Ethical Analysis of Appropriate Incentive Measures Promoting Organ Donation in Bangladesh

Abstract

Bangladesh, a Muslim-majority country, has a national organ donation law that was passed in 1999 and revised in 2018. The law allows living-related and brain-dead donor organ transplantation. There are no legal barriers to these two types of organ donations, but there is no legislation providing necessary costs and incentive measures associated with successful organ transplants. However, many governments across the globe provide different types of incentives for motivating living donors and families of deceased donors. This study assesses the merits and demerits of incentive measures already in use around the world and proposes ethical measures that can promote organ donation in Bangladesh. The primary focus of this paper is to present an ethical analysis of the comparison of incentive measures on organ donation between Bangladesh and the Islamic Republic of Iran as two Muslim countries that operate organ donation for transplantation practices according to Islamic principles. In this paper, I mainly argue that providing a fixed bare minimum financial incentive measure to distantly related living donors and families of deceased donors will encourage Bangladeshis to donate organs in a manner that is ethically justifiable, morally permissible, and socio-economically appropriate. The government of Bangladesh should revise the existing biomedical law to include a provision related to incentive measures and set a strict policy to properly regulate these measures as key stewardship that can ethically promote organ donation for transplantation.

Introduction

In Bangladesh, kidneys are the major organ for transplant, but only 2000 kidneys have been legally transplanted across the country (Rashid et al. 2021; Prothom 2020; Siraj 2021a). According to various sources, 130 end-stage renal failure patients receive kidney transplants each year, despite 5000 people needing them (Siraj 2021a). The actual rate of end-stage organ failure is unknown in Bangladesh as there is still no national database (Siraj 2016), but each year many patients die because they cannot obtain organs for transplants.

The pressure to find ethical ways to improve organ supply is intensifying as the demand for kidneys far outstrips the supply. The government of Bangladesh (1999) passed national legislation in 1999 and subsequently revised the existing law in 2018 to regulate organ donations. The government has also instituted several campaigns to make Bangladeshis aware of organ donations. The government revised the law to extend the donor pool in the existing lists. The original law allowed several immediate family members as organ donors but the revised law included certain remote relatives in the existing lists. The law sets a priority system for donating organs for transplantation that descends from the aforementioned list, with a close relative always having a higher priority than those who are less close. The law also provides an opportunity for all who need organ donation but gives priority to the wishes of the brain-dead donor’s family. The law mainly gives priority access to family members in receiving organs from their brain-dead donors.

Along with international regulations and legal frameworks, the law prohibits the selling of organs or the receiving of any financial benefits in exchange for organs (Section 9). It also prohibits financial dealings related to the exchange of human organs and forbids any other campaigns related to selling organs. However, the law does not include any provisions related to financial reimbursement including fees for surgery, transplantation, in-patient hospitalization during recovery, loss of earnings, follow-up care, post-operative care, and medication, intensive care unit (ICU) access and ventilators, burial or funereal services, and corpse transportation (Siraj 2021b).

Kidneys from related living donors remain the main source of organs for transplantation in Bangladesh, but greater progress on organ donation is still unsatisfactory. Who wants to donate organs willingly in an environment where post-operative care for the donor is almost non-existent or where the family will always be willing to pay for ICU support and ventilator use to keep their relative’s brain-dead organs alive (Siraj 2021b)? Despite policy revisions, campaign strategies, and priority measures, there has been no successful effort to identify the types of incentive measures permissible under international regulations and domestic law to encourage organ donation. In this paper, I review the relevant law on organ donation and explore if there is scope for ethically justifiable and legally permissible incentive measures in Bangladesh that will promote organ donation in the country. I specifically refer to and compare organ donation incentive measures in the Islamic Republic of Iran to those in Bangladesh. The main purpose of this paper is not to carry out an ethical analysis of Bangladesh’s organ donation law but to carry out an ethical analysis of providing appropriate incentive measures to related living donors and families of brain-dead donors in organ procurement and transplantation in Bangladesh.

Legal Regulations and International Frameworks concerning Incentive Measures on Organ Donation

Organ sales are strictly prohibited by international accords. The most relevant reference is the World Health Organization’s legally non-binding Resolution on the Guiding Principles on Human Cell, Tissue, and Organ Transplantation (WHO 2010). Article 5 states that “human cells, tissues, and organs should only be donated freely, without any monetary payment or other rewards of monetary value. Purchasing, or offering to purchase, cells, tissues or organs for transplantation, or their sale by living persons or by the next of kin for deceased persons, should be banned.” The same clause of the Guiding Principle states that the prohibition on the sale or purchase of human cells, tissues, or organs does not preclude the reimbursement of reasonable and verifiable expenses incurred by the donor, such as lost income, or the payment of costs associated with recovering, processing, preserving, and supplying human cells, tissues, or organs for transplantation. The WHO Guiding Principles allow for compensation of necessary expenses for organ donation (Levy 2018).

The prohibition of organ sales is also mentioned in other international laws. The Council of Europe’s Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. Article 21 of the convention declares “the human body and its parts shall not, as such, give rise to financial gain” (Council of Europe 1997). The Additional Protocol on Transplantation of the Council of Europe also refines the restriction imposed by the convention by barring not just monetary gain, but also any other comparable benefit in exchange for an organ (Council of Europe 2002). However, the same clause allows for exceptions to the rule, such as reimbursement for lost earnings and other legitimate expenses for living donors. The Additional Protocol’s Article 19 provides a legally binding international commitment for states to take all appropriate measures to promote organ donation (Council of Europe 2002).

The reward gifting approach is reflected in a report issued in 2013 by the UK Nuffield Council on Bioethics. The Council stated that body parts should not be “‘bought” or “sold” directly, such as exchanging money for body parts. According to the Council, the government has a role in encouraging people to donate their organs. Although altruism should remain at the center of donating because it underlies important community values, this does not rule out the possibility of receiving a reward (Nuffield Council on Bioethics 2011).

