A Cost-Benefit Analysis of Government Compensation of Kidney Donors

Kidney-DiseaseThe latest issue of the American Journal of Transplantation has an excellent and comprehensive cost-benefit analysis of paying kidney donors by Held, McCormick, Ojo, and Roberts. Earlier, Becker and Elias estimated that a payment of $15,000 per living donor would be sufficient to eliminate the US waiting list. The authors adopt a larger figure of $45,000 for living donors and $10,000 for deceased donors and find that even at these rates paying donors generates benefits far in excess of costs.

In particular, a program of government compensation of kidney donors would provide the following benefits (quoting from the article):

  • Transplant kidneys would be readily available to all patients who had a medical need for them, which would prevent 5000 to 10 000 premature deaths each year and significantly reduce the suffering of 100 000 more receiving dialysis.
  • This would be particularly beneficial to patients who are poor and African American because they are considerably overrepresented on the transplant waiting list. Indeed, it would be a boon to poor kidney recipients because it would enable them to reap the great benefits of transplantation at very little expense to themselves.
  • Because transplant candidates would no longer have to spend almost 5 years receiving dialysis while waiting for a transplant kidney, they would be younger and healthier when they receive their transplant, increasing the chances of a successful transplantation.
  • With a large number of transplant kidneys available, it would be much easier to ensure the medical compatibility of donors and recipients, which would increase the success rate of transplantation.
  • Taxpayers would save about $12 billion each year. Dialysis is not only an inferior therapy for end-stage renadisease (ESRD), it is also almost 4 times as expensive pequality-adjusted life-year (QALY) gained as a transplant.

Comments

As someone who may need a transplant at some point, I have a vested interest in seeing this become policy.

But if it remains illegal, I'll argue that kidneys should be taken by force from healthy people, at random, for little or no compensation. I see a difference in degree, but not in kind, between mandatory kidney donation and, say, mandatory vaccination.

Well, there are quite a few differences:

A) Donating a kidney doesn't make you more healthy, whereas vaccination does;
B) Vaccination doesn't take anything from you, it adds something to you (immunity)
C) Vaccination isn't mandatory. You can choose not to vaccinate your children, you just lose the ability to put them into a public school.

Good points! But consider: (A) the *policy* might make you more healthy if you end up needing a kidney someday [you never know]; (B) like donating a kidney, getting vaccinated carries (small) risks; (C) plenty of people would advocate making vaccinations mandatory.

Donating a kidney does not carry small risks. It is a major surgery, and surgery always carries significant risks. Also there could be long term consequences stemming from both the surgery and the loss of one kidney. I think you must be joking about randomly seizing a kidney by force from an innocent person.

The risk of donation is about the same as childbirth.

up to you whether you consider that "significant"

The risk of childbirth would be a lot lower if we weren't doing 1/3 of them by C-section.

And there is a significant public good aspect to vaccination.

As there is with mandatory kidney donation. Kidney disease can strike any member of the public, and the ratio of good kidneys to bad kidneys is large, so mandatory kidney donation is essentially nonexclusive and nonrivalrous.

I don't think buying and selling kidneys is ideal, but it clearly beats a kidney draft I think (just like voluntary military service is less cruel than conscription). When you think of what a kidney draft would look like (handcuffing people to the hospital bed? Imprisoning people who refuse to "donate"?), it all looks pretty inhumane. Also, most people can't donate, so what happens to them?

Better I think to give donors lifetime health insurance and a yearly stipend tied to their participating in follow-up care and study.

Agreed on all points. The market solution is best. But if it isn't politically feasible, kidney draft is the next best solution.

It's good that you disclosed your vested interest up front.

Lifetime health insurance? So now we're boosting the cost to maybe $200000? Still cost effective?

I will not catch kidney disease from you.

Mandatory and uncompensated kidney donation would accord beautifully with the progressive philosophy: one's assets aren't one's own; they're society's; and they can and should be re-allocated wherever they'll do society the most good.

If we introduced a policy of enforced kidney redistribution, I suspect that a certain portion of the population would try to get out of it. At present, the FDA doesn't allow men who've have sex with men within the past year to donate blood; they'd probably be equally strict about the transplantation of solid organs. Assuming that I'm strongly motivated to keep both of my kidneys, it'd be in my interest to do the MSM thing.

