What Is the Price of Altruism?

[Clark]

http://onlinelibrary.wiley.com/doi/10.1111/ajt.13590/full

Editorial
What Is the Price of Altruism?
      R. N. Formica Jr.1,* andK. A. Newell2
Article first published online: 4 FEB 2016
DOI: 10.1111/ajt.13590
American Journal of Transplantation
Early View (Online Version of Record published before inclusion in an issue)

In this issue of the American Journal of Transplantation, Rodrigue and colleagues reported a prospective cohort study that surveyed living kidney donors (LKDs) to quantify the donation-related costs incurred in the 12 months following the surgery [1]. They reported that 92% of LKDs incurred costs related to transportation, lodging, meals, and health care. In addition, 36% of LKDs and 19% of their caregivers reported lost wages. Although 21% received some financial assistance, 89% reported a net financial loss at 12 mo with one-third reporting a loss in excess of $2500. Although it is tempting to consider using these findings as a basis for estimating the costs born by living donors, it must be recognized that although this is the largest study of its type, the LKD cohort reported represents <3% of the living donor transplants performed in the United States during the reported time period, and a geographic perspective from the Northeast is overrepresented. Furthermore, to estimate the total costs for LKDs, one must combine these data with the costs associated with the evaluation for living kidney donation that were recently reported by this group [2]. These findings are similar to costs incurred by LKDs in Canada [3], adding validity to the finding.
Despite limitations, these works demonstrate that an expense is incurred when donating a kidney. Historically, LKDs have been considered to be altruistic people who willingly pay out of pocket to help others. Relying on this altruism has been considered one of the more viable approaches to reducing the waitlist; however, current thought has shifted to link decreased living kidney donation to the increased recognition of the costs borne by LKDs. To date, there are no data to support this assumption and no certainty that reimbursing these costs would lead to increased numbers of LKDs. Does this mean we should continue to expect living donors to pay for their altruism? No. We believe LKDs should be reimbursed for all costs associated with living kidney donation. Moreover, we must also consider the increasing awareness that LKDs may face greater long-term medical risks than were previously appreciated [4] and that these risks may be associated with additional adverse financial consequences that should be justly compensated.
To identify problems without proposing solutions is not productive. With regard to reimbursement of living donors, the logistics of finding the funds and distributing them are the primary problems. With respect to money to support donor costs, it should be noted that living kidney donation saves money and all parties benefit financially—recipients, physicians, hospitals, payers and, ultimately, society. It has been estimated, based on a mean waiting time for a kidney transplant of 49 mo, that private payers expend $250 000–400 000 on end-stage renal disease care during the 33 mo that Medicare is the secondary insurer, and Medicare spends nearly $100 000 for the additional 16 mo during which it is the primary payer [5]. Because living donor transplantation shortens dialysis exposure, shouldn't these savings be used to pay for donor expenses? With respect to distributing the funds to living donors, a mechanism already exists. The U.S. Health Resources and Service Administration (HRSA) awarded a grant supporting the National Living Donor Assistance Center (NLDAC) that covers the cost of travel, surgery and follow-up of living donors and a companion. To date, NLDAC has supported the evaluation of 3918 potential donors, of whom 1941 have completed their donation [6]. Notably, 75% felt that donation would not have been possible without the support provided (average reimbursement $2767). NLDAC has several limitations imposed by the terms of the HRSA grant that that would need to be modified for the center to serve as a clearinghouse for funds to reimburse donors. Eligible costs, for example, are limited to reimbursement for travel and not lost wages, the annual income of eligible donors must fall below 300% of the poverty level, and total reimbursement cannot exceed $6000. NLDAC, however, has the expertise and infrastructure in place, and all that is required is expanding the mandate of its grant.
Regardless of limitations, this study by Rodrigue and colleagues brings much needed data to this discussion. Although there is debate about the appropriateness of incentives for living organ donation and the distinction between providing an incentive and removing a barrier, there is agreement that a person donating an organ should not incur a penalty. Valuing the giver does not dilute the value of the gift. No justifiable argument exists to perpetuate a system that benefits society at the expense of LKDs. Charity and philanthropy through donor assistance organizations should not be relied upon to relieve the financial burden incurred by living organ donors. It is the responsibility of society at large, through the cost savings realized in the care of patients with end-stage renal disease, to pay the costs incurred by donors.