The legal framework of the European Union is also relevant since it puts legally binding obligations on member states. The Charter of Fundamental Rights imposes “the prohibition on making the human body and its parts as such a source of financial gain” (European Union 2010a). According to the directive (2010/45/EU) on standards of quality and safety of human organs intended for transplantation, “donations of organs from deceased and living donors are voluntary and unpaid” (European Union 2010b). The “principle of non-payment” does not exclude living donors from receiving compensation, limiting it to the expenses and loss of income related to the donation (Levy 2018).

Edited recently in 2018, the Istanbul Declaration on Organ Trafficking and Transplant Tourism, adopted in 2008 at an international conference organized by the Transplantation Society and the International Society of Nephrology, completely prohibits payments for organs or benefits to the potential donor (Steering Committee of the Istanbul Summit 2008). The Declaration does not exclude giving health/life insurance coverage, job opportunities, governmental services, reimbursement for reasonable expenses incurred by donors (e.g., lost income and out-of-pocket expenses, long-distance telephone calls, travel, accommodation, and subsistence expenses, medical expenses incurred for post-discharge care of the donor) in accordance with the donation event.

The Global Observatory on Donation and Transplantation provides a global database of existing organ donation legal frameworks, in which all countries globally and Bangladesh domestically prohibit the sale of human organs but provide necessary expenses in the event of organ donation that does not conflict with existing legal frameworks prohibiting organ sales (WHO-ONT 2022; Government of Bangladesh 1999).

To summarize, international regulations and Bangladesh’s domestic law on organ donation prohibit organ selling or exchanging monetary benefits for organs, but these legal provisions allow incentives and reimbursement for reasonable costs generated with organ procurement and transplantation.

Incentive Measures used in Organ Donation

Countries globally mainly use three categories of public policy instruments to promote organ donations (Levy 2018). The first lists legal regulation, which is applied as guidelines to the selection of potential organ donors or the adoption of specific protocols for determining brain death. Regulations guide transplant teams to obtain organs from both living and cadaver donors and to successfully perform transplants (Bagheri 2005). The second category is public awareness campaigns. When the public is provided with accurate information on organ donation, it will encourage people to make donation decisions (Levy 2018). If financial support in the process of organ procurement and transplantation is lacking; however, simply offering information to persons about organ donation may not be enough to change someone’s behavior pattern towards making donation decisions. The third category involves using financial incentives to encourage people to donate organs. There are three types of incentive measures used globally to promote organ donation. Some provide honorary incentives, while others provide necessary reimbursement and priority access to organ receipt and yet others include financial compensation for organ donation (Fan and Ding 2020; Levy 2018). I will discuss the benefits and demerits of each incentive measure as well as the fundamental cultural values that each incentive measure is focused on. In this section, I primarily present a descriptive analysis of the advantages and disadvantages of each incentive measure for organ donation in cultural settings.

Honorary Incentive Measures

The honorary incentive encourages persons to donate organs as gifts and promotes a set of values associated with such donations, such as human dignity, reciprocity, solidarity, compassion, and altruism (Sharp and Randhawa 2014; Delmonico and Scheper-Hughes 2002). Organ donation practices in developed Western countries (the USA, for example) are dominated by this liberal approach. The US National Organ Transplant Act of 1984 governs organ transplantation, prohibiting the sale of organs. The American Society of Transplantation supports providing associated costs such as the short- and long-term health insurance related to the effects of living donation. In the USA, healthcare insurance covers all medical services related to organ donation including evaluation, hospitalization, surgery, follow-up care, and treatment of any post-operative complications. Several states of the USA have also passed legislation that provides paid leave to organ and bone marrow donors. The laws also offer tax benefits for living and deceased organ donations and to employers of donors. In 2000, the state of Pennsylvania in the USA initiated a system to provide US$300 to the families of deceased organ donors to help with burial costs (Gansen 2002). The existing donation system focuses on encouraging people to register as organ donors in the event of death or to act as living donors. Along with these efforts, the American Organ Procurement Organizations offer organ donors and their families several honorary incentives, such as a donor memorial garden, religious brochures on donation, the Donor Family Memorial box, the Donor Medal of Honor, special Gift of Hope flags, a sympathy card, a detailed outcome letter, a certificate of honor, a “We Remember” card, specialist services, and so on (Fan and Ding 2020). These non-financial honorary incentives act as motivating factors for donors or their families in the event of organ donation. Thus, the rate of organ donation in the USA has gradually increased. In 2021, 41,354 organ transplants (34,813 deceased donors and 6541 living donors) were performed in the USA, an increase of 5.9% over 2020 (Organ Procurement and Transplantation Network).

Americans give honorary incentives, insurance, and tax benefits to gain the trust and confidence of potential donors and families of brain-dead donors. The cultural value that underpins donating organs is the sense that human life should be saved regardless of who it belongs to. One can contribute to saving another person’s life or become a deceased donor after death. As a result, in the USA, both law and practice encourage people to donate their organs to anyone else. This approach to organ donation ensures selflessness, as donors and their families should be hesitant about receiving any material or monetary benefit in exchange for their organ donation. Americans believe that if payment is received for organ donation, it will commercialize human life. The Islamic cultural value system prohibits the payment system between donors and recipients but it allows offering to donors and their families necessary costs, reimbursements, and honorary incentives in organ procurement and transplantation (Atighetchi 2007; Al-Bar and Chamsi-Pasha 2015; Siraj 2021b; Aksoy 2001). In contrast to what has been done in the USA, no associated costs, reimbursements, or honorary incentive measures have yet been offered to donors and their families in Bangladesh.

