Results for “organ donation”
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Incentives for Organ Donation

Lottery tickets for vaccination seems to have been reasonably succesful. What else could we use incentives for? Al Roth sends us to kidney surgeon Arthur Matas’s argument for testing incentives for organ donation:

A regulated system of incentives for donation could provide a sizable increase in the number of kidneys available for transplant. Yet incentives for kidney donation are illegal in the US.
…Initially, the concept of incentives for living donation can be unsettling (some have said “repugnant”4). Yet ethicists worldwide have argued that there is no ethical reason to prohibit incentives. And studies show that the public is in favor of incentives. Additionally, dialysis is more expensive than transplant; a regulated system of incentives would be cost saving to the health care system.

We accept kidney donation. Any successful argument against incentivized donation must be able to differentiate it from our currently accepted conventional donation. Notably, incentives are legal for plasma, sperm, and egg donation or surrogate motherhood, and certainly there are risks involved with egg donation and surrogate motherhood. Gill and Sade5 argue that the only difference between donating and selling is monetary self-interest, and monetary self-interest alone does not warrant legal prohibition.

It is time to move past the feelings that incentives are wrong to the reality that as a result of a potentially preventable shortage of organs, patients on the waiting list are dying or becoming too sick to transplant….It is time for professional societies and patient groups to advocate for changing the law to allow trials of incentives for donation.

See many previous posts at MR on organ donation and blood donation.

Some Good News on Organ Donation

Representative Matt Cartwright (D-PA 17th District) has introduced the Organ Donor Clarification Act. The act would:

  • Clarify that certain reimbursements are not valuable consideration but are reimbursements for expenses a donor incurs
  • Allow government-run pilot programs to test the effect of providing non cash incentives to promote organ donation.  These pilot programs would have to pass ethical board scrutiny, be approved by HHS, distribute organs through the current merit based system, and last no longer than five years.

Importantly the legislation has been endorsed by the American Medical Association and a number of other groups including Fair Allocations in Research Foundation, Transplant Recipients International Organization and WaitList Zero.

See my piece on the organ shortage in Entrepreneurial Economics and previous MR posts for more.

The Golden Rule of Organ Donation

Here is Joseph Roth, president and CEO of New Jersey Organ and Tissue Sharing Network:

Caseworkers from our organization recently went to the hospital to visit the family of a woman who suffered a stroke. The woman was dead, but machines continued to keep her organs functioning. She was an ideal candidate to be an organ donor. Her husband, it turns out, was on the waiting list to receive a heart.

Our caseworkers asked the husband if he would allow his wife’s organs to be donated. The husband, to the shock of our caseworkers, said no. He simply refused. Here was a man willing to accept an organ to save his own life, but who refused to allow a family member to give the gift of life to another person.

…Cases like this are rare, thankfully, but are nonetheless troublesome.

Roth continues:

Our proposal — we call it the Golden Rule proposal — would permit health insurers in New Jersey to limit transplant coverage for people who decline to register as organ donors. It would be the first such law in the nation. No one would be denied an organ. But under the proposal, insurers could limit reimbursement for the hospital and medical costs associated with transplants of the kidney, pancreas, liver, heart, intestines and lungs.

I am not in favor of messing with the insurance system for this purpose but have argued for a more direct approach. Under what I call a “no-give, no-take” rule if you are not willing to sign your organ donor card you go to the bottom of the list should you one day need an organ. Israel recently introduced a version of no-give, no take which gives those who previously signed their organ donor cards points pushing them up the list should they need an organ transplant–as a result, tens of thousands of people rushed to sign their organ donor cards.

Hat tip to David Undis whose excellent group Lifesharers (I am an adviser) is implementing a private version of no-give, no take in the United States.

Here is my piece on Life Saving Incentives and here are previous MR posts on organ donation.

Presumed Consent and Organ Donation

A New York assemblyman wants NY to adopt a presumed consent law for organ donation. 

The legislation, introduced by Assemblyman Richard Brodsky, a Westchester Democrat, is in two parts: the first step would end the right of the next of kin to challenge the decisions of their dead or dying relatives to donate their organs.

