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Using Incentives to Increase Organ Donation,[object Object],Alex Tabarrok,[object Object],Department of Economics,[object Object],George Mason University,[object Object]
Incentives to-increase-kidney-donation
A World Shortage,[object Object],Millions of people suffer from kidney disease and the numbers are increasing rapidly but in 2007 there were just 64,606 kidney-transplant operations in the entire world.,[object Object],Due to the shortage many countries are now experimenting with innovative incentive systems designed to increase the supply of organs.,[object Object]
The Problem,[object Object],The National Organ Transplant Act (NOTA) of 1984 states:,[object Object],In other words, incentives for organ donors are illegal.  But incentives could increase the supply of organs and save lives.,[object Object],Let’s look at the problems and paradoxes of NOTA.,[object Object],“It shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation...”,[object Object]
Incentives and Paired Kidney Exchanges,[object Object],About one-third of potential living donors are incompatible with their intended recipient.,[object Object],Kidney exchanges (trade) make everyone better off.  ,[object Object],Kidney exchanges encourage donation with incentives: Donors give a kidney so that their loved one gets a kidney. ,[object Object],A kidney is clearly “valuable consideration” so kidney exchanges could be illegal under NOTA.  The Norwood Act (2007) amended NOTA so it would not apply to kidney exchanges.,[object Object],Kidney exchanges are important but  limited because barter is much harder than monetary exchange.,[object Object],Picture from UCLA Kidney Exchange.,[object Object],www.transplants.ucla.edu/KidneyExchange,[object Object]
Incentives and Whole Body Donation,[object Object],[object Object]
Absurd situation: Whole body donation for medical and scientific uses is often compensated—typically a free cremation.
As a result, there is a surplus of whole bodies used for scientific research and a shortage of organs needed to save lives.,[object Object]
Compensation for Cadaveric Donation in Israel,[object Object],In 2010 Israel legalized payments to donor families to "memorialize" the deceased. ,[object Object],Funds for memorials may be as high as 50,000 shekel, or $13,400.,[object Object],The money is paid by a nonprofit group and may be used in any way the families see fit to memorialize the deceased.,[object Object],In the ceremony to present the first check under this program the director of the charity making the memorial payment, said:,[object Object],"In this country we always talk about military heroism. ... [T]his is clearly a case of civilian heroism. [His organs] saved four lives. ... [T]he family should be blessed.“,[object Object],In 1994 the Pennsylvania legislature established a trust fund to reimburse donor families up to $3000 for funeral expenses but the plan was never implemented because of fear that it violated NOTA.,[object Object]
Incentives: No Give, No Take,[object Object],Organs today are treated like a commons – anyone can receive any organ whether or not they were willing to contribute to the commons, i.e. be an organ donor.,[object Object],Consider a no-give, no-take policy for organs.,[object Object],People who have signed their organ donor card are given priority if they should one day need an organ.  ,[object Object],Advantages of no-give, no take.,[object Object],Satisfies most people’s moral intuitions.,[object Object],Can be implemented easily be adding points to current system.  (Similarly to program already in place for live organ donors.),[object Object]
Reciprocity in Singapore, Israel and the United States,[object Object],[object Object]
In Israel in the case of kidneys two points on an 18 point scale are given if the candidate had three or more years previous to being listed signed their organ card. 
LifeSharers.org is an “organ club.”  Anyone can join.  Members agree that if their organs should become available they will go first to a fellow LifeSharers member.
Important.  No-give, no-take systems are widely seen as ethical but their primary virtue is to increase the incentive to donate!,[object Object]
Using Financial Compensation to Leverage Live Donation,[object Object],Kidney chains begin with a donor who does not receive a kidney (to a loved one) in return. If the original donor gives to someone who has a willing but incompatible live donor a chain can be created.,[object Object],Financial compensation could potentially be used to  begin many more kidney chains. 			        Picture from People Magazine, Nov. 30, 2009,[object Object]
Financial Compensation for Live Donation in Iran (and Singapore),[object Object],Iran is the only country in the world regularly paying compensation for live donors.,[object Object],In a new program, Singapore allows payments for lost income, medical costs and lifetime insurance coverage.  First payment was Nov. 2009.,[object Object],The Iranian system began in 1988 and eliminated the shortage of kidneys by 1999.  ,[object Object],Iran is the only country in the world without a shortage of kidneys.,[object Object],The Iranian system is managed by a nonprofit, volunteer-run patient association.,[object Object],Payments from government and charity are ~$3,500-$6,000.,[object Object]
Understanding Compensation,[object Object],[object Object]
We can compensate donors but continue to allocate organs according to the UNOS point system.
Compensation need not be upfront but could come in the form of an annuity, tuition voucher or contribution to a retirement plan.
In the latter case compensation should be a higher amount.
Compensation should also include a substantial non-monetary recognition for the gift of life.,[object Object]
Saving Money While Saving Lives,[object Object],At $10,000 per cadaveric donation the cost of financial compensation for 12,000 organs would be $120 million and savings would be $480 million.  ,[object Object],Net savings of $360 million per year.,[object Object],[object Object]
What would it take to increase cadaveric donation from 8000 to 12,000 a year? $2500, $5,000, $10,000? Assume, $10,000.

