AMA to study financial incentives for organ donors

Calls for modification of current law

The American Medical Association in Chicago at its annual meeting in June adopted policy calling for the modification of current law to allow pilot studies on financial incentives for organ donation from people who have died.

While the AMA has supported financial incentives for about 15 years, the new policy calls for a change in the National Organ Transplantation Act of 1984, which prohibits financial incentives for organ donation, AMA board member Joseph Annis, MD, tells Medical Ethics Advisor.

The 1984 act forbids what is termed "valuable consideration" for organ donors.

"Basically, the general feeling was that we should appeal to altruism as the motivation for people and their families donating organs from the cadavers," Annis says. "And we're speaking of organ donation from people that have died — not from living donors. That's a whole different ethical issue."

Annis cites research that indicates the percentage of people who donate organs after death hovers between 35% and 50%. And those numbers remain steady despite efforts to increase the number of donors through advertising and public education about the importance of organ donation.

While the number of donors remains in the same range, "the number of people who need donated organs continues to rise," Annis says.

"That being the case, we're seeing about 6,000 people a year, roughly 16 a day, die who are waiting for transplants," Annis says. "So, we're looking at ways of increasing the number of donors, and doing it in an ethical fashion."

There have been debates on both sides of the financial incentives issue, with some suggesting that people with less money would be exploited in favor of people with more money if money was offered in return for organ donation, Annis says.

"It's an ambiguous area," he says. "It's an area that I think we'd like to study, because the only way you can really find out if something will work and what will work is to study it."

However, to take such a scientific approach ultimately to conduct pilot studies would require a change in the federal law.

Originally, the resolution that was set forth by the South Carolina delegation of the AMA for consideration was to call for legislation to change the law to allow financial incentives. After discussion by the AMA's House of Delegates, it was decided that they would call for a change in law to allow only for the issue to be studied.

Annis said any study of the issue without a change in the law to allow financial incentives would be "theoretical," and the AMA will likely reconsider the issue to call for a change in law in the future.

A variety of measures to compensate donors or their families could be considered, he says, such as a tax credit for the deceased's estate or money to go toward a funeral.

An ethicist's view of the proposal

Scott D. Halpern, MD, PhD, an ethicist at the University of Pennsylvania in Philadelphia, suggests that the AMA's proposal "is viewed by some as a lot less controversial than other proposals that have been highlighted by people in the community and by academics regarding incentives for people to donate one of their kidneys while they're alive.

Halpern, who is currently conducting research on financing incentives for living kidney donations, says is personal view is that paying a living person for a kidney donation might be not only "more beneficial from a social standpoint, but also less ethically concerning."

"The AMA policy refers to deceased organ donors. There are problems there. The first problem is: it would be wrong to think that there is a tremendous untapped supply of deceased donors that would reasonably be swayed by the offering of incentives," Halpern says.

Still, even if there is a "small minority" of people who would be encouraged to donate their organs if financial incentives were offered in return, then it would be worthwhile to study the issue.

Other strategies might offer even stronger incentive to increase the number of organ donors following death. He suggests a model in place in several European countries, which have policies that make everyone an organ donor at birth. If they choose not to be organ donors, they have to take action to opt-out of that status.

In the United States, the model is exactly the opposite, Halpern says, whereby people are required to "opt-in" to be organ donors.

"We know that organ donation rates in countries that have an opt-out policy are about twice as high as they are in countries that have an opt-in policy," Halpern says. "And you don't need to offer money to do that, you just need to change the default."

Offering money for organ donation, he says, "raises some concerns, justifiable or not, about the commodification of the body."

Some of those concerns are that any financial incentive would likely go to the deceased's family, as opposed to the donor, which he suggests could "impact either clinicians' judgment about pursuing organ donation or affect families' decisions about whether they allow the patient to become an organ donor."

"What we want to happen is that patients become organ donors because they have an interest in doing so," he says.

Finally, though, he says he doesn't oppose the AMA's call to study financial incentives for organ donors.

"What they're saying is we should explore the possibility, and we should do it in an evidence-based, research-oriented manner," he says. "That's very reasonable."

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Sources

  • Scott D. Halpern, MD, PhD, Division of Pulmonary and Critical Care Medicine, Center for Bioethics, University of Pennsylvania School of Medicine, Philadelphia. Phone: (215) 898-1462. E-mail: Scott.Halpern@uphs.upenn.edu.