In a second measure, which is far more contentious, people would have to indicate in official documents – their driver’s licenses, most commonly – that they specifically don’t want to donate organs. If the box is not checked, it is presumed the person wants to donate.

The first thing to note about this proposal is that contrary to what Brodsky suggests, the problem isn't families who refuse to follow the wishes of the potential donor–as a rule, families who know, follow.  The problem is that families often don't know what their loves ones would have wanted because many people don't sign their organ donor cards.  

In fact, the way presumed consent actually works is not by overriding the wishes of the family it's by making the wishes of the potential donor more clearly known to her family.  In most presumed consent countries the family still has the ultimate say in practice because what doctor is going to want to go against the wishes of the family in a time of grief?  Instead, presumed consent increases the probability that families say yes by changing their background information from my loved one didn't opt-in to my loved one didn't opt-out. 

So under presumed consent we get more families saying yes–but not all–and there are other constraints such as the number of people who die in a way that makes their organs available for transplant and the availability of transplant surgeons and facilities to do the operation and so forth.

In a roundtable on this issue with Sally Satel, Art Kaplan and others, Kieran Hiely notes:

Spain’s success is due to effective management of the transplant
system, not a simple legal rule. Similarly, Italy’s donation rate grew
rapidly in the 1990s thanks to investment in its system, not because of
its long-standing presumed consent law. Some countries, notably
Austria, do have “true” presumed consent, with no kin veto. But they do
not outperform countries like the U.S. by any great margin.

I'm actually a bit more positive than Kieran, the best evidence is that presumed consent raises donation rates by perhaps 20-30%.  Not bad, but not enough to eliminate the shortage.  To do that, as Satel notes in her contribution to the roundtable it will take live donation.

Kieran also writes:

It’s also worth remembering that, since the 1970s, the U.S.
“transplant community” has worked hard to allay public concerns that
surgeons might be too eager to harvest organs, or that the state might
play too calculating a role in deciding what happens to the bodies of
potential donors.

The latter point is especially important in the United States.  Brazil, for example, switched to presumed consent and then switched back to opt-in when people became fearful and outraged and donation rates fell.  It's not hard to imagine similar blowback in the United States.

It's also worth remembering that considered as a whole the U.S. system is the best in the world.  Spain does have a very high rate of deceased donation, but it does poorly on live donation.  Iran leads the world on live donation because it compensates donors but due to religious feelings about the sacredness of the body Iran, like other Muslim countries, does poorly on deceased donation.  The US does well on both deceased and live donation and in total leads the world.

We can do better but we do need to tread carefully.


Organ Donation in Israel

Israel may begin something like a no-give, no-take rule for organ donation.  Under a new proposal someone who had previously signed their organ donor card would be given points helping them to move up the waiting list should they one day need a transplant organ.  See here for more on the no-give, no take rule.   

Thanks to the ever-entrepreneurial Dave Undis for the pointer.

Incentives for Organ Donation

In an important editorial the Washington Post advocates giving points in the current organ allocation system to people who have previously signed their organ donor cards.  I have long argued for such a system (see Entrepreneurial Economics and here) and am an advisor to Lifesharers an organization that is implementing a similar system privately.

The decision to pledge organs could be linked to the chance of
receiving one: People who check the box on the driver’s-license
application when they are healthy would, if they later fell sick, get
extra points in the system used to assign their position on the
transplant waiting list (other factors include how long you have waited
and how well an available organ would match your blood type and immune

Thanks to Dave Undis for the pointer.

Cadaveric vs Live Organ Donation

The basic point is simple – financial incentives for cadaveric donation of organs would save lives and would also reduce the demand for live donation, a costly and difficult procedure. (See my previous posts on this issue here and here). Tyler’s post obscures the basic point by introducing a debate about “a truly free market in organs” by which he means allowing payment for live donors. I won’t be drawn into that debate today, not because it isn’t an interesting issue, but because it is not germane to the issue of financial incentives for cadaveric donation. We should have the latter regardless of our position on the former. Note also that for obvious reasons live donation primarily affects kidneys only and doesn’t reach the issue of how to save the lives of transplant patients who needs hearts, lungs and other organs.