Of course, I'd have to document the transaction(s), since lots of people would try to escape kidney seizure by falsely claiming MSM status. As I understand, a similar situation obtained during the Vietnam war: a prospective draftee who claimed to bre gay had to convince the draft board that he was the real McCoy, and not just a straight boy faking it to escape the draft.

Since homosexuality has lost a lot of its social stigma in the years since the Nixon administration, we can expect lots of people to use this particular dodge to escape the kidney-donation draft. Happily, a progressive government would have a response to this. If your number's drawn, a kidney is removed regardless of your lifestyle choices; but if those choices put you in one of the no-transplantation classes, the organ's shipped off to a medical-waste facility instead of transplanted. This will deter selfish people from taking up gay sex in order to avoid sharing their bodily parts with society's most vulnerable members.

That philosophy is regressive. Just because they spin it with an inaccurate label is no excuse for you letting them get away with it.

Body B November 25, 2015 at 1:26 pm

Mandatory and uncompensated kidney donation would accord beautifully with the progressive philosophy: one’s assets aren’t one’s own; they’re society’s; and they can and should be re-allocated wherever they’ll do society the most good.

I can see the slogan now - You didn't grow that!

There is literature on this. Robert Silverberg wrote a bitter short story which was really about the Vietnam Draft and, presumably, his desire to see the Khmer Rouge come to power, called "Caught up in the organ draft" or something like that.

There are ways to make mandatory and uncompensated kidney donations even more progressive.

Make it part of reparations for slavery: take kidneys from Whites only and give them to Blacks.

Take kidneys from Global Warming deniers and give them to LGBTQ people.

Introduce a new Kidney tax bracket for high earners (one percenters).

Give free kidneys to all Syrian refugees who need them.

The possibilities are endless.

@Ricardo

"I’ll argue that kidneys should be taken by force from healthy people, at random, for little or no compensation."

That's a new low. Even for you.

What was my previous low?

IDK. I was just messing with you. I wanted to express that imo your idea is really bad.

But if it remains illegal, I’ll argue that kidneys should be taken by force from healthy people, at random, for little or no compensation. I see a difference in degree, but not in kind, between mandatory kidney donation and, say, mandatory vaccination.

Sounds like a plan. But actually if we take a page from Larry Niven's notebook (with a hat tip to the Chinese) we can solve this problem much more cheaply *and* resolve a lot of problems in the Inner Cities *and* reduce the problems of mass incarceration: We can take all the organs of anyone who commits their third felony.

Not just the kidneys, but the hearts, the livers, the corneas. Whatever.

Pressure is reduced on the prison system. Everyone gets the organ they need. Crime drops in urban areas. It really is a win-win. Needless to say the poor would benefit even more. Not only would they get even cheaper organs, but they are the main victims of recidivists.

How about we offer prisoners a reduction in their sentences in exchange for a kidney? Or just take a kidney as restitution for violent crimes like rape and murder?

Malaysia does. I am not sure it is a good idea as we don't actually want criminals, with or without their kidneys, back on the street. Prison is expensive.

So let's start with those guilty of three violent crimes and/or murder. Mandatory organ donation as a form of execution. It is a win-win.

Also it deals with the problem of a false conviction. Tragic, of course, if it happens. But three lives could be saved.

Seems like a no brainer. What's the explanation for why this isn't already a thing? I can see why you might not want private individuals buying kidneys off one another, but doing it this way seems like pure upside.

Just off the top of my head, I think it's related to what seems to be a deep-seated human need to respect the bodies of our dead loved ones, and the desire to have our own bodies respected after death. It's largely irrational, though I suppose the potential for disease transmission there may be evolutionary reasons for this revulsion of mutilating corpses and for the desire to bury bodies. Medical researchers and surgeons and physicians in the not-so-distant past faced extreme penalties for using cadavers in their training and research, even when it' was overwhelmingly obvious that it's to society's benefit to do so. I remember being surprised when I first became a driver that I had a little hesitation about putting that 'donor' sticker on my driver's license. I knew it was the right thing to do, and that my family would be happy for my decision if and when it was implemented, but there was still an irrational hesitation.

