Must All Living Donor Compensation Be Viewed as Valuable Consideration?

Our paper (1Gaston RS Danovitch GM Epstein RA Kahn JP Matas AJ Schnitzler MA. Limiting financial disincentives in live organ donation: A rational solution to the kidney shortage..Am J Transplant. 2006; 6: 2548-2555Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar) was put together by a group of six concerned individuals, with widely disparate views regarding the issue of financial incentives to stimulate donation. Some overtly favor a market-based approach to compensating live donors; others are completely opposed to introducing any financial component into the transaction (2Danovitch GM, Leichtman AB. Kidney vending: The “Trojan Horse” of organ transplantation. Clin J Am Soc Nephrol ePress doi: 10.2215/CJN.03030906, 4 October 2006.Google Scholar,3Matas AJ. The case for living kidney sales: Rationale, objections and concerns.see comment..Am J Transplant. 2004; 4: 2007-2017Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar). Our common task was to see how this group of physicians and academics might creatively address the issue of donor compensation. Although each of us would likely draft significantly different responses to Klarenbach (4Klarenbach S. Letter to the editor. Am J Transplant, (in press).Google Scholar) and Fox (5Fox MD. The price is wrong: The moral cost of living donor inducements..Am J Transplant. 2006; 6: 2529-2530Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar), this reply, though written by the first author (RSG), has been reviewed and agreed upon by all. Klarenbach’s letter and Fox’s editorial both reflect the complexity inherent in discussing this topic, from very different perspectives. Klarenbach acknowledges our basic premise: burdens assumed by living donors are greater than previously acknowledged, with significant physical and financial implications. Fox merely reiterates allegiance to altruism, minimizes risks associated with donation, and clings to preservation of the purity of motivation as the ultimate good. Klarenbach responds to the issue of donor risk with the sort of creativity we hoped to stimulate in formulating our proposal: what risks do donors assume and how can we offset the impact of those risks to encourage donation? While we applaud his recognition of donor sacrifice, we find his distinction between reimbursing costs and financial gain too restrictive. What is the true cost of losing a kidney? We concur with Klarenbach that providing financial gain to donors as incentive to stimulate donation is potentially problematic. Where we differ is on what counts as financial gain. It has now become generally accepted that reimbursement of out of pocket expenses (travel, lodging, lost wages, etc.) does not constitute ‘valuable consideration’. We were careful in our article to craft a proposed package of benefits that would only reimburse for the real costs of donation, but in no way should be construed as leaving a donor better off, financially or physically, than before donating. The Fox editorial, with its ‘The Price is Right’ analogy, embodies the impasse that has to date limited the ability of the transplant community to deal effectively with these issues. Our society, in multiple instances where compensation is granted, tacitly acknowledges that the consequences of physical loss might have significant repercussions down the road, even if they do not actually occur. Our current abject failure to offer any compensation for donor risk unfortunately leads us to characterize as gain even those reimbursements reasonably linked to actual sacrifice. We, the transplant community, must rethink our faulty logic in this regard. Finally, healthcare policy in the United States makes no provision for long-term donor coverage that is the de facto norm in Canada and Western Europe. Indeed, American participants in the oft-cited Amsterdam conference on care of the live kidney donor overcame compelling arguments of attendees from much of the rest of the world, such that a proposed mandate for all kidney donors to have lifetime access to appropriate follow up healthcare was not included in the final document (6Ethics Committee of the Transplantation Society. A report of the Amsterdam Forum on the Care of the Live Kidney Donor: Data and medical guidelines. Transplantation 2005; 79: S53–S66.Google Scholar). Is our proposal to provide health insurance an appropriate hedge against uncertain health risk, or financial gain for a donor? Although its associated cost dwarfs the direct reimbursement we propose to offset donor sacrifices, is it reasonable to argue the latter, but not the former, to represent financial gain? None of us would be so bold as to maintain we offer the ultimate answer for the vexing problems associated with donor risk and compensation. However, unlike Fox’s contention, this proposal is not a ‘smokescreen’ for markets. What is needed now is not hasty denunciation of intermediate proposals, but sincere effort to break the current logjam so that our patients are no longer penalized by this ongoing and pointless squabble.