Priority Access

Only a few legal and regulatory frameworks incentivize living organ donation, with the key exception of Israel’s Organ Transplant Law, which has resulted in a significant improvement in organ donation rates. The Israeli Organ Transplantation Law, passed in 2008, includes a provision that prohibits reimbursement for illegal transplant tourism and, among other things, removes disincentives to a living donation by providing modest insurance reimbursement and social support services. These include earning loss reimbursement before and during recovery; transportation refund for the donor and relatives during and after the donation; and a 5-year reimbursement of medical expenses, work capability loss, life insurance, and psychiatric consultation, and therapy (Lavee et al. 2013). Israeli law offers the incentive of allocation priority for registered donors as part of its public policy to promote organ donation. Israel’s public policy of encouraging deceased donation gives priority on the organ transplant list to registered donors and close relatives who consent to successful posthumous donation should they ever require donated organs (Roth 2015). According to preliminary evaluations, the Israeli law had a positive response in terms of donation rates, which increased from 7.8 to 11.4 donors per million populations (pmp) in 2011 (Lavee et al. 2013).

Similarly, Spanish law offers priority to relatives of dead organ donors or those who have previously registered as potential organ donors. Spain also offers a government-funded program that supports families of post-mortem donors with funeral expenses to encourage posthumously donated donors (Rodríguez-Arias et al. 2010). Spain claimed a deceased organ donation rate of 46.9 organ donors pmp in 2017, the highest in the world (National Transplant Organization, Health Ministry of Spain).

Compensation Measures

In China, a compensation policy for deceased donor organs was first launched in 2010 in five provinces and cities as a pilot project. For financial compensation, two aspects were considered. The “thank you” form communicates the Red Cross Society of China’s gratitude for the subscription to organ donation. The “help” is in the form of social welfare assistance for low-income families. This program marks a turning point in China’s transplant history. In March 2012, there were a total of 207 deceased donors and the proportion of poor donors among the 207 deceased donors was significantly higher than that of other donors (90% of the 207 deceased donors’ families faced financial difficulties) (Wu and Fang 2013). Because of the inclusion of this particularly vulnerable group, the donor compensation effort has been criticized. According to recent data, several of these families agreed to donate because they needed financial assistance (Wu and Fang 2013). It is thought that low-income families agreed to donate as they were eligible for an additional payment of around US$4800 (Wu and Fang 2013). Families of deceased donors may allow physicians to procure organs from their relatives’ bodies after death if there is a chance to receive huge monetary rewards for organ donations.

Singapore has also affirmed the legitimacy of offering living kidney donor’s monetary compensation. Living altruistic organ donors are financially reimbursed for their charitable acts. While the Singapore Human Organ Transplantation Act makes the trade and sale of human organs and blood illegal, it does allow the living organ donor to be compensated for the costs of the operation and pre-operation tests (e.g., health checks, laboratory tests, donation operations, follow-up visits at the hospital). Furthermore, donors are entitled to compensation for any loss of wages that may be reasonably incurred as a result of organ donation (e.g., self-employed or daily-wage workers). In addition, if donors are having financial difficulties but still want to donate an organ to a loved one, the National Kidney Foundation offers a S$10 million Kidney Live Donor Support Fund to help needy living donors. Only kidney-related medical welfare and insurance will be covered by financial support (Min 2018). These financial reimbursements and necessary costs associated with organ procurement and transplantation encourage Singaporeans to donate organs for transplantations. The organ donation rate in Singapore has gradually improved (both deceased and living organ transplant rate for kidneys was 16 pmp in 2019 (Ministry of Health, Singapore).

What can we thus learn from the honorary incentive approach, priority access measures, and financial compensation systems, and what can we apply to biomedical practice in other countries such as Bangladesh? In this study, I have demonstrated other incentive measures exist for organ donation, such as in Israel, Spain, China, and Singapore, but my main focus is on the ethical analysis of the comparison between Bangladesh, Qatar, and Iran, three Muslim countries that operate organ donation for transplantation practices according to Islamic principles. In the next section, I present a comparison of ethical analysis of incentive measures regarding organ donation between Qatar and Iran.

Incentive Measures for Organ Donation in Qatar and Iran

The Qatari government operates a relatively successful living and posthumously donated organ donation program for Qatari citizens and non-Qatari residents. The Qatar government provides fees for transplant surgery for all Qataris and non-Qataris, supplies free medications, and required post-operative follow-up care. All procedures related to organ transplantation in the State of Qatar are free of charge for all patients. The government also provides lifetime medical insurance for all living donors, monetary compensation for any health problems that arise, life insurance, priority for transplantation in the event of future renal failure, and other benefits such as free flight tickets. All Qatari legal residents, including migrant workers, are also entitled to receive health insurance, which employers must provide. Financial compensation is also provided for the loss of wages. In addition, travel and social security assistance is provided for families of deceased donors (El-Menyar et al. 2020). In other words, family members of the deceased would be offered a free airplane ticket to accompany the deceased body for transplant purposes. The government also awards the donors of organs an honorary medal known as the “medal of altruism,” and in the case of donating the deceased’s organs, the medal is awarded in the deceased’s name and handed over to their nearest kin as the Qatari government acknowledgment. The Qatari government also provides fees for organ suitability testing between donors and recipients and adequate post-operative care for donors. Offering adequate post-operative follow-up care for donors is a “reconciliatory step” to gain trust that leads donors primarily to donate willingly (Barr et al. 2006). Qatar is one of the world’s richest nations, with a population of roughly 3 million people compared to Iran’s 84 million and Bangladesh’s 165 million. As a result, Qatar can be more generous with its compensation measures. These medical facilities and compensation packages encourage Qatari citizens and non-Qataris into donating organs during their lifetime and after death. Thus, the rate of organ donation in Qatar has risen gradually.