And I agree, this sounds like a no brainer. But for a lot of people, these kinds of decisions are made in the 'gut' and not in the brain.

@Kevin

"It’s largely irrational"

It's clearly not.

Care to explain? It may not have been irrational at all in the remote past, but it is now. In our time, our bodies end up either cremated (in which case having our kidney's, our eyes, our heart, etc. 'harvested' before being incinerated wouldn't make the slightest difference, especially since when the crematorium gives the family those ashes they don't give them all the ashes, or even necessarily the correct ashes) or our carcass is cut up (if there's an autopsy), roughly sewn back together, with organs just tossed into the empty chest cavity, and put in a sealed box where there is no risk of contamination. So what is rational about denying the possibility that some living person would have a benefit (along with one's living kin, with the $10k) from some soon-to-be-buried and never seen again body part?

Commodification of the human body is seen as taboo. Donating a kidney is considered to be undertaking a risky medical procedure for payment, which is generally condemned by bioethicists. There is also a class element, in which the wealthy could afford the kidneys while the poor would provide them.

Note that I reporting on common assertions by bioethicists, not endorsing them.

Why stop at kidneys?

There are not many organs that one can donate while alive with little risk. So stopping at kidneys, liver, bone marrow, eggs, sperm, and blood is somewhat logical. Payments after death are another matter. The logic of shortening the waiting list is the same, only now with negligible risk to the donor.

We are starting with the kidneys, not stopping at them.

"There is also a class element, in which the wealthy could afford the kidneys while the poor would provide them."

If you limited the government payments to donations from the deceased, you could eliminate a lot of the qualms. While there would likely be a similar demographic difference in the increase in donations, at least it would only be on those that were already dead and could not get worse off.

Organs from living people greatly increase the chance of the recipient's survival.

Rich is meaningless unless you can afford some things the poor cannot.

Let's make kidney donations tax deductible. Or better yet, make them a refundable tax credit, the "Earned Kidney Tax Credit".

Lol - bioethicists.

I do wonder what, exactly, they have ever done to help the plight of humanity. My guess would be that they have done absolutely nothing while globe trotting to speak at conferences at the governments' expense.

Leaches through and through.

Yeah, and we are consistent about it being unethical to do risky things for payment, like commercial fishing, rough necking, professional football.......

I would add concerns that the poor would be forced to sell body parts to feed their families.

Blacks and the poor would be the main beneficiaries of the program, so this seems reasonable. Sort of like using gasoline taxes to pay for roads.

Do you prefer their families starve?

I'm all in favor of paying donors or their estates, but this is a false dichotomy. Essentially nobody starves in the US. Though Ted may have been saying other people would have that concern, not that he himself did.

We would face the considerably more icky consequence of people being forced to sell body parts for luxury consumption goods, like fancy sneakers and cable TV.

Not to mention forcing drug addicts to sell body parts to get their next hit. How unfair is that?

It's interesting that most of the comments are about the issue of living donors, and all the money and class and exploitation issues that brings up. I think the striking thing about this proposal is the idea of substantial payment, which could either go to a charity of the deceased choice, or to the deceased next of kin, in payment for being a post-mortem donor.

Right now volunteering to be an organ donor is mostly about being 'a good person' and being thoughtfully enlightened. Yet the majority of drivers in states where it's a simple check-off to allow for organ donation after death choose not to allow themselves to be part of the program. A lot of this is driven by misinformation and irrational fear (maybe I'm too old or ill, maybe the doctors won't try too hard to save me if they can take my organs). Having a post-mortem payment would bring the discussion out into the open, and motivate more people to go beyond altruism.

Why post-mortem payment? How about if you have the donor box checked for all of 2015, that pays for your 2016 car tax. You can opt out at any time, but then you'll pay your next year's car tax yourself.

It would have to be hard to back out of, and it would have to have priority over the choices of the deceased's next-of-kin. My impression is ticking that little box on your driver's license doesn't do much and that the shortage is mostly due to the difficulty of convincing mom and dad that they should cut up little Suzy because she's brain dead.

