Altruism + incentive = more organ donations

In March 2006 a friend gave me her right kidney. I had been searching for a donor for more than a year — my kidneys mysteriously gave out in 2004 — and things were not going well.

Three friends offered to donate but backed out. Frustrated at first, I soon found myself oddly relieved. I dreaded the constricting obligation that would surely come with accepting such a sacrifice. I wished I could buy a kidney just to avert the emotional debt.

Soon, however, I wanted to buy one for a more obvious reason: without a new kidney, I would spend years on life-draining dialysis. Mercifully, in late 2005 I received an e-mail from Virginia, a casual friend who lived halfway across the country. Virginia was a brilliant writer who had heard from a mutual friend that I needed a kidney.

Though Virginia had never before given blood or even signed an organ donor card, the decision to donate, she told me months later, was quick and sure: “I felt intense empathy and imagined how desperate you must feel.” My glorious donor never suggested that I might owe her a thing beyond the extraordinary gratitude that decency demands. And she was bracingly pragmatic. “You needed a body part,” she said, “I was happy to give it.”

Virginia’s generosity spared me the physical and psychological rigours of dialysis and the premature death it guaranteed. I was lucky. In the US, where I live, there are 84,000 people in need of a kidney and every day 12 of them die waiting for one.

Though altruism saved me, the paradoxical lesson I learnt is that we cannot rely on it as the sole legitimate motive for donating an organ. Altruism hasn’t come close to producing enough organs — in the US, Britain and the world. The Nuffield Council on Bioethics, a British ethics think-tank, has come to the same realisation. It has asked more than 1,000 transplant professionals, legal scholars, ethicists and interested parties from all over the world (me among them) this question: “Can we ethically increase organ donation?”

The council will add our suggestions to the broad range of actions it is considering — from the sedately polite (sending an official “thank you” to the donor) to the audacious (creating a full-blown free market in body parts.) Let the innovating begin. Something must be done about the 8,000 people who wait for an organ transplant in the UK, which has one of the lowest donation rates in the EU.

The last Government promoted “presumed consent”. Applied elsewhere in Europe, the policy assumes that one is willing to be a posthumous donor unless one has previously registered an objection.

Presumed consent went nowhere. After canvassing public opinion, the UK Organ Donation Taskforce rejected the idea. Among the reasons cited by Paul Murphy, a Leeds physician who served on the task force, consent] has the potential to undermine the concept of donations as a gift”.

That’s not how Frank Deasy would have seen it. To the acclaimed Irish screenwriter of the BBC series Prime Suspect, a new liver would have been a gift from heaven. In fact, Deasy was a vocal supporter of presumed consent. “I am only one of thousands of patients on organ transplant lists in Britain, living on our own, invisible, death row,” Deasy said a week before his death last September at age 49.

Practically speaking, however, presumed consent is no panacea. In Spain and Italy, countries held as exemplars, growth in donation rates reflects better management, not the success of “presumed consent” laws.

Don’t get me wrong: everyone everywhere should agree to donate at death. It will make a real difference — but it still won’t meet the dire need for kidneys. A few countries have been more imaginative. Singapore, for example, has set aside $7 million for a fund to cover lifetime health insurance costs for anyone who donates a kidney while alive. In Israel, citizens who register to become posthumous donors get slight priority if they ever need an organ. Also, Israeli families may now accept up to $13,400 to “memorialise” the deceased donor with, for example, a scholarship in his name. Most controversially, Iran pays cash to kidney donors. It is the only country that has wiped out its waiting list.

Surely, the Nuffield Council will be interested in the efforts of other countries. As for me, I will tell them that providing donor benefits is a key solution to the altruism shortage.

As a reward for saving the life of a stranger, third parties such as governments, charities or insurers, should be allowed to provide some kind of benefit to donors. Cash? Although my libertarian colleagues make a compelling argument for a traditional market arrangement — needy patients who can afford it will remove themselves from the pool, increasing the chances that others can receive an altruistically donated posthumous kidney — many people are uneasy about offering lump-sum cash payments. It is not only unfair to those who cannot purchase, the critics say, but cash is too much of a lure for the economically strapped.

Thus, the answer is to provide in-kind rewards. These could take many forms — perhaps a contribution to a retirement fund, an offer of lifetime health insurance, a tuition voucher or a large charitable contribution in their name. This would not attract desperate people who might otherwise rush to donate for a large sum of instant cash.

Living kidney donors would be carefully screened for physical and emotional impediments to safe donation and be guaranteed follow-up medical care for any complications. In the case of deceased donation, funeral benefits could be offered to the estate of those who relinquished transplantable organs at death. Newly available organs would be distributed to the next person in line, according to current allocation rules.

Beyond a public health problem, the organ shortage has created a human rights fiasco as well. About 10 per cent of all transplants performed worldwide take place on the illicit market, according to the World Health Organisation. Corrupt brokers in the developing world often exploit poor and illiterate donors.

Last year I visited Manila, until very recently a hub of illicit organ trafficking. In a Calcutta-like village called Payatas, I saw entire families at work on massive, stinking garbage heaps, sorting recyclables. This is the kind of crushing poverty that makes people think about selling a kidney. Manila clamped down on black- market sales but the tragic and predictable trade-off is that even more Filipinos are now dying of renal failure. What’s more, the wealthiest among them still fly elsewhere to countries where illicit sales boom.

In the end, the only way to starve underground markets abroad is to provide more transplants at home. And the only way to do this is to break radically — and ethically — with the status quo. Unfortunately, too many doctors and transplant specialists, well meaning as they are, seem to forget that altruism is not an end in itself. It is only a means to spur donations. The true end, of course, is to save more lives.

Sally Satel, a resident scholar at the American Enterprise Institute and editor of When Altruism Isn’t Enough: The Case for Compensating Kidney Donors.