Only one country, the Islamic Republic of Iran, has a legal and regulated system for payment exchange for organ donation. Once an organ failure patient is identified, transplant professionals search for a medically suitable living-related donor for transplantation. In doing so, physicians advise the patient to find a potential donor within their family (Ghods 2002). If a patient does not have any related potential donors, or a potential relative donor is not willing to donate, then the recipient is referred to the Dialysis and Transplant Patients Association (DATPA) to find an organ from a deceased donor (DD), waiting in the queue for a maximum of 6 months (Hammond 2018). If the patient does not find an organ from a DDs, the DATPA searches for suitable organs from living unrelated donors (LUD) (Hammond 2018).

Although the program of unrelated kidney donor organ transplantation started in Iran in 1988 (Ghods 2002), the initiative to provide financial compensation to living unrelated donors (LUDs) began in 1997 (Bagheri 2006). The reason for introducing compensation for LUDs was the recognition by Iranian society that receiving kidneys from LUDs would increase the donation rate (Bagheri 2006).

What is the amount of compensation an unrelated kidney donor receives in Iran? LUDs receive a fixed stipend from the Iranian government, as well as medical insurance, transplant, hospital charges, and medicines at reduced prices (Mahdavi-Mazdeh 2012; Tober 2007). The LUDs also receive an additional reward from recipients for organ donations as determined by negotiations (Mahdavi-Mazdeh 2012; Bagheri 2006). Living-related donors (LRDs) do not usually accept money from the recipient families because their motives are to support a loved one (Tober 2007) but they do receive health coverage for at least a year and subsidized medicines from government hospitals for years. The government also pays for transplant surgeries.

In the “negotiation” stage, the potential LUD and the recipient engage in bargaining, where the LUD receives an extra reward from the recipients for their donation (Mahdavi-Mazdeh 2012, 629). The meeting usually takes place on the foundation or university premises, where a reserved space is provided for their negotiation (Mahdavi-Mazdeh 2012). This means that donors meet with recipients prior to donation to confirm payments from recipients under the DATPA control (Rizvi et al. 2009). The DATPA has no record of the agreed amount for the exchange of kidneys and has no role in the negotiation process (Mahdavi-Mazdeh 2012). However, a pilot study shows that a potential kidney recipient would need to deposit around US$3500 with the government/charity organization before the transplant, and the money would be paid to the donor after the transplantation (Mahdavi-Mazdeh 2012). Actually, the precise amount deposited is determined by negotiation between the donor and the beneficiary. However, the DATPA only maintains certain controls or formalities over the issue by introducing another potential donor to the recipients in cases where the LUD requires an unusual amount of money (Mahdavi-Mazdeh 2012). Such avaricious donors may be removed from the potential donor lists (Mahdavi-Mazdeh 2012). Iranian biomedical law suggests that if LUDs demand a large amount of money and recipients are unable to pay, potential donors will be barred from the donor list, but very few potential donors are actually barred because there are always wealthy recipients in need of organs and healthy, particularly poor, donors looking for a quick fix to their financial problems. As a result, poor LUDs are convinced or enticed by recipients and sell their organs without altruism. Iranian scholars affirm that the unrelated kidney donation program is a government-controlled organ transplantation system where no surgical team or brokers are permitted to participate in a monetary transaction and no intermediary receives any payment. All financial transactions are settled directly between the LUD and the recipient. If a financially poor recipient is unable to pay an extra reward to the LUD, DATPA then seeks assistance from charities to pay the extra reward to the LUD. By 1999, the compensated living unrelated kidney donation program successfully eliminated the transplantation waiting list of the country (Ghods 2002).

As discussed earlier, a LUD currently receives 10 million rials (approximately US$1200) from the government or charities, 1 year’s healthcare insurance, expensive medicines at subsidized prices, and additional money directly from organ recipients. For additional rewards, if potential recipients are unable to pay donors, there are charities that can help recipients to afford the costs. Except for organ recipients paying additional rewards to donors, I consider that all compensations are fair and morally permissible. If 10 million rials would be counted as compensation (e.g., reparation) for altruistic donations, recipients may therefore wish to offer gifts to altruistic donors for their follow-up care, post-operative complications and overall wellbeing, but what disturbs me most is the additional reward gifted by the recipients directly. The fixed amount of compensation (10 million rials) might be considered altruistic, as donors and recipients are not here negotiating a price for organs. Moreover, medical services such as subsidized medicines and 1 year’s free healthcare insurance are necessary for donors to recover good health. However, a question then unavoidably arises as to how much the additional rewards for organs are worth. This additional reward is not a “regulated” transaction, as potential donors and recipients usually engage in bargaining for organs (Griffin 2007). This type of bargaining is generally found in open markets, where buyers and sellers exchange everyday commodities in the same manner. While the overall Iranian living unrelated kidney donation program is heavily restricted, it does openly allow LUDs to receive monetary rewards involving bargaining. Placing humans in markets as commodities is a morally wrong activity and such type of practice subverts the concept of “giftedness” for organ donation. This type of biomedical practice should not be imported into practice anywhere in the world, including in Bangladesh. If unlimited amounts of money are offered to donors, poor donors will be more inclined to donate organs for transplantation, without altruism but in order to escape from poverty, as is currently happening in Iran. Most transplantable organs have been procured from Iranian LUDs, and the vast majority of them are from poor socio-economic groups (Zargooshi 2001).

