Perspectives of Transplant Physicians and Surgeons on Reimbursement, Compensation, and Incentives for Living Kidney Donors

doi:10.1053/j.ajkd.2014.02.019

American Journal of Kidney Diseases

Volume 64, Issue 4, October 2014, Pages 622-632

https://doi.org/10.1053/j.ajkd.2014.02.019 Get rights and content

Background

The shortage of donors for organ transplantation has stimulated debate on financial incentives for living kidney donors. This study aims to describe the range of attitudes and opinions of transplant physicians on financial reimbursement, compensation, and incentives in living kidney donation.

Study Design

Qualitative study.

Setting & Participants

110 transplant nephrologists and surgeons from 12 countries across 43 transplantation units in Europe, Australasia, and North America.

Methodology

Face-to-face semistructured interviews were conducted.

Analytical Approach

Transcripts were thematically analyzed.

Results

We identified 7 major themes. Prioritizing the removal of disincentives for living kidney donors was largely deemed acceptable. By contrast, provision of financial incentives raised concerns about undermining benevolence, compromising human dignity and value, and traversing market forces. Some contended that financial incentives potentially were legitimate if regulated, arguing that this would maximize utility in transplantation, but most also acknowledged the difficulty and that operational feasibility of a regulated system of financial incentivization may be limited.

Limitations

Participants were English speaking and from Western high-income countries; therefore, the transferability of our findings may be limited.

Conclusions

Transplantation specialists believed that minimizing disincentives would support equity and justice in living kidney donation. Direct financial incentivization for living kidney donors, even in the context of a regulated market, was regarded by most as unjustified because of the potential moral consequences and uncertain feasibility. Removing financial disincentives and safeguarding the intrinsic volunteerism, value, and meaning of donation were viewed to uphold integrity in living kidney donation.

Section snippets

Study Overview

This multinational study was undertaken to elicit the perspectives of transplant nephrologists and surgeons on the uncertainties, challenges, and controversies in living kidney donation.²² This article focuses on the attitudes and opinions of clinicians on financial reimbursement, compensation, and incentivization in the context of a regulated system. The working definitions are provided in Box 1.

Participant Selection and Practice Setting

Transplant nephrologists or surgeons involved in living kidney donor transplantation in the United

Study Participants

In total, 64 transplant nephrologists and 46 surgeons participated (response rate, 89%). Travel and clinical commitments were reasons for nonparticipation. On average, interviews were 45 minutes in duration. Participant characteristics are provided in Table 1.

Themes

We identified 7 major themes: undermining benevolence, potential legitimacy, compromising human dignity or value, prioritizing removal of disincentives, limited operational feasibility, traversing market forces, and maximizing utility. For

Discussion

The World Health Organization, the Declaration of Istanbul,¹² and the laws in most countries prohibit financial incentives for living organ donation. However, the unmet demand for kidney transplants has driven debate on financial support and incentives for living kidney donors. Removing financial disincentives for donors by providing reimbursement was largely deemed acceptable among transplant nephrologists and surgeons. Financial payment beyond reimbursement, even in the context of a regulated

Acknowledgements

We thank all participants for contributing their time in sharing their insightful and interesting perspectives. With permission, we acknowledge by name (by region and interview order): United States: Gabriel Danovitch, Anjay Rastogi, Naim Issa, Richard Spong, Ty Dunn, Hassan Ibrahim, Raja Kandaswamy, Arthur Matas, Tim Pruett, Bertram Kasiske, Ajay Israni, Arthur Ney, Mark Odland, Meena Sahadevan, Nabil Dagher, Karl Womer, Robert Montgomery, Bernd Schroppel, Barbara Murphy, Rajani Dinavahi,

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Cited by (24)

