Debate on Financial Incentives Is Off the Mark of National and International Realities

Abstract

All along the way of the debate on financial incentives, it has been evident that there is much to agree: Rejection of human and organ trafficking and tourism as detailed in the Istanbul Declaration; The need to remove obstacles to live organ donation; Reimbursement of expenses to avoid potential or real financial loss for the live organ donor; Objecting to inclusion of living kidney donation as a preexisting condition when donors seek health and life insurance; and Providing care for the live donor in the event of complications surrounding the donation event. Those objectives have not been accomplished in the United States or internationally and could be the basis of consensus to make change. Drs. Hippen and Matas (1) have submitted a reply to the recent letter that addressed realities in the United States. They proposed yet again trials of financial incentives, suggesting the development of “study groups that would devise a menu of incentives, each with limited fungibility, from which potential donors could choose. ” This time they also respond with a defense of the Iranian system. Of course, the detail and extent of “limited fungibility” remains to be determined, lingering as a major pitfall for many. Perhaps, however, such “study groups” would do well to visit those locations that would be impacted by such US trials, such as the Philippines, Pakistan, Egypt and China, and the location that Hippen and Matas reference to support such trials—Iran. In our visit to Iran, only months ago, we found patients awaiting kidney transplantation on dialysis. What is unknown in Iran, is the extent of end-stage renal disease throughout the country. We await the presentation of credible and current data from Iran. Drs. Hippen and Matas should be seeking those data as well, rather than relying on an outdated report (2). Contrary to their opinion shaped, it seems, by such selected literature reports, we found in our visit to Iran “that underground organ brokering and Internet solicitation are generally recognized as problems in Iran.” Iran started down this road years ago with well-intentioned individuals such as Drs. Hippen and Matas leading the way; and now—what was predictable then in Iran, and has thus been tested already for the United States and internationally—is the reality today in Iran. Drs. Hippen and Matas suggest that there are many more patients who are not on the waiting lists in the United States, and so even if 35% of the wait list are inactive and not eligible for kidneys derived, for example from their proposed plan—they suggest that we recognize that there are plenty more patients out there in the United States for transplantation. They seem, however, to overlook that the major premise for their contention to buy organs is undermined by the fact that ½ of those removed from the kidney wait list because of death, die inactive on the list. As to the remainder that die active, why were nearly 900 standard criteria (medically eligible) deceased donor kidneys discarded last year in the United States? Death on the list categorized as inactive is not solved by a study group of financial incentives but could be solved by available kidneys discarded. If there are so many patients ready to undergo transplants who have not been placed to the waiting list, why is the number of live kidney donors falling in the United States? If it is because of obstacles to live donation, surely US transplant physicians must work on that problem nationally as noted earlier. Has the United States reached limitation on transplantation through inadequate human and other insufficient resources for centers to do more kidney transplants? Here lie two issues (reduced number of live donors and discarded deceased donor kidneys) that cry out for action immediately regarding existing resources and irrespective of market proposals. Drs. Hippen and Matas acknowledge that they do not have a priority concern for the list of patients awaiting hearts, livers, and lungs, so they overlook the predictable consequences of a kidney market focus. In those places that have had such a restricted view, including the reality in Iran, the patients awaiting deceased donor organs suffer when there is the expectation that one can readily buy a kidney in the market place. There is indeed more to combating organ trafficking than a Declaration, but the way organ trafficking can continue is by a naïve defense of the Iranian system and by the unrealistic suggestion to the international community that the United States should follow suit instead of dealing with its readily apparent resource limitations to the practice of kidney transplantation. Nicholas L. Tilney1 Jeremy R. Chapman2 Francis L. Delmonico3 1 Department of Surgery Brigham and Women's Hospital Boston, MA 2 Centre for Transplant and Renal Research University of Sydney Westmead Hospital Westmead, Australia 3 Massachusetts General Hospital Boston, MA