What is the Islamic principles on monetary compensation and monetary reward for organ donors for transplantation? I use the terms “compensation” as reparation and “reward” as an incentive to make the ethical argument more clear and consistent for this paper. A contemporary Muslim bioethicist, Dariusch Atighetchi, sees that there is a difficulty in distinguishing between the sale of human organs and the practice of offering monetary rewards received for donations (Atighetchi 2007, 180). The obvious reason is that, in both cases, recipients and donors desperately engage in bargaining for organs — as is done in Iran — that makes the issue most critical and debated. While most Islamic scholars and religious institutes including the Jeddah Council of the Academy of Islamic Law (Resolution no. 26 on organ transplants, 6–11 February 1988) ban organ selling completely, they emphasize that organ recipients could consider bearing the expenses or paying monetary compensation to donors as a sign of appreciation that is necessary for altruistic donors’ survival (Atighetchi 2007). Engaging in a negotiating position between donors and recipients for the purpose of determining monetary reward is similar to the practice of organ selling (Siraj 2016; Natour and Fishman 2011), and these types of immoral practices should not be supported by biomedical law and healthcare practice.

I support Sahin Aksoy’s view on offering monetary rewards to altruistic organ donors. Aksoy (2001, 468) sees that despite Islam prohibiting organ sale, the giving of fixed monetary reward for altruistic organ donation can be permitted as Islam does permit exceptions. He recognizes that human organs are not a mere property that can be donated freely and should not even be considered a legitimate part of the trade or a way of earning or generating income, but that does not mean that any financial reward associated with organ donations should be considered forbidden. As Islam permits exceptions, offering financial rewards to donors for altruistic organs does not infringe the spirit of Islamic principles as it is a natural way of life (Aksoy 2001, 468). I also support Aksoy (2001, 469) as he views a limited degree of reward (e.g., half the blood money such as 5000 Kuwaiti Dinars) for altruistic organ donations as a mechanism to motivate donors as it can be considered an example of the robust realism of the Islamic way. Aksoy (2001, 472) also suggests that some small amount of monetary reward can be offered to donors under state supervision if it encourages people to donate organs and promotes public welfare. According to Aksoy, a limited monetary reward would not coerce altruistic donors to donate organs against their altruism as the monetary reward is limited and fixed. The permanent committee of a supreme Islamic Judicial Authority in Saudi Arabia issued a ruling that “there is nothing wrong with accepting it (an amount of money as a gift), without you (the recipient) longing for that, and you can respond in kind if you are able to with an appropriate gift, or you can supplicate for him, because the Prophet Muhammad is reported to have said that “Whoever does you a favor, respond in kind, and if you can’t find the means of doing so, then keep praying for him until you think that you have responded in kind” (“Giving Gifts in Islam” 2019). This Prophetic verse can be interpreted as offering limited monetary gifts intrinsically is a moral appreciation by recipients that shows friendship and honor to altruistic donors. When donors see that these monetary benefits can be used for post-operative care after transplantation, such limited monetary gifts may motivate living donors to donate organs for transplantation altruistically.

The next section illustrates how and to what extent the Qatari and Iranian approaches to organ donation incentive measures can be applied to biomedical practices in other countries like Bangladesh. Qatar is both wealthy and smaller than Bangladesh; Qatari biomedical practices are not feasible for Bangladesh. All organ transplant procedures are provided free of charge to all patients in Qatar, including the costs of transplant surgery, free medications, lifetime medical insurance for all living donors, monetary compensation for any health problems that arise, and life insurance for donors, as previously stated. The Bangladeshi government is unable to afford these fees, as well as the post-operative care is given in Qatar. Only Bangladesh may benefit from an honorary incentive measure like Qatar’s “medal of altruism,” which encourages organ donation.

Ethical Alternatives for Organ Donation in Bangladesh

Let me briefly discuss the laws and practices governing organ donation for transplantation in Bangladesh. The government of Bangladesh (1999) first legislated the Human Organ Transplantation Act in 1999 which allowed organ transplantation from both brain-dead and living-related donors. According to this law, a husband and wife, adult son and daughter, father and mother, adult brother and sister, and other adult relatives connected by blood such as uncles and aunts from both the paternal and maternal sides of the family can legally donate their organs for transplantation. That is, the 1999 Act approved only three categories of relatives who can legally donate their organs for transplantation. The first category includes first-degree blood relatives such as the father and mother, adult son and daughter, and adult brother and sister. The second category includes second-degree blood relatives, e.g., uncles and aunts on both the paternal and maternal sides. The third category comprises spouses, a husband, and a wife (Section 2:4). In other words, donors from only twelve specific relations to the recipient were allowed to legally donate organs for transplantation in the country.

The government of Bangladesh subsequently revised the 1999 act in January 2018 to address donor scarcity, adding certain remote relatives such as grandparents, grandchildren, and first cousins as potential donors to the existing lists (grandparents are defined as the parents of one’s father or mother; grandchildren are the children of one’s son or daughter; and first cousins are the children of one’s paternal or maternal uncles or aunts). The revised law also redefined the term close relative to include these more distant relatives. Unrelated donors are not legally allowed to donate organs for transplantation in Bangladesh — a practice that is permitted in Iran. The 2018 law also prioritizes the order of organ donors, prescribing that relatives mentioned earlier in the list take priority in receiving organs for transplantation over those mentioned subsequently (Section 2:2). For instance, a son gives priority to his parent to receive his organs before uncles and aunts.

The 2018 law also laid a foundation to initiate the transplantation of vital organs from brain-dead donors (Siraj 2021a). The law prioritizes family members for receiving posthumously donated organs from their brain-dead relatives and includes a provision that gives priority to the wishes of the brain-dead donor. A family member or other person can get priority in receiving organs of an individual whose brain death is declared if that individual has given written consent for the donation of an organ during their lifetime. In this way, the law gives priority to immediate family members in receiving organs from their brain-dead patients. The incentive of allocation priority may necessitate the creation of an official national organ donor registry (Rosenblum et al. 2012). A registry like this might be run as a computerized electronic database that keeps track of and centralizes consent from willing potential deceased organ donors (Levy 2018). Currently, there is no national database for organ donors to register as potential deceased donors, and one should be developed as soon as possible. The successful start to the transplantation of vital organs from brain-dead donors in organ procurement and transplantation would be impossible without identifying an eligible deceased donor organ.