Tax Incentives for Organ Donation

It looks like Wisconsin will soon let organ donors take up to a $10,000 tax deduction to cover travel expenses, lodging, and lost income. I have mixed feelings. I am in favor of compensating donors or their families for organ donation but the net tax break is quite small. More importantly, one of the costs of the current system is that we rely on live donors far too much. Although I encourage, respect and admire donors, we should not kid ourselves, donation is not easy and not riskless. It can take a month or more to recover from the operation. We rely on live donors to an increasing extent only because of the shortage of cadaveric donors. All else being equal, therefore, I would prefer to see financial compensation for cadaveric donation or for signing your organ donor card.

Incentivizing Plasma Donation for Convalescent Therapy

Kominers, Pathak, Sonmez, and Unver apply market design tools to incentivize convalescent therapy:

COVID-19 convalescent plasma (CCP) therapy is currently a leading treatment for COVID-19. At present, there is a shortage of CCP relative to demand. We develop and analyze a model of centralized CCP allocation that incorporates both donation and distribution. In order to increase CCP supply, we introduce a mechanism that utilizes two incentive schemes, respectively based on principles of “paying it backward” and “paying it forward.” Under the first scheme, CCP donors obtain treatment vouchers that can be transferred to patients of their choosing. Under the latter scheme, patients obtain priority for CCP therapy in exchange for a future pledge to donate CCP if possible. We show that in steady-state, both principles generally increase overall treatment rates for all patients|not just those who are voucher-prioritized or pledged to donate. Our results also hold under certain conditions if a fraction of CCP is reserved for patients who participate in clinical trials. Finally, we examine the implications of pooling blood types on the efficiency and equity of CCP distribution.

The idea is quite similar to the “no give, no take” rule for organ donation that I have promoted for many years. Namely, if you don’t sign your organ donor card you go to the back of the queue should you ever need an organ donation. Israel adopted the idea some years ago by giving points to people who signed their organ donor card. As with no-give, no-take, the point of the rules that Kominers et al. promote isn’t fairness per se but rather as an incentive to increase donations and thus increase the supply of plasma.

New Zealand to Compensate Organ Donors for Lost Earnings

NZ Ministry of Health: People who donate a kidney or part of their liver can now do so knowing they can be fully compensated for lost earnings as a result of their donation surgery.

The Ministry of Health will be implementing compensation for live organ donors from 5 December. People who donate a live organ will be fully recompensed for lost earnings for up to 12 weeks while they recover. This will be paid weekly following the donation surgery. In the past donors received some assistance in the form of a benefit for this.

Former GMU student, Eric Crampton, now Senior Fellow at University of Canterbury had a role in the design.

Hat tip: Frank McCormick.

New Zealand to Compensate Organ Donors

New Zealand will now compensate live organ donors for all lost income:

Today’s unanimous cross-party support for the Compensation for Live Organ Donors Bill represents a critical step in reducing the burgeoning waiting list for kidney donations, according to Kidney Health New Zealand chief executive Max Reid.

“The Bill effectively removes what is known to be one of the single greatest barriers to live organ donation in NZ,” Mr Reid says. “Until now the level of financial assistance (based on the sickness benefit) has been insufficient to cover even an average mortgage repayment, and the process required to access that support both cumbersome and demeaning. The two major changes that this legislation introduces – increasing compensation to 100% of lost income, and transferring responsibility for the management of that financial assistance being moved from WINZ to the Ministry of Health – will unquestionably remove two major disincentives that exist within the current regime.”

Eric Crampton (former GMU student, now NZ economist who supported the bill) notes that a key move in generating political support was that New Zealand MP Chris Bishop framed the bill as compensating donors for lost wages rather than paying them. A decrease in the disincentive to donate–an increase in the incentive to donate. To an economist, potato, potato. But for people whose kidneys fail in New Zealand, the right framing may have been the difference between life and death.

