http://www.ajkd.org/article/S0272-6386(14)00991-3/fulltextAmerican Journal of Kidney Diseases
Volume 64, Issue 4, Pages 484–485, October 2014
Incentivization of Living Donation: Is It Time to Cross the Bridge?
Puneet Sood, MD, Sundaram Hariharan, MDemail
DOI:
http://dx.doi.org/10.1053/j.ajkd.2014.06.023Abstract
Kidney transplantation is the treatment of choice for chronic kidney failure. However, transplantation is restricted due to the limited supply of both living and deceased donor organs.1 Increasing numbers of patients on transplant waiting lists, longer waiting times for transplantation, higher mortality of patients while on waiting lists, and better outcomes after kidney transplantation compared to long-term dialysis treatment have forced transplantation surgeons and physicians to explore alternatives to traditional transplantation protocols. These alternatives include optimizing the use of living and deceased donor kidneys by eliminating major HLA antigen matching, accepting kidneys from non–heart-beating or hepatitis C virus–infected deceased donors, implementing living donor exchange programs, and matching anticipated survival of recipients and deceased donor organs based on donor variables.
Select countries, such as Austria, Belgium, Spain, and Singapore, have adopted “presumed consent” for all potential deceased donors unless the donor objects in his or her lifetime.2 However, such a law would not pass the legislature in many countries, including the United States. Despite sustained efforts, the deceased donor pool and organ transplant numbers have not kept pace with the ever-increasing number of patients awaiting transplantation. Thus, it is imperative that transplantation professionals consider other options to enhance living or deceased donation.
In this issue of AJKD, Tong et al3 summarize the knowledge, attitudes, beliefs, and practices of 110 transplantation nephrologists and surgeons from 43 transplantation units across 12 developed countries in Europe, Australasia, and North America, representing an overall response rate of 89%. Participants were asked to share their perspectives on incentivizing living organ donation. Most participants accepted prioritizing the removal of disincentives for living kidney donors. On the other hand, participants worried that financial incentives might undercut altruism, erode human dignity, and promote commercialization of the donor process. Arguing the benefit of financial incentives in promoting transplantation, some participants contended that such incentives are legitimate if appropriately regulated; however, most participants recognized the difficulty of operating a regulated system of financial incentivization.
We applaud this analysis and interpretation from a group of knowledgeable professionals from select developed countries. The authors appropriately acknowledge and emphasize that this report does not capture the opinions and beliefs of the entire transplantation community, which varies by region in terms of socioeconomic and cultural setup, access to health care, and norms. Removal of disincentives to living donation, as favored by most of the respondents, is a reasonable approach: because living donation is a voluntary decision made at the individual level, efforts must be made at this level to adequately address barriers to the donation process. The report also discusses opinions on living donor incentives, a conversation that is very important, timely, and obviously contentious. We have to keep in mind that if living or deceased organ donation had been developed today, as opposed to in the 1950s and 1960s, it is unlikely that the current gridlocked and polarized US legislative system would permit it. Thus, instead of harboring firm beliefs about donor incentives, we believe strongly that solving the organ shortage problem involves thinking outside the box and infusing enthusiasm into organ donation efforts. It also is high time to create a meaningful, creative, and constructive consensus on this topic. In this editorial, we suggest several potential options that we believe would be beneficial in facing the problem of organ shortage.
Removal of simple barriers to organ donation. In cases of living donation, lost wages, as well as lodging, travel, medical, and out-of-pocket expenses, should be taken into account. These are simple barriers to living donation that must be addressed in earnest and eliminated. Certain states and regions in the United States have already adopted some practices to limit these barriers, and we strongly believe that similar initiatives should be available to all donors across the country. However, we suspect that this approach will enhance donation only marginally, thus still not meeting current transplant demands.
Development of a newer nationalized living donor program. We should think seriously about developing a regional or nationalized living donor program, similar to the deceased donor program, with strict government oversight. Family members and friends would retain the right to make a direct donation, but at the same time, all living donors would be educated about nondirected donation and encouraged to participate in a donation chain that would lead to their intended recipients. The nondirected living donor program we propose should involve the organ procurement organization (OPO) and transplantation center. In this system, OPOs potentially could expand their role to include registering and tracking voluntary nondirected donors in a given service area. The OPOs then could offer nondirected organ donations to local centers, just as occurs with deceased donor organs.
The workup for these nondirected donors could take place under the aegis of a transplantation center and would be paid for by a financial arrangement between the center, OPO, and insurance carrier or government agency. The process would be tracked by the United Network for Organ Sharing or a similar national organization. Recipient selection for a nondirected donor should be the same as that of a deceased donor: scientific, equitable, and transparent. This proposed plan is a large undertaking and could require more than a decade to implement in the United States. However, because there is an established well-organized deceased donor program, the architecture is already in place for it to be extended to altruistic living donor transplantation.
Source of incentive to donors. If incentives are to be given to donors, we believe that all donors, both directed and nondirected, should be incentivized, keeping the process unbiased and transparent. As to the controversy concerning who should incentivize the donor, we believe that incentives should not come from recipients or their family members because this would clearly disadvantage patients of lower socioeconomic status. Instead, the source should be a central organization, such as a private insurance carrier or governmental agency, with strict oversight. This will eliminate the bias of a direct incentive from recipient to donor, as well as problems of exploitation arising from such a donation. In addition, this approach will result in a standardized incentive for all living donors irrespective of age, sex, race, religious background, or socioeconomic status. This approach is sensible, but would have to pass all regulatory barriers and will increase the cost of kidney transplantation. However, increasing donation, and thus transplantation, will lead to an overall reduction in cost and greater benefit to patients with chronic kidney failure.
What kind of incentive can be given to donors? In our view, providing direct monetary benefit to donors is not acceptable and will clearly undermine altruism. Further, it would be financially devastating even in developed countries. Lessons learned from developing nations, mainly due to lack of oversight, are very telling: direct compensation will advantage the rich and disadvantage those of low socioeconomic status. Instead, donors should receive some form of indirect financial support for their long-term health. For example, they could be given additional life insurance for a certain duration (eg, 20 years postdonation, but not beyond the age of 65 years); comprehensive health insurance covering annual physical examinations and routine monitoring of laboratory values, imaging, and treatment of illnesses; supplemental health insurance to enhance an existing insurance plan; or tax incentives for 1-2 years postdonation. This approach is logical and without substantial financial burden because it would involve insuring healthy people. Funding for indirect compensation should be provided by a government program such as Medicare or the recipient’s insurance carrier.
Importance of strict regulations and oversight. Strict regulations and oversight are mandatory if we are to establish an incentive for donors. Oversight has to come from the government through agencies such as the Centers for Medicare & Medicaid Services. This approach will benefit donors, recipients, and transplantation centers, as well as OPOs supporting living donor programs.
In this editorial, we have provided a few potential options that should be considered to augment living donation. However, we acknowledge that we do not know the outcome of our proposed strategies because it is not possible to perform controlled trials. Moreover, we are open to other suggestions for enhancing organ donation. That being said, we believe strongly that the mentioned approaches will help redefine organ donation with the hope of increasing donor numbers. We firmly believe that when we implement any changes, the ethics of organ donation and transplantation should be preserved. Nevertheless, when it comes to incentivization, we contend that it is time to cross the bridge.
Topic: Perspectives of Transplant Physicians and Surgeons on Reimbursement, Compensatio (Read 3269 times)