Study: Payments would increase organ donation

Hey, buddy, can you spare a kidney?

What if you got $10,000 for your trouble? $100,000? Or more?

With 106,131 Americans now on waiting lists for an organ - 83,754 of them for kidneys - researchers at the University of Pennsylvania and the Philadelphia VA Medical Center sought to find out whether financial incentives would increase living organ donation.

Their findings - that payments would draw more participants without relying disproportionately on poor people - are highly controversial. Several ethicists yesterday criticized the study.

Still, the issue is of huge interest locally. The Philadelphia region has nine transplant centers, including seven for adults, and Pennsylvania ranks second nationally in the number of organs transplanted, behind California.

The idea of paying donors for organs has long been taboo because of concerns that it would unduly influence some people - particularly the poorest - to donate without fully appreciating the risks.

Scott Halpern, a Penn doctor and senior fellow at the school's Center for Bioethics, and colleagues surveyed 342 rail and trolley commuters in Philadelphia and its suburbs to see how money would change their willingness to donate.

"We were surprised to find that, contrary to what a lot of ethicists were concerned about, people were as able to discern risks in the face of a $100,000 payment as with no payment," Halpern said.

And he said that while payments increased the number of participants who said they would give a kidney to a stranger, those increases were similar for those with high and low incomes.

"Theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence," the Penn team concluded in the study that appears today in the Annals of Internal Medicine.

They reported that participants' willingness to give increased significantly as health risks to donors diminished, when payments rose, and if recipient and donor were related.

And they called for "a real-world test of regulated payments for kidney donation . . . to definitively show whether payment provides a viable and ethical method" to increase the supply of kidneys.

Last year, 6,453 people in the United States died waiting for an organ. Nearly 92 percent of them died waiting for organs that living donors could have supplied - 4,456 needed a new kidney and 1,452 a liver.

Still, several medical ethicists said they were concerned that the study didn't address the overarching question of whether it is ethical to pay for an irreplaceable body part.

Moreover, Lainie Ross of the University of Chicago's MacLean Center for Clinical Medical Ethics said, answers to a hypothetical survey about organ donation could not mimic the real world.

"The actual number of living donors who make nondirected donations to strangers is about 100 a year," she said.

So the fact that 30 percent of the participants in Halpern's study said they would donate suggested that they were just providing what they thought was the appropriate answer.

"We are seeing a lot of socially desirable answering," she said.

Another problem, Ross said, was that by asking a group of commuters - even a range of urban and suburban participants with high and low incomes - the study likely missed those most vulnerable to financial incentives, "the poorest of the poor, as we know from the data from" Iran, where payments are allowed.

Ultimately, Ross said, the Penn researchers didn't ask: "Is this the right thing to do?"

The answer is no, said George J. Annas, chairman of the department of health law, bioethics, and human rights at Boston University School of Public Health.

"I think it is out of bounds," Annas said. "We know we can live with the system we have now. We have no idea about what another system would do."

For example, would the payment system for living donors cause families of deceased donors to seek compensation? Would such a payment system reduce or eliminate the donations from people who now serve as living donors?

Both Annas and Ross said that before experimenting with a paid system, better treatment for chronic illnesses such as diabetes and high blood pressure that can cause kidneys and other organs to fail is needed.

"We have to concentrate not just on the supply side, but on the demand side, too," Annas said.

Last month in a commentary in the New York Times, Sander S. Florman of the Mount Sinai Medical Center wrote that the current transplant system is broken.

He said a thriving black market in human organs exists in the United States and across the globe. Moreover, he wrote, little is being done to enforce laws against selling organs.

Florman, director of the Mount Sinai transplant center, said that to save and improve many more lives, the supply of organs needs to be increased.

He suggests an opt-out system for deceased donation, where people are presumed to consent to organ donation at death unless they specifically decline to do so.

Currently, the United States has an opt-in system. People must indicate that they are willing to donate before they die, and their surviving family members are asked to make a final decision.