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Free funerals for organ donors: are donation incentives unethical?

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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