This incentive system has ethical value as it encourages Bangladeshis to donate their organs to their close relatives and immediate family members before extending them to others. The family approach implies that while saving the life of a human by donating organs is itself an altruistic act, it is even more valued when it is done to save the life of a relative. The Islamic ethical tradition emphasizes that one should love every human being (Quran 5:32), but at the same time, one should love one’s family members more than other people. Muslims thus have a moral obligation to donate organs to their relatives. This obligation is more greatly valued when it relates to saving the lives of close relatives or immediate family members because supporting close relatives or immediate family members has great value in Islam (Quran 17:26). And this moral obligation varies according to the specific relationship between the two individuals, with the emphasis on saving the lives of the closest relatives having a greater reward than for that of other relatives (Siraj 2021b). Specifically, the law sets down a principle stating that a living donor or the immediate family members of a deceased donor, whenever in need of organ transplantation, has a reasonable priority right to the distribution of donated organs. The law puts the donor’s desires and the health of their family first. Prioritizing family members may inspire people to become organ donors in the event of their own death, particularly since preserving a relative’s life through organ donation is highly valued and encouraged in Islam (Siraj 2021a; Moazam 2006).

The next issue to address is what the Islamic principles say about who among family members should get priority in receiving compensation. Muslim families are generally collective in nature and act as moral enterprises (Dhami and Sheikh 2000). Offering care and support to needy family members is a moral duty, responsibility, and obligation. Members of a Muslim family who are economically affluent are morally obligated to care for those who are in need. Most Muslims believe that if Almighty Allah has blessed them with wealth, they should bear some responsibility for their relatives who are in need of financial assistance. As a result, members of the family have a strong sense of filial piety and a moral obligation to assist and care for their relatives. This care and assistance are not equal for all members of families. Extended family members receive less care and support than immediate family members. One of the basic Islamic principles is that it offers the best care and support to immediate family members first. The graded love and care are the basis of the Islamic structure of the family. As an immediate relative always receives priority in receiving organs for transplantation in Muslim Bangladeshi families, this Islamic principle can be equally applied to the argument on compensating immediate and extended family members. Numerous Quranic principles encourage providing financial support to immediate family members first before offering it to distant relatives. Islam considers fulfilling one basic need to be a right (Quran 6:141; 30:38; 51:19; 70:24) that the immediate relatives owe over distant relatives (Quran 16:90; 17:23,26). For instance, a parent should be compensated for the event of post-operative support for organ donation and transplantation before other distant relatives such as first cousins.

The next issue to address is also why incentive measures are necessary and who among the family members should be included. Bangladeshi families are not typically a nuclear family comprising only a husband, wife, and their adult children, but rather an extended collective family commonly formed by parents, adult sons and daughters and their wives and husbands and their children, grandparents, and other relatives (Siraj 2021b). Married sons usually continue to live with their parents. Only in very few cases a married daughter along with her husband and their offspring live in with her parents. But the family relationship between married daughters and their parents is very strong. According to the kinship ideal that is used by Bangladeshi collective society, unmarried uncles and aunts both from maternal and paternal sides live in extended families but they mostly live in different “joint” families once they get married. First cousins (the sons and daughters both from the maternal and paternal uncle and aunts) are typically thought of as distant relatives.

As hundreds and thousands of kidney failure patients continue to die each year due to the unavailability of organs, we should urgently consider the ways of increasing their supply. My justification is that offering financial incentives for extended family members are the only justifiable alternative measure for Bangladeshis regarding organ donation for transplantation.

Why should financial incentives be excluded from immediate family members? The close kinship relation may encourage father and mother, son and daughter, and spouses into donating organs for transplantation. These close relatives already share economic facilities and other social capital, and offering financial incentives to them will lead to a perplexing and embarrassing situation. These close relatives may use their shared economic resources for organ procurement and transplantation as well as donor’s follow-up care and post-operative care. Both paternal and maternal uncles and aunts may be willing to donate organs to their other relatives in cases where support for post-operative care is limited.

However, first cousins do not typically share common housing and/or financial resources. Although extended family motivations and blood ties may encourage first cousins to donate organs to their non-close relatives, placing them as organ donors in areas where post-operative healthcare coverage is scarce may put them at grave medical risk. Allowing these extended family members to receive a financial incentive for post-operative care is thus necessary and reasonable. If the government extends the existing requirement of the law and practice of living organ donation beyond family members, however, this measure will significantly increase organ selling in Bangladesh (Siraj 2020). Poor people can easily sell their organs in the name of altruistic donations.

How much monetary reward can be offered to extended family member donors? A small amount of reward can be offered to extended relative donors to express thanks. Although some extended relatives may have good wishes to donate organs to their distant relatives, we cannot claim they always donate organs altruistically. As a hidden organ market has already thrived in Bangladesh (Moniruzzaman 2019, 2012), we do not believe that extended blood relations will always motivate people to donate organs without receiving any monetary benefit. We should consider that a small amount of monetary gift may encourage extended relatives to donate organs altruistically. These benefits may be used by extended relatives for follow-up care and post-operative complications and necessary medicines. I argue that the monetary benefit can be the minimum amount of 100,000 BDT (equivalent to approximately US$1164).

