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Free funerals for organ donors: are donation incentives unethical?

The Nuffield Council on Bioethics in the United Kingdom has suggested a scheme to gauge support for the idea of government funding for funerals of people who donate their organs. The recommendation follows…

Families need to discuss organ donations so they don’t withdraw consent after death. Muffet/Flickr

The Nuffield Council on Bioethics in the United Kingdom has suggested a scheme to gauge support for the idea of government funding for funerals of people who donate their organs.

The recommendation follows an 18-month investigation into ways to increase the rate of organ donation in the UK, which is very similar to Australia’s.

There were 309 organ donors in Australia last year, leading to 931 transplants. Despite this, at any one time there are around 1700 people on waiting lists for organ transplantations.

Waiting times for transplants average between six months and four years, depending upon the organ required.

Australia’s national organ donation rate is 13.8 donors per million population (pmp). We don’t compare well with countries like Spain with its donation rate of 34.3, or France with 24.7 and Norway with 19.9 pmp.

Like Australia, the United Kingdom has a relatively low donation rate of around 14 pmp.

And like Australia, there’s a gap not only between the number of donors and potential recipients, but also between those who express general support for donation, and those who proceed to donate.

The main reason for this gap is because families of the deceased often don’t know the potential donor’s wishes, and therefore withhold consent.

Less commonly, families override known wishes, and in this case, clinicians don’t proceed in the face of family opposition.

It is these gaps that have prompted the Nuffield Council on Bioethics to advise the UK government to encourage donation by offering free funerals for organ donors.

Is it ethical?

Organ donation is based on the notion of the gift, which captures both the idea that organs should be freely given rather than taken, and that organs are “priceless” – not the kind of thing that should be bought and sold for money.

Altruism is the core ethical value underlying these ideas, a value that is cherished within the organ donation and wider community. So the challenge is to find ways of encouraging donation without starting on the slippery slope to a market in organs.

The Nuffield Council on Bioethics claims that offering a free funeral is a form of reward that encourages rather than undermines altruism.

Free funerals are not in themselves attractive enough to make a person donate when they would otherwise not.

It’s not an offer too good to refuse, and the benefit of the free funeral goes to the deceased person’s family rather than the donor herself.

We could say the donor is doubly altruistic – once in donating her organs, and again in saving her family the cost of a funeral.

Grey areas

Free funerals have been offered to those who donate their bodies to medical schools for many years.

This practice hasn’t undermined the view that altruism lies behind these donations: it’s hard to imagine that someone would donate their body for dissection just to get a free funeral.

In contrast, buying organs from living donors involves a sum of money that’s meant to induce the person to sell their organ.

These transactions raise serious questions about coercion and exploitation, especially when those selling organs are in very poor circumstances with few other options for earning money.

Talking helps

It is unclear whether offering free funerals will actually increase donation rates. Despite the rhetoric of the gift, many people do like to be recognised for generous acts, and free funerals may be the kind of recognition that is valued by potential donors.

But if it’s true that the offer is not enough to change a person’s mind about donation, then the government may incur the extra costs of funerals without gaining any extra donors.

The Nuffield Bioethics Council notes that we need a trial to find out what the effects of the offer of free funerals would be.

In the meantime, the suggestion has prompted media discussion about organ donation, and this is a good thing.

Fewer than one in five Australians have had a memorable discussion about organ donation with their families.

If talk of free funerals encourages more discussion, then perhaps some of the current 42% of families who refuse consent for organ donation will reach a different decision.

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16 Comments sorted by

  1. Mark Fabian

    Editor, ANU

    This was an interesting article. I am concerned though about a statement in the body of the text which is misleading:
    "The main reason for this gap is because families of the deceased often don’t know the potential donor’s wishes, and therefore withhold consent."
    This is not correct. The main reason why we lag behind Spain and others is because we simply don't have as large a number of suitable donors, at least in terms of kidneys. In almost all cases, only individuals who die while on a respirator…

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  2. Jason Yip

    logged in via Twitter

    Wouldn't it be simpler, more effective, and cheaper to simply switch to an opt-out scheme?

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  3. Robert Wiblin

    logged in via Twitter

    It blows my mind that people are paid to sit around wringing their hands saying things like:

    "These transactions raise serious questions about coercion and exploitation, especially when those selling organs are in very poor circumstances with few other options for earning money."

    Why is this of particular concern? Poor people might do all kinds of things for money - for example work. We don't ban the sale of labour because some people might be coerced to do it or exploited. At most we put a minimum…

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  4. Robert Wiblin

    logged in via Twitter

    There are two key reasons people are freaked out by organ sales. One is our intrinsic disgust reaction to pulling apart the body, tied to one of the key moral senses, purity (read more: http://faculty.virginia.edu/haidtlab/mft/index.php). This evolved sense probably existed to encourage good hygiene but it is no guide to morality or legislation. Finding homosexuality disgusting is no reason to ban consenting adults from engaging in it. So too for organ sales. We know how to sterilise things now…

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  5. Colin MacGillivray

    Architect, retired, Sarawak

    "...42% of families who refuse consent for organ donation despite the dead person’s wishes ....."
    That is the key of course.
    The family should have no right to reverse a dead person's wishes. Perhaps the social network Facebook should have a place for individuals to state that they wanted their organs donated and they could refresh this wish every month so there would be no argument.
    The hospital could check the Facebook page for the dead person and show it to the family and proceed with harvesting.
    Problem solved I think.