Community preferences for the allocation of scarce healthcare resources during the COVID-19 pandemic: a review of the literature
2022, Public Health
Citation Excerpt :
This process is not dissimilar to what has occurred in other fields where there are scarce health resources. Arguably the most prominent example is that of allocating donated organs, where previous work has synthesised the views of ethicists,3,12–14 clinicians15,16 and the public17–20 as to how this allocation process should take place. However, none of the current COVID-19 guidelines involved community consultation;21–27 therefore, it is unknown to what extent the current COVID-19 allocation policies align with community preferences and values.
The purpose of this thematic review is to examine the literature on the publics’ preferences of scarce medical resource allocation during COVID-19.
Literature review.
A review of Ovid MEDLINE, Embase, CINAHL and Scopus was performed between December 2019 and June 2022 for eligible articles.
Fifteen studies using three methodologies and spanning five continents were included. Five key themes were identified: (1) prioritise the youngest; (2) save the most lives; (3) egalitarian allocation approaches; (4) prioritise healthcare workers; and (5) bias against particular groups. The public gave high priority to allocation that saved the most lives, particularly to patients who are younger and healthcare workers. Themes present but not supported as broadly were giving priority to individuals with disabilities, high frailty or those with behaviours that may have contributed to their ill-health (e.g. smokers). Allocation involving egalitarian approaches received the least support among community members.
The general public prefer rationing scarce medical resources in the COVID-19 pandemic based on saving the most lives and giving priority to the youngest and frontline healthcare workers rather than giving preference to patients with disabilities, frailty or perceived behaviours that may have contributed to their own ill-health. There is also little public support for allocation based on egalitarian strategies.
Opinions of Health Care Personnel Regarding Disincentives and Incentives for Living Kidney Donation at a Single Center
2018, Transplantation Proceedings
Citation Excerpt :
We could not perform a statistical analysis of the invited comments given the variability of the responses. Our study found that the majority (> 85%) of respondents (both aged <25 and ≥25 years) supported removing financial disincentives for living kidney donation, a finding that is well supported in other studies [5,8,9]. Reimbursement of expenses is considered ethical and justifiable and is supported by the 2008 working group for the Declaration of Istanbul on Organ Trafficking and Transplant Tourism [10] and the American Medical Association's Council on Ethics and Judicial Affairs.
Transplant societies continue to actively concentrate on increasing rates of living kidney donation (LKD) to bridge the gap between individuals awaiting transplantation and the number of kidneys available. A widely discussed strategy to increase living donation rates is the provision of incentives and removal of disincentives. Though opinions of the public regarding this strategy have been studied, the opinions of health care providers, including younger professionals, are less clear. We studied the opinions of medical students and other health care providers on strategies to increase LKD to determine if opinions were different among those < 25 or ≥ 25 years of age.
A simple cross-sectional survey was conducted at an academic medical center. Participants included medical students and employees in Internal Medicine, General Surgery, and the Organ Transplantation Center. Pearson's χ² and Fisher's exact test were conducted on the responses regarding disincentives and incentives to determine whether opinions differed based on age.
Six hundred and twenty-four participants completed the survey. There was no statistical difference in opinions between groups on reimbursing transportation costs, loss of wages, or childcare costs, but those aged ≥ 25 were more agreeable with covering food/lodging costs compared to those < 25 (96.5% vs 90.7%, P = .009). Respondents < 25 years old were more willing to donate a kidney for a financial incentive (P = .0002) accepting a median amount of $25,000.
Health care personnel broadly support removing financial disincentives for living kidney donation, and those ≥ 25 were more in favor of covering food/lodging costs compared to those < 25. Those < 25 years old were more likely to accept financial incentives towards donating their kidney compared to those ≥ 25 years.
Paid Organ Donation: An Italian Perspective
2015, Transplantation Proceedings
Citation Excerpt :
In Poland, according to a written questionnaire proposed to high school and university students, “most young people are not willing to be paid donors, but they want to help disinterestedly” [19]. Similar results have obtained from research work that has been done in Germany [20] on students of medicine and economics, in Switzerland [21] in the Vaud French-speaking population (including physicians), and in other countries (from Asia, Australia, and Northern America) on the general public [22] or on physicians, particularly nephrologists [23], transplant physicians, and surgeons [24], or on both general public and transplant professionals [25,26]. In all of these studies the proposal of direct (cash money) financial incentives for donation has been accepted mainly by poor or indebted people, which suggests the potential risk of organ commercialism.
The only countries that have allowed financial incentives for organ donation are Iran since 1988, and later on, Singapore and Saudi Arabia. In Europe, and of course in Italy, financial incentives for donors are prohibited. The author has completed extensive research via the Internet (PubMed) of worldwide scientific literature on paid organ donation, also researching studies concerning public opinion on organ commercialism and “regulated markets”. Italian transplant laws also have been reported and analyzed.
Financial Incentives for Living Kidney Donors: Are They Necessary?
2015, American Journal of Kidney Diseases
Citation Excerpt :
Conversely, financial incentives represent material gains for donors, with a commercial value greater than actual costs incurred as a consequence of donation or donor evaluation. Despite international consensus regarding the ethical acceptability of removing financial disincentives to living donation,38 few countries provide comprehensive support to address disincentives. In the United States, a recent report from the National Living Donor Assistance Center (NLDAC) showed that living donors who qualified for support incurred average travel costs of $2,767, and that 39% identified lost wages of $2,784 on average.9
In the face of the perceived failure of altruistic organ donation programs to generate sufficient kidneys to meet demand, introducing financial incentives for living donors is sometimes argued as the only effective strategy by which lives currently lost while awaiting kidney transplantation might be saved. This argument from life-saving necessity is implicit in many incentive proposals, but rarely challenged by opponents. The core empirical claims on which it rests are thus rarely interrogated: that the gap between supply of and demand for donor kidneys is large and growing, the current system cannot meet demand, and financial incentives would increase the overall supply of kidneys and thus save lives. We consider these claims in the context of the United States. While we acknowledge the plausibility of claims that incentives, if sufficiently large, may successfully recruit greater numbers of living donors, we argue that strategies compatible with the existing altruistic system may also increase the supply of kidneys and save lives otherwise lost to kidney failure. We conclude that current appeals to the life-saving necessity argument have yet to establish sufficient grounds to justify trials of incentives.
Compensation and incentives for living organ donors: A double-edged sword that may resolve the current organ shortage crisis
2015, American Journal of Kidney Diseases
Incentivization of living donation: Is it time to cross the bridge?
2014, American Journal of Kidney Diseases

