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For love, not money: kidney exchange encourages social contract

Many readers will have seen advertisements encouraging people to talk to their loved ones about organ donation. This is part of the government’s latest set of initiatives to increase Australia’s organ…

How do we encourage more Australians to become live kidney donors? CarbonNYC

Many readers will have seen advertisements encouraging people to talk to their loved ones about organ donation. This is part of the government’s latest set of initiatives to increase Australia’s organ donation rate, but it fails in one important respect.

The government’s plan is to optimise the system for procuring organs from deceased individuals and its reform package is the best way to get more organs such as hearts and lungs, which cannot be procured from live donors. But for kidneys, an organ in critically short supply and available from live donors, the package is going to fall well short of what’s required.

Australia, unlike Spain and other countries with high rates deceased organ donation, has relatively few people dying while connected to a respirator. And only individuals who die in this manner are suitable for organ donation because organs tend to expire from lack of oxygen long before they can be transplanted.

Typically, only individuals who suffer death by cerebral trauma, such as car accident victims, end up (brain) dead on a respirator. Such deaths account for less than 1% of hospital deaths in Australia.

What this effectively means is that we could get the whole country to sign up as organ donors and it would have little-to-no effect on donation rates, because it wouldn’t affect how many people die in hospital on a respirator.

For love or money?

So why did the government go ahead with advertisements about talking to your loved ones about organ donation despite its obvious inadequacy?

Policy in this area remains hopelessly mired in the gift of life doctrine, which holds that donating an organ should be uncompromised by incentives. Note, for instance, the Australian and New Zealand Intensive Care Society (ANZICS) guidelines on organ donation – that state organ and tissue donation is “an unconditional, altruistic, non commercial act”.

The doctrine claims that having individuals receive life-saving organs from anonymous individuals reaffirms the social contract — the notion that we look out for each other because we are all part of the same society and so we care about each other.

In contrast, commercial systems encourage people to donate only when it’s in their interest. In such systems, the primary motivation for saving a life is selfishness – and this leads to social atomisation.

Advocates of commercial approaches to kidney acquisition generally acknowledge that this is all well and good, but that any positive gains derived from social solidarity are offset by the suffering of individuals on dialysis. They want to see a system that gets more transplantable kidneys.

The debate between the commercial and gift of life camps is currently at an impasse in Australia. Until there’s a major breakthrough, any policy proposals must secure more kidneys while maintaining social solidarity.

Bartering and the social contract

One option to break the impasse is kidney exchange: say you have kidney failure and I offer to donate you one, but our tissue or blood type are mismatched. Both our details are placed on a database, which matches us to other people who may be in a similar situation.

My kidney is found to be compatible with another recipient and their donor is compatible with yours. A swap ensues in which both people in need of a kidney receive one. A sufficiently large database ensures the possibility of five-way swaps, which maximises efficient distribution.

Kidney exchange means that all kidneys are good, including old donors for young recipients and other similarly compromised cases. It allows recipients to tap into extended social networks, such as sports clubs, workplaces and unions, to try and find someone willing to donate, and then be matched with the most suitable donor.

The involvement of broad social networks and directed donation facilitates altruism and builds community solidarity on a micro level, satisfying the gift of life principle. The unpaid live donor system is optimised, and a great deal of publicity pertaining to the kidney shortage is achieved on an intimate level, rather than through impersonal national advertising campaigns.

In places where it has been implemented, kidney exchange has led to modest improvements in kidney supply. This includes Japan, where, due to a scandal at the time of the country’s first heart transplant (there were allegations that the donor was not quite dead), there’s strong opposition to both commercial and cadaveric procurement.

A similar system for blood procurement in the post-war years worked by requiring recipients of blood transfusions to pay back the blood, often in quantities they were unable to provide themselves (in the case of haemophiliacs, for instance). So people would activate their social networks to donate blood on their behalf, entrenching community bonds and publicising blood shortages.

It’s important to acknowledge the complexity of the kidney supply issue and not dismiss aspects of it as unethical or because it makes us squeamish. At a time when many people are experiencing very real suffering, we need to look for possible ways forward, and the introduction of a kidney exchange program seems a matter of routine prudence. It’s not a silver bullet but does produce increases so there’s no reason not to use it.