Monday, March 20, 2023
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Table. Recommended Characteristics of a Proposal to Provide Financial Incentives for Deceased Donation[15]
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Table. Recommended Characteristics of a Proposal to Provide Financial Incentives for Deceased Donation[15]
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The current approach to acquiring organs for transplantation relies on the voluntarism of live donors and the altruism of deceased donor families. This practice has an important statutory authorization. Section 301 of the National Organ Transplant Act (NOTA) of 1984 states, "It shall be unlawful for any person to knowingly acquire, receive or otherwise transfer any human organ for valuable consideration for use in human transplantation."[1] "Valuable consideration" is considered a monetary transfer or a transfer of valuable property among donor, recipient, and/or organ broker in a sale transaction.[2] Consent for organ donation as prescribed by federal law may not be induced for profit by a money payment; thus, NOTA §301 outlaws the purchase and sale of organs.
However, public education to increase the rate of altruistic consent for organ donation has not resulted in an adequate supply of organs to meet the demand of those in need. During the past decade, the altruistic approach has resulted in only a 15% increase in deceased organ recovery.[3] As a result, an increasing number of candidates for transplantation have turned to live donors to provide organs not available from the deceased donor pool. In 2001, the number of live donors exceeded the number of deceased donors.[3] Furthermore, some segments of our society are suggesting that the NOTA prohibition of financial incentives for organ donation be reconsidered so that a means of increasing the consent rate from the national average of 45% can be tested.[4,5] The purpose of this review is to outline the types of financial incentives that could be awarded in the setting of both deceased and live donation and provide insight into the prospects for a revised NOTA being enacted that would permit financial incentives or organ payments to be used.
A financial incentive for deceased organ donation could be accomplished by the following approaches: (1) a direct payment for organs, (2) an income tax or estate benefit, (3) a reimbursement for funeral expenses, and (4) a contribution to a charitable organization determined by the family or the deceased.
In October 2000, the American Society of Transplant Surgeons (ASTS) convened a panel of ethicists, organ procurement organization (OPO) executives, physicians, and surgeons to determine whether any of these approaches could be used as an ethically acceptable model for a pilot trial to increase donation.[6] The ethical methods outlined in the Table were developed so that they could be applied to any proposal to elucidate its propriety.
These 4 approaches (payments, tax benefit, funeral reimbursement, and charitable contribution) were considered in a spectrum of a societal perception, ranging from the extreme view of the donor family being bribed to emphasizing a thank you and gratitude for consenting to donation. An inverse relationship between financial incentives that would be acceptable by the ethical methods (eg, a contribution to a charity chosen by the family or a reimbursement for funeral expenses) and those approaches that would most likely increase the rate of donation (eg, direct payment or tax incentive) was evident.
The panel concluded that reimbursement for funeral expenses fits within the guidelines and maintains the standards established by the ethical methods ( Table ) and recommended that a pilot demonstration project be conducted. Following the presentation of a report by the ASTS Ethics Committee at the American Transplant Congress of 2002, a Washington Post headline read, "Surgeons Back Study of Payment for Organs Plan Aimed at Boosting Donor Rates."[7] This headline, which mischaracterized the ASTS Ethics Committee's intent not to endorse payments, had a chilling effect on the transplant community's enthusiasm to move this proposal forward. The ASTS subsequently was compelled to issue a disclaimer stating, "The American Society of Transplant Surgeons opposes payments for living and deceased donor organs ... payments would constitute the exchange of money for an organ, by the sale from a vendor not a donor. Payments would arbitrarily assign a market value to body parts, commodified and conceivably differentiated by gender, ethnicity and the social status of the vendor."
The following refrain has been a common assertion by the advocates of financial incentives: Everyone in the deceased organ transplant process (other than the organ donor or next-of-kin who gives consent for cadaver donation) is compensated: a salary is provided to the OPO coordinator who obtains family consent, the OPO charges an acquisition fee for organ recovery, and the transplant surgeons and physicians and the transplant center charge for hospitalization. The proponents of financial incentives have underscored this reality in their attempts to develop test projects to assess the objective of increasing the consent rate. However, the major hurdle for approval of such demonstration projects is the prohibition of financial incentives for organ donation by NOTA. For example, in 1994, a Pennsylvania law that included a pilot program for reimbursement of funeral expenses to donor families was not implemented because the state's attorney general was cautioned by government officials that such a program would be a violation of NOTA.[6] Unless NOTA is revised, any demonstration project – in Pennsylvania or elsewhere – is unlikely to be tested.
Those who oppose financial incentives for deceased donation assert a slippery slope to the subsequent development of payment for live donor organs. In addition, financial incentives for deceased donation conceivably bring several undesirable consequences; they could (1) risk the withholding of medical information that results in the transmission of donor disease (malignancy or infection) to the transplant recipient, (2) influence the family of a patient to prematurely withdraw care, and (3) result in the perception of the human organ as a commodity.
