Organs for sale? The ethics of paying living kidney donors

Reimbursing for costs is standard in research but large payments present problems. Flickr/PACOM

The Commonwealth Government is considering a proposal from Kidney Health Australia to reimburse living kidney donors for reasonable expenses incurred during the donation process, such as loss of income or travel expenses.

Meanwhile, senior research fellow at the University of Dundee in the United Kingdom, Sue Rabbitt Roff, has argued in the British Medical Journal that in order to raise live organ donation rates, donors should receive an average annual income.

So what are the ethical implications of paying for organs? Associate Professor Malcolm Parker, University of Queensland’s head of Medical Ethics, Law and Professional Practice explains:

Reimbursing living kidney donors for lost income is a reasonable proposal. Clearly, it’s directed towards increasing the organ donation rate to make it somewhat more attractive for living donors to at least consider this route.

The question that arises is whether payment could be construed as a coercive incentive. But if there’s a limit on the payment and it’s restricted to lost income and other associated costs, that argument becomes weak.

Payments are not unheard of in medical, psychological and pharmaceutical research trials – the reimbursements are designed to cover expenses that the participant has incurred in the process of getting to and participating in the trial.

Clearly, there’s more involved in becoming a live organ donor but similarly, I think many people support the idea of reimbursements for costs incurred, up to a limit.

Such a scheme could increase the rate of live organ donors to some extent but given the invasiveness of the procedure and the lifelong implications, I expect any increase would be modest.

What do you make of Sue Rabbit Roff’s argument that live donors should be paid the equivalent of an annual income for donated kidneys?

This payment would obviously be a lot higher than just reimbursing for costs incurred and time off work so it may well prove to be a greater incentive.

In this scenario, the question of coercion comes more into view and you have to ask whether this will persuade certain people, particularly people with low income, to consider donating their kidney when otherwise they wouldn’t.

And does that amount of money, or that degree of compensation, render their decision somehow coercive or involuntary?

There’s no in-principle answer to that – coercion won’t necessarily occur. But in certain cases you might find that someone who is desperate for money will become involved, when otherwise they wouldn’t have.

This is certainly not the first time that payment for organs has been proposed.

The prevailing view is that we shouldn’t have an organ market because it should be an altruistic arrangement. But there has certainly been pressure mounting over the years to find ways to increase the number of organ donors.

How is the cash for organ idea playing out internationally?

There’s a market for organs – it’s perfectly clear that’s happening. It’s also clear that there are vulnerable groups who are more subtly coerced or blatantly exploited.

The far extreme of that is criminal activity where people are abducted and have their organs removed. That’s not a common occurrence though we know it does happen.

We’re aware of the Chinese situation – where executed prisoner’s organs are used – and this probably occurs in other countries as well.

We hear that the Chinese are attempting to regulate this practise more strongly but it’s difficult to know exactly where they’re at.

So there are markets and activities occurring around the world which are different from the standard altruistic practise of organ donation.

These underground activities are different from the proposed compensation of wages lost or even an annual income – they’re somewhere along that continuum but not quite at that far down the end.

More broadly, how can we increase rates of organ donation in Australia – is an opt-out policy, where consent is assumed, the answer?

No. Where the organ donation rates are significantly higher than Australia’s, it’s more a result of the quality of the processes that have been instituted in hospitals and other healthcare institutions, such as the introduction of transplant coordinators, financial supports, and so on, rather than the adoption of an opt-out system.

Spain, for example, has the highest rate of organ donation in the western world and this likely comes down to the processes in place rather than whether they’ve got an opt out system.

I wouldn’t predict an opt-out organ donation system would have a huge impact in Australia.