It would probably work better with live donors who can make their own decisions.

That depends...in some states the donor registration is legally binding and cannot be reversed after you are deceased (e.g. Illinois). In practice, however, the organ procurement company will often respect the family's wishes to avoid drawn out battles.

(I am a general surgeon but don't do transplant work)

Thanks for the detail. Any idea of what percentage of "ticking the box" results in a successful transplant, or even an attempt at one? I'd accept "under particular circumstances, such as an organ-preserving death of a young person" if the data is so limited.

I don't have exact numbers but would suspect it's pretty low. the best donors tend to be younger relatively healthy people who die due to head trauma (e.g. gunshot to the head, unhelmeted motorcyclists). most people die for other reasons and are ruled out from donating for a variety of reasons related to how they die or their underlying medical comorbidities.

the numbers are higher for skin and cornea donations as these tissues are more resilient to injury than the more fragile organs like the kidney or lungs.

Thanks!

That's actually pretty brilliant! Even if a large percentage of people only participate for a few years, the cost to the transplant programs would be small, especially if they're willing to pay $10,000 for a cadaveric kidney.

That was at Mark Thorson, btw.

"A lot of this is driven by misinformation and irrational fear"

Don't be to sure about this. I'm a physician with a organ donor card that says one thing: "Don't take my organs at any case. I don't allow it." I know colleagues that got similar wills - as a tattoo: No PEG, no organ donation.

I've even seen studies that conclude doctors are more against organ donations than the average population. They recommend it to their patients but they won't do it themselves. That's true for a lot of medical treatments.

*too sure

Your experience is very different than mine. I'm a former physician who has been fine with being an organ donor since as long as it's been a check-box on the driver's license. The vast majority of my physician friends are also donors. Having done some rotations with some transplant teams, I think there are some organ transplant programs that are far from cost effective and probably aren't worth pursuing at the state of our current abilities, but kidney transplants are a no-brainer. Just curious, why are you so against it. Do you refuse to donate blood, too?

Yes, I refuse blood, too. With blood it’s mostly about the money. I know that the Red Cross makes like 100-200€ with my blood each time. They still don’t split the money with me. They don’t even communicate their secret.

With other organs it’s about the same. It’s again about the money but this time it’s even worse. The surgeons make so much money with it while you take all the risks. Kidney donations is not like spending blood. You take real risks. Risks that can change your life forever. Another problem is premature diagnosis of death. This can still happen, especially in European countries.

What could go wrong?

Are all kidneys created equal?
For recipients who need rare kidney types it may be better to adjust the price according to the demand for the particular type--in a way approximating a market.

Different blood types are more or less in demand. Also some patients are highly sensitized to foreign antibodies and can only accept a transplant from 1% (or less) of the population.

If you were to have the government set a price, ideally it would be high enough that there would be queueing to donate (that's also a good way of ensuring it's not exploitative). That might help avoid adjusting the price.

How far did they get in the paper on the long term health costs to the living donors? Minimum or Maximum ages for donors? Long term affects for living 30+ years on one kidney maybe? 15k doesn't sound like a lot of money to me to undergo major surgery, much less any long term health and lifestyle changes.

But of course there are plenty of poor people to take advantage of who will misjudge the long term cost, which is half the fun in economics.

The best papers on the health consequences of living kidney donation are Segev, 2010 (http://www.ncbi.nlm.nih.gov/pubmed/20215610) and Muzaale 2014 (http://www.ncbi.nlm.nih.gov/pubmed/24519297). Those papers find that donation doesn't increase long-term mortality vs. matched controls and that it increases lifetime risk of kidney failure from 0.1% to 0.9% (the average American's risk is 3.2% but kidney donors start off healthier). Mjoen, 2014 (http://www.nature.com/ki/journal/v86/n1/abs/ki2013460a.html) finds higher risk of mortality but lots of transplant people have problems with its methodology. It's well-established that kidney donors are as healthy or healthier post-donation than the average population, but they also started out healthier to begin with.

