Letter to the Editor
A Regulated System of Incentives for Living Kidney Donation: It Is Time for Opposing Groups to Have a Meaningful Dialogue!
A. J. Matas1,* andR. E. Hays2
Article first published online: 1 JUL 2014
DOI: 10.1111/ajt.12814
American Journal of Transplantation
Early View (Online Version of Record published before inclusion in an issue)
To the Editor:
The shortage of organs is a crisis in clinical transplantation. In spite of numerous attempts to increase both living and deceased kidney donation rates in the United States, there has not been a change in the last 10 years. The combination of an increasing number of transplant candidates and no change in donation rates has resulted in increased waiting times and significant morbidity and mortality for those waiting. In the last 10 years, over sixty thousand candidates have been removed from the waiting list because of death or becoming too sick for undergoing transplantion [1]. A regulated system of incentives has the potential to increase living donation rates and thereby reduce transplant candidate morbidity and mortality.
Despite the potential benefits to recipients, the concept of a trial of incentives remains controversial, with strong proponents and opponents [2-7]. Both groups have the same facts. Both agree that there is a shortage of organs; both favor removal of disincentives to donation; both likely agree that incentives may increase donation (only a trial will determine this) and that increased donation rates benefit patients and society. In addition, both are committed to the safety and well being of donors; both are opposed to unregulated underground markets and agree that such systems have done a disservice to donors and recipients.
Yet, with these shared facts and opinions, there is a dichotomy of conclusions. Both groups believe that they are morally, ethically and in practice, correct. Why, given they share similar information, do opinions differ? A possible explanation can be found in Jonathan Haidt's framework of individual morality being based on six principles (care/harm; liberty/oppression; fairness/cheating; loyalty/betrayal; sanctity/degradation and authority/subversion) and the relative importance given to each [8]. He suggests that these differences in emphasis lead to widely divergent conclusions. In the context of politics, he describes a “conservative moral matrix” (equal emphasis on each principle), a “liberal moral matrix” (strong emphasis on care/harm; liberty/oppression and fairness/cheating with little emphasis on the others) and a “libertarian moral matrix” (major emphasis on liberty/oppression). Importantly, the lack of appreciation of the source of the divergence of opinion results in: (a) each group neither understanding nor respecting the other's perspective, and (b) inability to have a meaningful dialogue [8].
This same concept may be applicable to the impasse between groups in the discussion of living donor incentives, in which the difference between groups appears to be a matter of emphasis. First, proponents emphasize the potential benefit of a regulated system (for recipients), and use key words such as organ crisis, transplant candidate mortality and societal benefit. Opponents emphasize the potential risk to donors, and the impact that approving a system might have on society's moral perspective, and, citing the harms of unregulated markets, use key words such as coercion, exploitation, undermining dignity, repugnance and commodification. Second, proponents emphasize local, structured trials in countries, such as the United States, capable of providing structure, regulation and transparency. Opponents emphasize developing a worldwide policy, and state that because many countries cannot provide regulation and transparency, incentives should be banned in all countries.
Is there a way to move forward? Based on their perspective of the data, proponents suggest that a well-designed trial—in a country with effective systems in place for regulation and monitoring, and with appropriate entry criteria and end points—would answer the critical questions that determine whether or not a regulated system of incentives is worth exploring further [2]. If a trial were to show increased donation rates but poor donor outcomes (health, psychosocial [social losses; regret]) compared to conventionally accepted donors, the system would be unacceptable, and scrapped. With their perspective, opponents identify—to date, theoretical—concerns about the impact on donors and aim for a global “one size fits all” policy.
Worldwide, transplanters could and should agree that lack of effective regulation regarding living donation is dangerous to donors and recipients alike. At the same time, it needs to be recognized that as people die on the transplant waitlist, discounting a possible way to increase access to transplant without first testing its impact, outcomes, and pros/cons on donors and recipients is premature. Opting not to conduct a trial of a regulated system of incentives has real consequences—morbidity and mortality in those with end-stage renal disease; and, it could be argued further, exploits current living donors who (in the United States) incur significant financial burdens by donating [9].
It is time for those with the full spectrum of opinions on the issue to have a meaningful dialogue. Given that the two groups share the same facts and the same concerns about donor safety, one possible way to initiate discussion is to narrow the field of focus. Perhaps, it should start with discussion as to whether or not, in a regulated system of incentives, both donor and recipient interests can be protected, and whether or not it is necessary to have a single global policy. If individual national policies are to be considered, the groups could discuss whether or not countries such as the United States, that can provide effective regulation and monitoring, and have maximized conventional donation, could consider trials of incentives in the context of the current impact of the organ shortage on their transplant candidates.
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