View all citing articles on Scopus

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Original InvestigationTransplantationPerspectives of Transplant Physicians and Surgeons on Reimbursement, Compensation, and Incentives for Living Kidney Donors

Background

Study Design

Setting & Participants

Methodology

Analytical Approach

Results

Limitations

Conclusions

Section snippets

Study Overview

Participant Selection and Practice Setting

Study Participants

Themes

Discussion

Acknowledgements

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Am J Transplant

Am J Transplant

Am J Transplant

Am J Transplant

Am J Transplant

Am J Transplant

Am J Transplant

Am J Transplant

Am J Transplant

Am J Transplant

Am J Transplant

Survival in recipients of marginal cadaveric donor kidneys compare with other recipients and wait-listed transplant candidates

J Am Soc Nephrol

Should we pay donors to increase the supply of organs for transplantation?

BMJ

Should we pay donors to increase the supply of organs for transplantation?

BMJ

Attitude toward strategies to increase organ donation: views of the general public and health professionals

Clin J Am Soc Nephrol

Regulated payments for living kidney donation: an empirical assessment of the ethical concerns

Ann Intern Med

The declaration of Istanbul on organ trafficking and transplant tourism

Clin J Am Soc Nephrol

Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul

Lancet

Payment for living organ donation should be legalised

BMJ

Original Investigation
Transplantation
Perspectives of Transplant Physicians and Surgeons on Reimbursement, Compensation, and Incentives for Living Kidney Donors