The Canadian Society of Transplantation tells on its website a story that is a mirror image of what is happening all over the world. More than two times as many Canadians are on waiting lists for transplant organs than there are suitable donor organs. Reportedly about 200 Canadians died last year while waiting for suitable organs. Most people on the waiting list are desperate for transplant kidneys. South of our border about 80,000 Americans are on waiting lists for kidney transplants. The current situation is not only unacceptable because people die preventable deaths when they could be looking forward to a productive and happy life, it is also immensely wasteful as kidney dialysis is a hugely expensive undertaking. How can we close the gap between the number of patients in need of transplant organs and the availability of suitable organs?
A number of different policies aimed at increasing the number of transplant organs in an ethical manner have been discussed and implemented in various countries around the world. I am personally in favor of an idea currently debated in PEI. The proposal is on the table that we should switch from an opt-in to an opt-out system of consent. The idea here is that for everyone who does not expressly refuse to donate their organs after their demise the reasonable assumption is made that they would be happy to see their organs utilized to preserve a fellow-Canadian’s life. However, some don’t like this proposition. As far as they are concerned, this is not just a question of solidarity but one of ownership. After all, nobody is entitled to take my car after my demise either, just because I have forgotten to stipulate that it should go to my loved-ones.
Here is where an alternative idea comes into play: perhaps we should consider incentivizing potential sources of transplant organs, ie people like you and me. I am focusing here primarily on living donor kidneys. We have reasonably persuasive data today suggesting that it is perfectly safe for most healthy people to donate kidneys. As the autonomous owners of our bodies we are entitled to make decisions with regard to how we wish to use our bodies. There are lots of things we are morally and legally entitled to do with our bodies, including engaging in risky activities like playing rugby, scuba diving in shark infested waters and many others. Strangely, when it comes to the use of our bodies for medical research or transplantation purposes, the response we get frequently from religious leaders, medical ethicists and others is that we should contribute from the goodness of our hearts, rather than from a less altruistic motive. Any sensible medical system would focus here on outcomes instead, namely a maximization of the number of available suitable transplant organs, rather then a second-guessing of vendors’ motives. Given that we already accept altruistically motivated living donor kidney donations, it does not strike me as particularly plausible that people should continue to lose their precious lives because of an unreasonable societal squeamishness when it comes to paying people for their spare kidneys for transplantation purposes.
It is important to recognize that our current system is not working in many ways. Precious lives are unnecessarily lost year after year. Desperate patients travel overseas and obtain kidneys frequently under questionable circumstances, often exploiting vulnerable impoverished people in developing countries. The list goes on. Suffice it to say: leaving things as they are is not a cost neutral choice!
Let’s try it
What I am proposing is to run a pilot program aimed at investigating whether strictly government regulated incentives for living donor transplant kidneys would result in additional available transplant organs with a resultant decrease or elimination of the current waiting lists. The objective of this pilot program would be two-fold: 1) develop a system that would create successful incentives for organ vendors to offer their spare kidneys while at the same time 2) ensure that sufficient safeguards are put in place to guarantee that whatever incentives are offered do not generate additional harms. Benjamin Hippen, a US based transplant specialist sums up what features a government regulated market for transplant organs should have: It prioritizes the safety of both vendors and recipients; it must be transparent with regard to risks to vendors and recipients; it must safeguard institutional integrity regarding guidelines for cooperating with kidney vendors, and last but not least it must operate under a robust legal framework.