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Incentives to-increase-kidney-donation

  • 1.
  • 3.
  • 4.
  • 5.
  • 6.
  • 7. Absurd situation: Whole body donation for medical and scientific uses is often compensated—typically a free cremation.
  • 8.
  • 9.
  • 10.
  • 11.
  • 12. In Israel in the case of kidneys two points on an 18 point scale are given if the candidate had three or more years previous to being listed signed their organ card. 
  • 13. LifeSharers.org is an “organ club.” Anyone can join. Members agree that if their organs should become available they will go first to a fellow LifeSharers member.
  • 14.
  • 15.
  • 16.
  • 17.
  • 18. We can compensate donors but continue to allocate organs according to the UNOS point system.
  • 19. Compensation need not be upfront but could come in the form of an annuity, tuition voucher or contribution to a retirement plan.
  • 20. In the latter case compensation should be a higher amount.
  • 21.
  • 22.
  • 23. What would it take to increase cadaveric donation from 8000 to 12,000 a year? $2500, $5,000, $10,000? Assume, $10,000.
  • 24. What would it take to increase live donation from 6,000 per year to 12,000? Assume, $15,000.
  • 25.
  • 26.
  • 27. Compensation is widely accepted as a payment for risk.
  • 28. The annual fatality risk from being a commercial fisherman in Alaska is 4 to 5 times higher than the one-time risk of donating a kidney.
  • 29.
  • 30. Attitudes about what is repugnant change.
  • 31.
  • 32.
  • 35.

Editor's Notes

  1. China alone has 92 million people with diabetes.http://www.reuters.com/article/idUSTRE62N66220100324I will mention some of these innovative methods from other countries as we proceed.
  2. Need to find two couples who are in incompatible with each other but compatible with their opposite number. Double-coincidence of wants problem.
  3. On whole body donation and incentives seeHarrington and Sayre, 2006. Paying for bodies, but not for organs, Regulation29 (4) (2006), pp. 14–19.
  4. The Organ Donation Law, passed the Knesset in 2008.See Kidney MitzvahL Israel's remarkable new steps to solve its organ shortage.By Sally Satel, http://www.slate.com/id/2242791/Quote from Satel’s article.On PA see Howard, David H. 2007. Producing Organ Donors. Journal of Economic Perspectives 21 (3): 25-36.
  5. Signing an organ donor card under no-give, no-take becomes a type of insurance policy – people have an increased incentive to sign because this increases their chances of getting an organ should they one day need one.
  6. 10 kidney transplant chain, 20 people. Pay it forward model.http://www.paireddonation.org/files/peopleMagazine.pdf
  7. Increasing from 8,000 to 12,000 is high but probably doable. Estimates suggest the current recovery rate of donatable arguments is about 50-60%. See Becker and Elias for estimates that the maximum supply is ~ 15,500-24,000.Increasing live donation to 12,000 is clearly doable with the right price since millions would be eligible to donate. Becker and Elias estimate an increase of about 6000 (there increase of 44% includes live and cadaveric donation.)
  8. Note that Commercial fishing fatalities in Alaska (1991-1996) were 140 per 100,000 or 14 per 10,000 per year. The risk to a live donor of a kidney is primarily in the 90 days after the operation and is a one-time risk of approximately 3 per 10,000 (per operation). After the operation there appears to be no additional risk to a kidney donor (donors can live perfectly well with one kidney.) Seehttp://www.cdc.gov/niosh/fishfat.htmlhttp://www.scientificamerican.com/article.cfm?id=kidney-donor-mortality