An ethical appraisal of financial incentives for organ donation

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Abbreviations

NOTA

National Organ Transplant Act

UNOS

United Network for Organ Sharing

Legally, the purchase or sale of human organs is not allowed, according to the National Organ Transplant Act (NOTA) and the Uniform Anatomical Gift Act. At present, the only form of compensation that is legally permissible includes reimbursement for living donors' expenses associated with “travel, housing, and lost wages.”1 The purpose of these payments is to mitigate financial loss living donors might incur as a result of the donation process, rather than provide financial incentive or encouragement to donate. Although NOTA permits reimbursements for living donors, most donors do not actually receive reimbursements, because insurance companies typically cover only the evaluation process, surgery, and postoperative care. Deceased donors and their families do not receive any form of compensation. In this commentary, we will synthesize existing conceptual arguments in favor of and against financial incentives, with an eye toward living donation. Many of the arguments are applicable to either the living or deceased donation context. We will conclude with recommendations, with the goal of advancing dialogue and systematic information‐gathering to further develop this issue.

The ethical landscape regarding financial incentives for organ donation is complex, with some ethicists arguing that any form of financial incentive is ethically impermissible, whereas others make ethical distinctions based on the purposes and intent of a financial contribution.2 One possible reason why we lack a strong ethical consensus is because the question is often approached differently, with some individuals examining the question through a process or “means” lens and others through an outcome or “ends” lens. Further confounding matters, the discussions often lack any sort of ethical methodology or grounding, which could be used to evaluate different financial‐incentive proposals.

Conceptual Arguments Favoring Financial Incentives

The demand for organs outpaces supply. More than 122,000 people are waiting for a transplant in the United States, and 22 people on the waiting list die each day.3 The principal motivating factor for exploring the viability of financial incentives rests on the notion that donation rates would increase if financial incentives were permitted. However, it is unclear whether there is evidence to support this. Furthermore, the amount of increase in donation rates would likely depend on the form of payment. For instance, a charitable contribution in honor of the decedent's memory would likely do little to increase donation rates. Conversely, direct payments probably have potential to yield the highest donation rates compared with other forms of payment (e.g., income tax credit). Therefore, although a key argument in favor of providing financial incentives is that payment would increase donation, it is unclear whether and how rates would be increased.

The second argument raised in favor of providing financial incentives is that organ donors are the only individuals who are directly involved in the transplantation process who do not receive a tangible benefit.4 Living donors may have limited resources, and some of them argue that they could use financial incentives to fund their education, medical bills, and various living expenses. As such, proponents of compensation argue that payment is an ideal (if not the optimal) means of providing reciprocity to those individuals who are willing to donate their organs (as living or deceased donors). After all, proponents argue, there are self‐sacrificing analogies, such as military enlistment, where the solider might receive incentives in the form of college tuition and enlistment bonuses.5

Another argument in favor of providing financial incentives is the support of society, at least in some data. In a poll conducted by the United Network for Organ Sharing (UNOS) Ad Hoc Donations Committee, half of the surveyed population favored some kind of compensation for organ donors. Interestingly, this opinion varied based on sex, socioeconomic level, and age, with males, those of lower socioeconomic levels, and 65% to 68% of individuals younger than 35 years favoring compensation.6 Other studies have had more mixed results, with some studies showing the approval for financial incentives to be as low as 12% to as high as 52%.7

Lastly, current standards permit noncommercial organ donation and commercial transactions of semen, plasma, and hair. By allowing for commercial transactions involving semen, plasma, and hair, these standards suggest that, at some level, individuals have the right to use their body parts as they please in accordance with autonomy. In keeping with the ethical principle of autonomy, some argue that financial incentives should be extended to organ donation in order to fully maximize autonomous‐based rights. That is, if patients had the ability to decide for themselves whether they would like to donate an organ for money or keep it, this would maximize autonomy.8

Conceptual Arguments Against Financial Incentives

A frequently cited argument against financial incentives is the belief that payments could lead to abuse through the exploitation of people in a lower socioeconomic bracket.9 Financial incentives could provide an actual or perceived element of coercion for those who may feel this is their only option to obtain an income. This, in turn, could create greater disparities between individuals, which may be carried over to transplantation, something that is seen in countries that allow buying and selling of organs.10 This is especially concerning because living liver donation is not without postoperative risk. Opponents of financial incentives argue that the donors may not only be exploited, but they could actually exploit others. For instance, living donors in need of financial incentives (out of economic desperation) may be inclined to misrepresent medical information to increase their likelihood of being selected as an organ donor.11

A second argument against financial incentives is that donation rates may actually decrease because of backlash from current donors who may feel that financial compensation undermines their altruistic contributions. When compensation is provided, donors do not feel the same degree of altruism or intrinsic emotional appeal in their gift or service as they do when they give purely altruistically. This has been seen in other contexts. For instance, a decrease in blood donations was seen after the change was made to allow financial compensation.12, 13

Moving Forward

We began this article arguing that, in order to advance arguments, it is important to have an ethical methodology that could be applied to financial‐incentive proposals in order to evaluate their ethical permissibility. Arnold and colleagues,2 for the Ethics Committee of the American Society of Transplant Surgeons, developed a methodology, which we summarize in Table 1 (with some of our own modifications, based on a typology we see within their framework).

Table 1.

Methodology for Evaluating Financial‐Incentive Proposals

Purpose or intent	Preserves the concept of the organ as a donated gift
	Conveys gratitude
	Preserves the current standard of altruism
	Honors the deceased (e.g., does not assign a monetary value for the individual's organs)
	Respects the sacred nature of the human body
Process	Is not an excessive inducement that would undermine personal values and alter decision making
Outcome	Does not lead to a slippery slope that fosters the sale of live human organs
	Maintains public trust in organ donation

Arnold and colleagues' framework may be incomplete, however, in that there are other process and outcome considerations that could be ethically relevant. For instance, in terms of process measures, it is conceivable that the government should take a role if any form of payment were allowed to ensure adherence to procedural safeguards, whether that be direct payments, income tax credits, payment for funeral expenses, or charitable contributions.14 If left to private companies, organ brokerage companies could easily become exploitative. If financial compensation were to be provided, one process measure might include that at the time the organ is procured, the donor will receive a contribution through a central agency.14 This could promote fairness in that one's ability to pay for an organ would be independent of any selection of the organ by operating through a central agency. The amount of payment, the source of it, and how it would be transferred are ethically relevant process considerations.

Conclusions

According to this framework, we share the Ethics Committee of the American Society of Transplant Surgeons' perspective that there is an ethical distinction between direct payment (which would be likely ethically impermissible because it violates several framework criteria, including concerns about commercialization or turning donor organs into a purchasable commodities) and a charitable contribution to show appreciation for donated organs (likely ethically permissible, if process questions were acknowledged and addressed). We think that direct payment for the organ undermines altruism more than cases where charitable contributions are provided or funeral expenses are paid for the deceased donor.

Several areas are worthy of further study. For instance, it is unclear whether the donors' families would appreciate the distinction between the types of payments and the implications they have on altruism. Thus, one area of future study might be identifying whether and when public perception of “payment” and “altruism” changes and how society views different types of compensation. More work is needed on recognizing and attending to logistical, process concerns associated with payment to ensure protection, concerns that may be just as ethically relevant as the “purpose or intent” considerations for donation.