This amount of limited monetary reward for altruistic donors is supported by Islamic scholars (Atighetchi 2007; Al-Bar and Chamsi-Pasha 2015). In many regions of the world, organ donors are not covered by national healthcare insurance. Who will look after living donors and bereaved families of brain-dead donors who do not have access to insurance? Islamic scholars favor offering a modest monetary reward to organ donors for post-operative follow-up treatment or to bereaved relatives of deceased donors to help with ICU and ventilator costs (Siraj 2021b). The limited monetary reward for the altruistic living relative donors is also culturally appropriate and socio-economically justified as more than half of the population still lives on less than US$2 a day. According to the World Bank, Bangladeshis had a GDP per capita of US$1961 in 2020. As the average income of the people is lower, offering limited rewards is the socio-economic reality. This monetary reward can be set for extended relative donors.

How much resources are necessary for a living donor to receive a long-term medical check-up, treatment, and medicines for good recovery? As the medical expenses of follow-up care for donors and medications are very expensive in Bangladesh (Rashid 2014; Siraj 2016), a proposed limited amount of 100,000 BDT (approximately US$1164) is necessary for donors to recover. Let me describe the issue in detail. The minimum fee for an organ donor to have a consultation with an expert physician is currently 2000 BDT (approximately US$23) in Bangladesh. It is assumed that a donor needs to receive follow-up care immediately after 1 month, 6 months, 1 year, and then annually lifelong for a good recovery. We assume that if a donor continues to live 20 years after transplantation and makes an appointment twice a year, the expense for consultation with physicians in total is 80,000 BDT (approximately US$931). The donors, therefore, need to pay for prescribed medicines and required physical examinations. At the same time, as expert transplant physicians are mostly available in the capital city Dhaka and in some cases at the divisional cities of Bangladesh, donors also need to pay the travel costs incurred. The donors may use the rest of the money for their medicines, physical tests, and travel purposes. If the government does not value donors’ intrinsic altruism, these charitable acts will be more difficult as the illegal purchase of organs through hidden transactions will increase. Offering some benefits allows each donor to feel satisfied with receiving such gifts while it decreases the commercialization of organs. I argue that denying such gifts may increase organ selling, and such practice will isolate many poor Bangladeshi people from their family and society.

As organ recipients receive benefits directly in organ procurement and transplantation, they should bear post-operative expenses incurred by extended relative donors. If recipients cannot bear these costs, it is a good reason to believe that extended relatives may not always wish to donate their organs in lieu of bearing the necessary costs by themselves. The recipients ought also to pay fees for appointments, suitability checking, hospital admission, surgery, traveling, and accommodation of donors. We should also recognize that the Bangladesh government (a lower-middle-income country whose resources are very scarce) may not always be able to provide costly surgery fees — as is provided by the Qatari and Iranian governments — for all transplants. Organ recipients or their families may deposit the required money to the authority of the respective transplant hospitals, taking approval from a proposed “national commission” that will shoulder all the expenses related to transplantation. The recipients as well as their families should also arrange the accommodation of donors’ relatives personally, if it is required. If we allow extended relatives to incur their personal expenses for donating organs, or if we deny offering such benefits for the pre- and post-transplantation costs, post-operative short-term follow-up care, and medicines, this would create a double burden for donors. We could not assist and save the lives of terminally ill patients because many extended family relatives may not always be willing to donate altruistically for fear of bearing the cost incurred, especially as current healthcare coverage in Bangladesh has plenty of gaps (Siraj 2020; 2016; Rashid et al. 2021). If recipients or their families are not able to arrange this compensatory award by themselves, the government or charities should come forward to help the needy.

There are good justifications for Bangladeshis to offer some benefits for receiving organs. As this reward is not an unduly attractive amount of money and may not even involve any brokering or negotiation, it may not jeopardize donors’ altruism. This amount of benefit is reasonable for altruistic donors. I am concerned that offering a higher monetary gift is socio-economically excessive and may motivate donors to make a potentially life-threatening sacrifice of important organs. If benefits are either set at a higher level or as is done similar in Iran as an additional monetary reward that involves bargaining — it would attract poor non-close relatives to donate organs to their relatives. I argue that the intentionally small monetary benefits for organs are meant to express thankful appreciation for receiving valuable organs, not to afford paying for it. We should recognize that some people may view the difference in offering monetary gifts from different perspectives (Delmonico et al. 2015). Although the benefit is set by monetary value, I argue that this benefit may not place donors and recipients in financial dealings for organs. It should be emphasized that this benefit is not worth valuable organs; it is only a thankful wish to extended relatives for receiving a gift of life. The purpose of offering monetary benefits to extended family members is to reduce the risk of donors’ negative health consequences or fear of loss of employment. These benefits may even be used by donors for their travel costs to the hospitals over long distances, impaired ability to work, as well as telephone charges. With this limited incentive program, extended relatives would never be compelled to act purely based on altruistic motivations. I assume offering some benefits for altruistic motivations makes donors happy to offer coerce-free consent in organ donation for transplantation.

Many may argue that extended relatives would be forcefully used by wealthy patients regarding organ donation for transplantation. If extended relatives see that patients have close relatives who are medically suitable for transplantation, however, they would not be forcefully motivated to donate organs because the current law and practice of living organ donation for transplantation encourages very close relatives to donate organs, as they are faithfully related by close blood or kin relations to each other. I agree with Mark Cherry’s viewpoint that relatives may wish to donate organs to avoid confrontations or to satisfy personal, family, or social objectives. The motive for donating organs to families is the fear of suffering and death of loved ones and the prospect of financial gain (Cherry 2015, 5). I contend that as close relatives are connected, either by blood or marriage, they usually donate to save the life of a loved one, not to earn financial gain. But I partially agree with him that if we offer some gifts for receiving altruistic organs to our non-close relatives, such benefits may secure the lives of recipients and, equally, donors may feel happy to save a life. This monetary gift may prevent creating a regulated market for human organs or discourage the sale of organs in hidden markets. I also argue that close relatives should always be given primacy to donate organs to their relatives, as the current Act does. That is, close relatives should feel enthusiastically obliged more than other extended relatives. A revision to the existing law to provide monetary benefits to extended relatives is the justifiable alternative that may help increase organ supply for transplantation.

