donors or to the families of deceased donors.
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From page 230... ...
HISTORY AND CONTEXT In the United States, organs from deceased individuals become available for use for transplantation through donation by express consent. In the 1960s, as it became possible to use organs from deceased individuals, it was sometimes unclear whose consent -- the decedent's, while he or she was alive, or the family's after the person's death -- was necessary and sufficient for donation because of variability in state laws.
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From page 231... ...
These legal bans did not end the discussion. The discrepancy between organ supply and need remained troubling; and even though the rates of organ donation increased, they remained disappointing, even with the adoption of measures such as required request, which assumed that there was no shortage of givers, only a shortage of askers (Caplan, 1984; Caplan and Welvang, 1989)
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From page 232... ...
On the basis of this model, permitting a market in organs could be an equitable and efficient way to achieve an increase in supply that would reduce the number of people on organ transplant waiting lists. However, this conclusion is dependent on the accuracy of the strong assumptions that underlie the theoretical model.
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From page 233... ...
The living-donor case is mentioned here mainly to contrast it with the far less straightforward case of obtaining organs from deceased donors. In the latter case, the organs become available only when the person dies.
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From page 234... ...
Barriers to a Futures Market Traditionally, the relatives of deceased individuals had the final word about whether organs would be donated, but this has been changing. Because society supports the right of individuals to control what happens to their bodies when they are alive, it is a natural extension to assume that they should also decide what happens to their bodies after death.
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From page 235... ...
However, some other complexities of the organ procurement process suggest that the creation of financial incentives for organ donation may be less important for donors and their families than it is for healthcare organizations and the participating healthcare professionals. A family does not simply make the decision to donate (or to honor the decedent's wish to donate)
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From page 236... ...
. The collaboratives have demonstrated that the application of quality improvement methods to the steps in this process can significantly increase the percentage of potential organ donations that are converted into actual donations.
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From page 237... ...
The U.S. healthcare system does not guarantee access to life-saving treatments such as organ transplantations, and the ability to pay does play a role in the distribution of this important good.
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From page 238... ...
. The various potential agents here would include the transplant recipient's physician, the organ donor's physician, the healthcare organizations in which the organ recovery and the transplantation occur, a specialized organ "broker" such as the United Network for Organ Sharing (UNOS)
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From page 239... ...
REGULATED COMMERCE IN ORGANS The proposals that warrant more serious consideration involve cash payments for organs -- or other financial incentives for organ donation-determined within a regulatory framework. They focus on obtaining organs while leaving organ distribution and allocation to other mechanisms, either current or newly devised.
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From page 240... ...
It is argued that the gift model of organ donation reinforces the values of human dignity, solidarity, compassion, and altruism (Murray, 1987, 1996; Kass,
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From page 241... ...
First, the living person's hypothesized liberty interest is not an absolute one and is subject to being overridden by important societal interests. Thus, for example, if payments to individuals were to interfere with efforts to maintain support for organ donation and were to reduce the organ supply, as suggested above, then the state could reasonably restrict an individual's right to sell his or her organs.
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From page 242... ...
Although some advocates for payments acknowledge that the adoption of a sale model raises legitimate ethical concerns, they believe that the lives saved by increased rates of organ donation outweigh all opposing concerns (Barnett et al., 1992)
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From page 243... ...
The committee is unaware of any scientific research bearing on the possibility that legitimizing financial payments will crowd out nonfinancial motivations for organ donation or on whether the problem could be reduced in a carefully regulated market. Policy makers are left to speculate about the effects of allowing financial payments on the perceptions and attitudes of a heterogeneous population of potential donors and potential vendors with varied and complex motivations.
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From page 244... ...
The 2005 National Survey of Organ Donation (Wells, 2005) found that 18.8 percent of respondents would be more likely to donate a family member's organs if they were offered a payment, 10.8 percent would be less likely to grant consent, and 68.2 percent would be neither more nor less likely to grant consent (2.2 percent of respondents selected "don't know")
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From page 245... ...
Some data indicate that most healthcare professionals involved in the donation process would be less comfortable requesting organ donation if financial incentives were offered (Altshuler and Evanisko, 1992)
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From page 246... ...
