A New Approach to Organ Donation

There are now more than 83,000 people in the U.S. on the waiting list for a kidney. Yet with less than 17,000 transplants done each year, more than 40 percent will die waiting. As bad, transplants are most likely to succeed when they are done early. So as the waiting time increases (now about 5 years), even those lucky enough to get a new kidney do not benefit as much as possible.

State Assemblyman Robert Brodsky’s proposed legislation to change New York organ donation law to one of "presumed consent" is one way to deal with the problem. That idea has predictably sparked a heated debate in Albany and statewide, and the ethical can of worms it opens has been treated extensively in medical journals and the mainstream media.

But there is a simpler and more effective way to increase the supply of kidneys and save the lives of thousands of people with end-stage renal disease each year: offer to pay donors.

Now, to a lot of people organ donation should be altruistic, and the idea of compensating donors seems repulsive. But the available data instruct us that it is an idea that we should at least consider.

Iran began paying organ donors in 1998, and eliminated the shortage by 1999. Singapore also legalized a government plan for paying organ donors, but it hasn’t been implemented yet.

Some economists, philosophers, and even transplant surgeons and nephrologists have advocated for starting a similar program in the U.S. Economics Nobel Laureate Gary Becker and Julio Elias estimated that paying donors $15,000 might erase the shortage. Transplant surgeon Arthur Matas and health policy professor Mark Schnitzler estimate that since dialysis is expensive, paying organ donors would end up saving the government $275,000 per transplant.

Three primary criticisms bedevil the compensation strategy: One, the prospect of payment can be so tempting that it blinds donors to the risks involved; second, it may lead only poor people to donate; third, it may turn altruistic donors away.

But since the practice of compensating for organ donation has been illegal since 1984, the hard data do not exist to figure out which side is right.

The best that can be done is polling, and scientists at the University of Pennsylvania recently did just that. They asked 409 railway passengers whether they would donate under a variety of conditions (different amount of money, different risks). And their results contradict all three arguments against incentives.

Not surprisingly, monetary incentives increased the likelihood of donation, and the higher the compensation, the greater the increase. What might be surprising, however, is that the effect of monetary incentives was similar for people at all levels of income. About 15 percent of participants were unwilling to donate for free but willing if offered money. This percentage was the same for poorer and wealthier individuals. Poorer people were more likely to donate when offered money, but they were also more likely to donate without any compensation.

The authors also found that the prospect of payment did not dull people to the risks. Those who faced higher risks if they donated were far less likely to donate than those with lower risks, even if offered $100,000 for a kidney.

Lastly, the prospect of compensation did not alter the likelihood of altruistic donation. The same percentage of people was willing to donate for free when asked before and after the offer of payment.

The study showed that people who are offered compensation for kidney donation are able to think rationally and weigh the pros and cons before making a decision.

Will these results convince all skeptics that paying Americans for donating kidneys is the right thing to do? Probably not. To many people, exchanging kidneys for money is intrinsically wrong or even repugnant, regardless of the consequences. After all, polls are not conclusive; what matters is not what people say they will do, but what they end up doing when faced with a real opportunity to sell their organs. However, since this is the best data we have, and with 5,000 people expected to die this year on the waiting list, we owe ourselves at least a geographically limited experiment in monetary incentives for kidneys.

Raymond Raad, M.D., M.P.H., is a resident in psychiatry at New York Presbyterian Hospital / Weill Cornell Medical Center and co-author of the Cato study, Bending the Productivity Curve: Why America Leads the World in Medical Innovation.