PENNSYLVANIA – In the first empirical study of how Americans might make decisions if offered financial incentives for kidney donation while alive, Penn researchers found that the offer of payment did not cloud a person’s judgment of the risks associated with live kidney donation, motivate poorer persons to sell a kidney, or “crowd out” a person’s altruistic incentives to donate.
The Penn researchers suggest that the potential benefits of a regulated national market for kidneys, in which donors receive payment according to a fixed and transparent schedule, could increase the supply of transplantable kidneys and help reduce the roughly 7,000 deaths per year among patients waiting to receive a kidney transplant.
The study was conducted under the direction of Scott D. Halpern, MD, PhD, MBioethics, assistant professor of medicine and assistant professor of epidemiology at the University of Pennsylvania School of Medicine, and is published in the current issue of the Annals of Internal Medicine.
“Contrary to what many ethicists have worried about, money does not seem to blind people to risk,” said Halpern. “People seemed to weigh the possible risks of kidney donation just as clearly in the face of a $100,000 payment as they did without any offer of payment.”
Payment for live kidney donation also does not seem to influence the poor to agree to donate their organ in greater numbers than the wealthy, as many critics had been concerned might happen. “The influence that a $10,000 incentive had on people earning more than $100,000 a year was equal to the influence of the same $10,000 incentive on people earning less than $20,000 a year,” Halpern said.
The study also addressed the concern that offering payments to people to provide a living kidney for transplant would undermine altruistic donation, particularly that people who charitably donate a kidney each year would suddenly start demanding money. “Our study suggests that one’s willingness to donate an organ for free is not affected by learning that payment for kidneys could be an option,” said Halpern. Currently, approximately 6,000 Americans charitably donate a kidney each year.
The Penn study comes amid a significant shortage of kidneys available for donation as well as increasing information regarding the safety of donating a kidney while alive. The inadequate supply of transplantable kidneys has led to substantial increases in the time patients must wait to receive a kidney transplant, the numbers of patients waiting, and the numbers of patients who die while waiting. In response, the transplant community has permitted the use of kidneys from donors with risk factors for harboring transmittable infections as well as from donors with other risk factors, such as older age or hypertension.
One consequence of the kidney shortage is that international black markets in the organs have surfaced, most of which lack safeguards to protect donors, are operated by organ brokers who commandeer the bulk of the payments, and feature wealthy foreigners purchasing organs from poor natives. As a result, much recent debate in both the lay and medical presses has focused on the alternative of a payment system for living kidney donation that would be tightly regulated and monitored by the United States government or its designee.
Within this context, Halpern and his colleagues decided to empirically examine many of the widespread assumptions of what has until now been almost exclusively a theoretical debate. “The results both corroborate predictions that payments cold effectively increase the supply of transplantable kidneys and cast doubt on the intuitions that payments would be undue, unjust, or undermining of a person’s otherwise altruistic behaviors,” the report concluded.
While the study found that lower-income people were more likely to donate kidneys whether or not they would be paid, it also found that people with lower incomes were generally more willing to donate a kidney than those with higher incomes. Halpern said that the reasons for lower-income persons’ greater willingness to donate kidneys might be explained “because kidney donation involves a commitment of time away from otherwise profitable employment for wealthier people, or perhaps because less-wealthy people have more friends or family members with kidney disease and thus are more willing to help such people.” But Halpern noted that these were speculations, saying “further research is needed to better understand this unexpected finding.”
Halpern was assisted in this research by Penn faculty members Peter Reese, MD, MSCE and David Asch, MD, MBA as well as what Halpern described as “three incredibly talented students,” including Penn medical students Rachel Kohn and Michael Rey and Bryn Mawr College undergraduate student Amelie Raz.