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    1. Robert Wiblin

      logged in via Twitter

      In reply to Colin MacGillivray

      Good idea Colin. It is astonishing that the law permits families to steal body parts from the dead against their clearly stated wishes. It's like we just allowed them to override the person's will because they didn't like with it. Total disgrace. If they want to change the person's decision they should do so while they are alive.

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  6. Colin MacGillivray

    Architect, retired, Sarawak

    Just put this on my Facebook notes. Any doctors out there who could comment on the wording?
    My organs to be donated after my death
    By Colin MacGillivray · 2 seconds ago
    When I die I want my organs to be harvested to help other people. If I die in a place where the advice of relatives is required please ensure that the first sentence is acted on.

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  7. Mark Fabian

    Editor, ANU

    I think there are two additional reasons why there is opposition to organ sales.
    1) Surgeons are uneasy about the practice because of the impact it might have on medical integrity. While I accept that this is a little weak given the increasing commercialisation of medical practice, it does still seem a legitmate concern.
    2) Commercialising organ donation sends a message that citizens will only assist each other if it is in their interests; specifically, their financial interest. It is socially atomising…

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    1. Robert Wiblin

      logged in via Twitter

      In reply to Mark Fabian

      Thanks for this. (1) I don't understand at all. They will perform more operations, save more lives, and someone else who provides a costly input to the operation will be compensated for their trouble. Those who don't want to do it won't have to. No threat to integrity. (2) Forcing us to do it out of goodwill and seeing that we are selfish enough to let people die is what sends the message that citizens will only assist each other if it is in their interest. That is just the reality. In any case…

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    2. Jason Yip

      logged in via Twitter

      In reply to Robert Wiblin

      My main problem with this is that is unnecessarily complicated, controversial, and lacking evidence that it works when we have opt-out schemes which is what the higher organ donation countries actually do.

      I don't see any particular benefit to experiment with alternative schemes unless as behavioural economics research.

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    3. Robert Wiblin

      logged in via Twitter

      In reply to Jason Yip

      Yeah opt-out is the easier solution, especially politically, and it would probably get us enough organs. But I want to challenge the nonsense arguments against organ sales (and commerce in general) that get peddled by bioethicists because otherwise they just gain general acceptance.

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  8. Mark Fabian

    Editor, ANU

    The evidence on opt-out is a little inconclusive. Some countries have experienced big jumps following the introduction of the legislation. In Belgium, organ procurement rose by 183% following its introduction. And an economic study of 22 countries over a ten-year period found that countries with opt-out performed 25-30% better on average than those that didn't (A. Abadie & S. Gay: “The Impact of Presumed Consent Legislation on Cadaveric Organ Donation – a cross country study” in Journal of Health…

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    1. Robert Wiblin

      logged in via Twitter

      In reply to Mark Fabian

      Interesting international experience Mark.

      Personally I have been reading on this for years and am yet to find a single coherent argument against sensibly regulated kidney sales. Certainly none strong enough to warrant letting hundreds of innocent people die each year due to the ban.

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    2. Mark Fabian

      Editor, ANU

      In reply to Robert Wiblin

      I would tend to agree with regards to a domestic market in Kidneys in Australia. As for an international market, I find the work of Zharghooshi fairly compelling in arguing against such a thing.
      J. Zharghooshi, “Iranian Kidney Donors: Motivations and Relations with Recipients” pg. 389 in The Journal of Urology, vol. 165, Feb. 2001, pp. 386-392
      He isn't as explicit as he could be, but his work shows pretty clearly that there seem to be a great many cases of uninformed consent, coercion by family members and desperate circumstances involved in Iranian kidney vending. This issues would likely be compounded by an open market.

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    3. Robert Wiblin

      logged in via Twitter

      In reply to Mark Fabian

      "uninformed consent, coercion by family members"

      Could presumably be resolved by regulation.

      "desperate circumstances"

      Were they made worse off by selling their kidney though or was their circumstance just bad to start with?

      Also, was the suffering of the donors greater than the benefit to the recipients do you think?

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    4. Robert Wiblin

      logged in via Twitter

      In reply to Mark Fabian

      I vaguely recall that there was a special stigma associated with donation in Iran and that contributed to their misery.

      What I would most want to know if why they sold their kidneys if they were going to be worse off.

      Perhaps they were just the first through the gate and just made a mistake. If future sellers can learn from their experience a ban is not necessary. The price would go up to compensate people for the greater hardship we now realise they experience.

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