Once a socially sanctioned payment system is in place, the payments will presumably be made to every organ donor family. For example, suppose there are 10,000 eligible organ donors, each donor can provide one transplantable organ, and initially, there is a 50 percent consent rate, producing 5,000 organs.
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From page 247... ...
Two especially promising options are the use of quality improvement techniques to improve the process of organ donation under a gift model (Chapter 4) and making medical practice changes that increase the number of decedents who are potential organ donors (Chapter 5)
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From page 248... ...
Offering and making a $1,000 payment earmarked for the deceased donor's funeral expenses as an incentive to consent to donation and an expression of gratitude for the decision may be conceptually and morally distinguishable from buying an organ. Such a payment in no way reflects the actual value of the organ, and it would be positioned within a gift model of organ donation, analogous to a tax incentive for charitable giving rather than a purchase.
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From page 249... ...
. The concern is that providing an "incentive" or "expression of gratitude" of material value in exchange for "donation" of an organ while claiming to oppose the sale of organs would be perceived as hypocrisy and would decrease respect for the organ transplantation enterprise.
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From page 250... ...
. Given the substantial uncertainty about the effects of offering financial incentives for donation and the genuine possibility that it could reduce the rates of organ donation, the committee is not in favor of making financial payments to benefit families, whether directly or indirectly, to increase organ donation rates.
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From page 251... ...
Essentially, payment interferes with the signal that families obtain from the individual's decision to sign up with an organ donation registry. Pilot Studies One response to the uncertainty about whether financial incentives for donation would increase the supply of organs for transplantation is to implement a pilot program that would try out a payment system on a small scale and study its effects.
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From page 252... ...
This view suggests that, through the act of donation, the transplantation community acquires an interest in the proper burial or cremation of the deceased body; the interest may not be as strong as the immediate family's but nonetheless sufficient enough to contribute to funeral expenses. Although the committee acknowledges that these motives for covering a funeral expense are both legitimate and morally distinguishable from the motive of increasing organ donation rates, the committee rejected the proposal to provide funeral benefits, even if it is justified and explained on these grounds.
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From page 253... ...
Community recognition might take the form of a public appreciation ceremony or the awarding of a medal of nominal material value to people who register as potential organ donors or to the families of deceased donors. There is general agreement that the decision to donate deserves gratitude and community recognition, but it is also agreed that the impact of recognition programs on organ donation rates would be small (Arnold et al., 2002)
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From page 254... ...
In any case, these are critical assumptions that surveys have not addressed. The point is that it is simply not known whether the people who currently decline organ donation would become organ donors if a reciprocity-based legal structure was in place, accompanied by an aggressive public education program and full implementation.
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From page 255... ...
Arguments Against Preferential Access The committee does not favor either of these models, largely because of insuperable practical problems in implementing them fairly. Even if it is assumed that an organ recovery and allocation system is properly grounded in reciprocity and that the adoption of either of the proposed approaches would increase the rates of organ donation, the committee is deeply concerned that they would not be fairly and carefully implemented and, as a result, that the adoption of either model would accentuate existing social inequalities and would disadvantage those who are uninformed about organ donation: most likely, poor people, recent immigrants, and the least
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From page 256... ...
People would need to be informed about the nature of organ donation and how to choose donation. A nationwide donor registry would need to be established and would need to rely unambiguously upon first-person (donor)
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From page 257... ...
The reciprocity argument also fails to take into account the lack of trust that some people from historically disadvantaged groups have in the healthcare system. A person who has inadequate access to health care and fears that organ donor status might increase his or her chances of receiving suboptimal treatment in a life-threatening health situation may be reluctant to be an organ donor, even though he or she would like to receive an organ
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From page 258... ...
The Organ Donation Breakthrough Collaboratives have demonstrated that the application of quality improvement methods to this process can signifi
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From page 259... ...
1992. Financial incentives for organ donation: The perspectives of healthcare professionals.
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From page 260... ...
2001. A positive analysis of financial incentives for cadaveric organ donation.
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From page 261... ...
1993. Financial Incentives for Organ Donation: A Report of the Payment Sub committee, United Network for Organ Sharing Ethics Committee.
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From page 262... ...
2003. Cadaveric organ donation: Encouraging the study of motivation.
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