Saving lives is more important than abstract moral concerns: financial incentives should be used to increase organ donation.

Abstract

Ever since organ donation became clinically feasible, there have not been enough organs to go around. Figure 1 shows the rate of change from a base value in 1995 through 2008, of three variables: (1) the number of deceased donors, (2) the number of patients with end-stage organ failure who are waiting for an organ, and (3) the number of waiting list patients who either die before an organ becomes available (ie, death on the waiting list or after removal from the waiting list as “too sick to transplant”) [1]. The number of potential recipients on transplant waiting lists has more than doubled, and now stands at over 100,000, whereas the number of deceased donors has increased by only half. Meanwhile, the numbers of deaths related to the organ shortage, which is now greater than 9,000 a year, has grown in parallel with the waiting list. Thus, the gap between supply and demand has grown every year for the past 15 years. Fig 1 Relative change (from 1988 baseline data) in the number of patients on organ waiting lists, deaths on the waiting list, and number of donors each year, 1988–2008. Graph derived from Organ Procurement and Transplantation Network data [1]. Approximately two thirds of the waiting list patients suffer from end-stage renal disease. Because the kidney is a paired organ, living individuals can donate one kidney, and several thousand donate every year, mostly to relatives with whom they have an emotional bond. The problem underlying the organ gap is not a lack of medically suitable organs from patients dying from severe brain damage; if all such patients became donors, the waiting list would shrink rapidly, yet only half of potential deceased donors actually donate, and many potential living donors are medically unsuitable or are unwilling to donate, so not enough organs are donated to satisfy the need for them. How can we increase the number of donors? When a difficult or dangerous job has to be done, such as working on high-rise construction projects, we give workers an added incentive to take these jobs by offering them more benefits, such as salary supplements. Perhaps offering a financial incentive for organ donation would increase the number of willing donors. But if offering people financial incentives could increase the supply of organs, should we do it? Would it be morally appropriate? Kidneys are by far the most common transplants and can come from either a deceased donor (two kidneys) or from a living donor (one kidney). Making the case for providing financial incentives to living donors is much more difficult than for deceased donors, so if that case can be made, the arguments can cover virtually all donations, from both living and deceased donors. Although this is a cardiothoracic surgery journal, the current debate centers on living donors of kidneys. This is more appropriate than might be obvious at first, because the arguments for and against financial incentives for organ donation can be generalized easily to both living and deceased donors, and therefore these can apply to the therapies of most immediate concern to cardiothoracic surgeons (ie, heart and lung transplantations). The debate is rendered more concrete by focusing on the case of a United States senator who has a decision to make.