While the law makes organ selling (Section 9) and the purchase of organs (Section 10) illegal, the huge shortage of transplant organs may encourage patients, especially those who may not wish to obtain organs from their relatives, to buy organs from hidden markets. By providing economic benefits to public officials and local government representatives, a number of wealthy patients easily obtain false relative certificates and forge passports with unrelated donors (Moniruzzaman 2010, 169). Under such a backdrop, allowing financial incentives to extended relatives (e.g., uncles and aunts both from paternal and maternal sides and their offspring) to donate organs is just and realistic. If we come to terms with this reality, we ought to allow safeguards that will protect black market donors from exploitation. Until now, organ donation from relatives has relied on altruism and voluntarism but offering some benefits to a number of distant relatives for receiving organs is also realistic. In most cases, because such relatives do not share economic resources in the families, offering some benefits for altruistic donations may aid them to be protected after transplantation. Thus offering this gift to extended relatives will increase the supply of organs, reward donors’ altruism, and preserve ethical principles.

The law offers incentive priority to family members in receiving organs from brain-dead donors because the costs of ICU care and ventilator support of the brain-dead donor to preserve the organs for transplantations are to be incurred by the donor’s family. That is, the organs of brain-dead patients are generally kept alive through artificial ventilation in the ICU (Truog 2007). The benefit of giving priority to a family relative for receiving organs outweighs the alternative as the incentive of saving the life of a relative is more likely to initiate the practice of vital organ transplantations from brain-dead donors in Bangladesh. But who will bear the costs related to the evaluation of potential donor and organ suitability, ICU care, ventilator use, and traveling if the organs of a brain-dead patient are to be removed for the benefit of outsiders of the family? Ought families of brain-dead patients agree to organ removal from their relatives’ bodies for the benefit of others? While the Iranian government provides surgery fees and related costs associated with deceased donor organ transplants such as ICU care and ventilator support, there is no clause in the Bangladeshi law with regard to financial compensation for the families of brain-dead donors to mitigate the costs related to the evaluation of potential donor and organ suitability, ICU care, ventilator use, and traveling, and the bereaved family will likely not agree to allow their brain-dead relative to donate their organs to non-family members, due to fear of incurring these costs (Siraj 2021b). The Iranian government provides a fixed financial support for organ donation because it has the highest nominal GDP in the Middle East. Bangladesh’s economy is gradually growing, but it is still a lower-middle-income country. Investing as much as Iran does in healthcare is truly impossible for the Bangladesh government. What ethical measures do we then have for promoting brain-dead organ donation in Bangladesh? As international regulations are favorable with providing related costs for obtaining organs from deceased donors, recipients may incur the costs related to the evaluation of potential donor and organ suitability, ICU care, ventilator use, and traveling for successful brain-dead organ removal. These costs should be paid directly by recipients or their immediate family members to transplant hospitals where brain-dead patients are kept alive for organ removal and to travel agents who assist brain-dead donors and their families in getting from the hospital to their homes for burial. If recipients are unable to pay these costs, the government or charities may come forward to help vulnerable recipients. In addition to these incentives, the government may offer honorary rewards to the family of deceased donors, such as a “medal of honor,” as Qatar does, to encourage Bangladeshis to donate their organs after death.

Concluding Remark

Under existing legal frameworks, human organs are not a traded commodity having monetary value, but international regulations encourage societies to provide reasonable and related compensation for donors and their families for the act of altruistic donation. A fixed financial incentive to altruistic donors is a kind of monetary reward that recipients can offer donors for follow-up care, post-operative complications, and future wellbeing. The recipients should also deposit fees for transplant surgery, costs related to the evaluation of organ suitability, travel, and related expenses. As the proposed incentive is fixed and a reasonably limited amount of money where no bargaining between donors and recipients is involved, this may not lead to transplant commercialization or commodification. On the other hand, recipients who are outsiders of families of deceased donor organs may mitigate costs related to the evaluation of potential donor and organ suitability, ICU care, ventilator use, surgery fees, and travel. Along with these incentives, the government may offer honorary incentive measures to families of brain-dead donors, such as a “medal of honor” for their humanitarian act of donation, which may motivate others to donate organs after death. These incentive measures may promote organ donation for transplantation in Bangladesh. Otherwise, merely revising the law to extend donor lists for living cases and offering family members of deceased donors priority access to organs will not generate improved organ donation in the country. An establishment of charities or government funds for organ donation may also help pay poor organ recipients who are unable to pay these costs. The government of Bangladesh should revise the existing law to include a provision related to incentive measures and set a strict policy to properly regulate these measures as key stewardship that can ethically promote organ donation. The government must safeguard the interests and well-being of the public. Islamic law also encourages the governments of Muslim communities to strictly regulate and control these matters. The Final Resolution of the International Seminar on Organ Donation for Transplantation in Indonesia states that organ donation and transplantation is a social and community interest, and governments should guide these interests by establishing requirements that allow humans to use organs (both from living and deceased donors) in accordance with medical science and noble character (Atighetchi 2007). The Resolution emphasizes that the requirements must be accompanied by strict rules and severe penalties for lawbreakers.

Funding

This study was funded in part by the Hong Kong Government Postgraduate Studentship (UGC-allocated funds), HKSAR.

Declarations

Ethics Approval

As this study does not involve any research on human or animal subjects, no ethical approval was obtained.

Consent to Participate

Not applicable

Consent for Publication

Not applicable

Conflict of Interest

The author declares no competing interests.