In their book SuperFreakonomics, Stephen J Dubner and Steven D Levitt discuss the terrible state of kidney donations worldwide – or almost worldwide. Wherever the culture is one of altruistic donations, people are dying waiting for transplants. But in one country, Iran, things are a little different. They have a system of paid and regulated living-unrelated kidney donation.
In 1988, Iran adopted a compensated and regulated living-unrelated donor renal transplant program. As a result, the number of renal transplants performed substantially increased such that in 1999, the renal transplant waiting list was completely eliminated. By the end of 2005, a total of 19,609 renal transplants were performed (3421 from living related, 15,356 from living-unrelated and 823 from deceased donors). In this program, many ethical problems that are associated with paid kidney donation also were prevented. Currently, Iran has no renal transplant waiting lists, and >50% of patients with ESRD in the country are living with a functioning graft.
In developed countries, the severe shortage of transplantable kidneys has forced the transplant community to adopt new strategies to expand the kidney donor pool.
For example, while it is illegal to sell kidneys, it is not illegal to trade them. I wrote about Paired Kidney Exchange recently, where incompatible donors can trade kidneys with compatible recipients. This approach has expanded into chain donations, where an altruistic donor, who isn’t asking for a kidney in return, kicks off a chain of paired exchanges. Economist Al Roth’s blog post describes how one altruistic kidney donor saved 10 lives.
Other ideas include commemorative medals and pins to honour donors, shorter prison terms, reduced funeral costs for the deceased donor and having health insurance organisations make payments to live donors. A really bizarre idea is a Dutch reality TV program, The Big Donor Show, in which three contestants compete to receive a kidney from a terminally ill donor (gross).
However, compared with the Iranian model, none of these approaches has the potential to eliminate or even alleviate steadily worsening kidney transplant waiting lists. So the SuperFreakonomics argument: set up a market in human organs that would save thousands of lives (and millions of dollars in dialysis costs) a year. Drop the altruism for economic common sense: governments pay donors $30k to $50k for their kidneys and watch the waiting lists fall.
This has triggered discussion and argument around the world, and there seems to be an evolving consensus amongst ethics committees, transplant surgeons, bioethics councils, dialysis associations and others that the organ donation process needs reform, with a focus on incentives. What kind of incentives? While probably not cold cash like the Iran model, they would still be financial, like tax breaks, guaranteed health insurance, college/university scholarships for the donor’s children, deposits in their retirement/ superannuation accounts, and so on.
So what’s the hold-up? The wave is building, let’s catch it. Contact your local kidney or transplant association and offer your help to make a case for reforming the donor process. Who has a better incentive?