You can find some more info on donor risk at our website here - http://waitlistzero.org/living-donation/risks/

$15K might not sound like much to you, but 29% of Americans at age 35 have net worths less than that:
http://www.shnugi.com/networth-percentile-calculator/?min_age=35&max_age=35&networth=15000

Seems like we can save a lot of hassle and money if we just stop giving away dialysis. Society doesn't really need old people anyway.

I like this idea. I have some issues with a regular kidney market, but this resolves them completely.

That said, I personally wouldn't give up a kidney for $45,000. I like having both of them.

But why do you like having two kidneys? The usual answer is that it's nice to have a backup... but most kidney diseases strike both kidneys at the same time, so people rarely benefit from having two. (The exceptions are cancer and traumatic injury.)

If you do get kidney disease, two half-functioning kidneys work better than one.

I think the donor deserves at least half of the total cost of a kidney transplant performed in the U.S. I suspect that would be more than $45,000. Anyone know how much that is?

Also, if international donors are allowed into the kidney market, we'll be swimming in kidneys even at $45,000.

Surgical cost varies (particularly by type of insurance) but it probably costs around $100K (Medicare) to $250K (private insurer).

International Kidney trade could improve the financial situation of many countries (Greece, for example).
Maybe it should be included in the Trans-Pacific Partnership.
Maybe it is.

Agreed. Though I would be a lot more willing to consider parting with one if in addition to the $45k I were given excellent insurance against problems with the remaining kidney, and moved to the head of the line of kidney recipients, if it came to that.

Kidney donors do receive waitlist priority (equivalent to waiting about four years). Agree about lifetime health insurance. Here's a good paper on what happens to kidney donors who need transplants -- http://www.ncbi.nlm.nih.gov/pubmed/25412818

While we are mandating things, let's require the purchase / procedure be covered by insurance.

Sounds good to me. It's not my money.

You forgot to blame Americans for being cowards. Why are you all afraid of selling your kidneys? Isn't America the land of the brave?

That'll help.

This is astonishing. I see "government compensation of kidney donors would" "be particularly beneficial to patients who are poor". Has the American Journal of Transplantation been infiltrated by Communists?

Agreed. The socioeconomic strata of those who benefit is irrelevant. This is like the inverse of the "women and minorities hardest hit" joke.

The author is making a defensive rhetorical move against common accusations that payments would exploit poor people .

As a person part of a family with two donors, both of whom gave a kidney to another family member, I find the author's focus absurd, and the notion of "drafting" donors grotesque. Yes, dialysis is expensive. We shouldn't be providing it to people who refuse to comply with exercise and diet requirements, and who continue to drink alcohol. I've actually come across people who were obviously resistant to controlling their diabetes. It was obvious. Asked if it was because they would lose various health care and rent supports, they said "yes." Fear of poverty. Amazing stuff.

The most common causes of renal necrosis are uncontrolled adult-onset diabetes and untreated high blood-pressure; intense substance abuse induced blood pressure spikes also cause kidney failure. (PCP, speed, and many other substances can blow out your kidneys via blood-pressure.) Failing to detect high BP or failing to take the prescribed BP meds often leads to kidney failure (and stroke). Failing to both exercise daily and eat right will increase the morbidity flowing from type 2 diabetes.

In summary, kidney failure is often, in the developed world, a self-induced condition, one flowing from alcohol consumption, lack of exercise, poor dietary habits, and lack of compliance with prescribed treatments.

It's politically correct to ignore the life-habits cause of much kidney failure. That will end the moment forced post-mortem or in vivo kidney removal approaches reality.

"In summary, kidney failure is often, in the developed world, a self-induced condition, one flowing from alcohol consumption, lack of exercise, poor dietary habits, and lack of compliance with prescribed treatments."

Well, exactly! But you could easily replace "kidney failure" with "poverty." If you're calling for a return to Victorian-era distinctions between the deserving and undeserving poor, I applaud you.

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I remember that day so well. I wiehsd all day I didn't have those anoying work things to do. I kept my phone on and every text message I explained as I'm sorry, I don't do this, but today I need know what is happening. I remember thinking it was amazing how fast it was over but knowing it was an eternity for you. I remember being so happy when I saw what was removed from Quinn and amazed that a kidney like that had sustained life. I am still amazed.

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