This is also a good time to remind readers of Held, McCormick, Ojo and Roberts, A Cost-Benefit Analysis of Government Compensation of Kidney Donors published in the American Journal of Transplantation.

From 5000 to 10 000 kidney patients die prematurely in the United States each year, and about 100 000 more suffer the debilitating effects of dialysis, because of a shortage of transplant kidneys. To reduce this shortage, many advocate having the government compensate kidney donors. This paper presents a comprehensive cost-benefit analysis of such a change. It considers not only the substantial savings to society because kidney recipients would no longer need expensive dialysis treatments—$1.45 million per kidney recipient—but also estimates the monetary value of the longer and healthier lives that kidney recipients enjoy—about $1.3 million per recipient. These numbers dwarf the proposed $45 000-per-kidney compensation that might be needed to end the kidney shortage and eliminate the kidney transplant waiting list. From the viewpoint of society, the net benefit from saving thousands of lives each year and reducing the suffering of 100 000 more receiving dialysis would be about $46 billion per year, with the benefits exceeding the costs by a factor of 3. In addition, it would save taxpayers about $12 billion each year.

China to stop harvesting organs from prisoners

The mainland – which has long been criticised by international human rights groups for using organs harvested from executed prisoners as its main source of organ transplants – will completely ban the practice from next year.

All organs used in future transplants must be from donors, the Southern Metropolis News quoted Dr Huang Jiefu as saying. Huang is former deputy director of the health ministry and director of the China Organ Donation and Transplant Committee.

Major transplant centres had already stopped using executed prisoners’ organs, said Huang, who chaired an industry forum in Kunming on Wednesday.

There is more here, via Mark Thorson.  The article notes China has one of the lowest voluntary organ donation rates in the world.  0.6 individuals out of a million sign up to donate their organs after they die, and that means the number of actual donors is lower yet.  If you google around, you will find some ambiguity as to whether the donation rate or the “register to donate rate” is that low, but as far as I can tell (try this Chinese source) it is the actual register to donate rate, in part because they just aren’t many ways to register right now.  Please let us know if you have additional information on this point.

Wikipedia by the way reports:

The wait times for organ transplants for organ recipients in China are much lower than elsewhere in the world, and there is evidence that the execution of prisoners for their organs is “timed for the convenience of the waiting recipient.

Here are some of Alex’s earlier posts on a market for transplanted organs.

Organ Donors for Compensation

Today Alexander Berger will donate a kidney:

NYTimes: On Thursday, I will donate one of my kidneys to someone I’ve never met. Most people think this sounds like an over-the-top personal sacrifice. But the procedure is safe and relatively painless. I will spend three days in the hospital and return to work within a month. I am 21, but even for someone decades older, the risk of death during surgery is about 1 in 3,000. My remaining kidney will grow to take up the slack of the one that has been removed, so I’ll be able do everything I can do now. And I’ll have given someone, on average, 10 more years of life, years free of the painful and debilitating burden of dialysis.

Alexander doesn’t want any praise or talk of “heroic sacrifice,” that is part of the problem. He wants to normalize donation and he argues for compensation in a regulated market.

The people waiting for kidneys aren’t dying because of kidney failure; they’re dying because of our failure — without Congress’s misguided effort to ban organ sales, they would have been able to get the kidneys they desperately needed.

…There’s no reason that paying for a kidney should be seen as predatory. Last week, the Ninth Circuit Court of Appeals issued a ruling legalizing compensation for bone marrow donors; we already allow paid plasma, sperm and egg donation, as well as payment for surrogate mothers. Contrary to early fears that paid surrogacy would exploit young, poor minority women, most surrogate mothers are married, middle class and white; the evidence suggests that, far from trying to “cash in,” they take pride in performing a service that brings others great happiness. And we regularly pay people to take socially beneficial but physically dangerous jobs — soldiers, police officers and firefighters all earn a living serving society while risking their lives — without worrying that they are taken advantage of. Compensated kidney donors should be no different.

Here are further MR posts on organ donation and here is Jon Diesel on Do Economists Reach a Conclusion on Organ Donation.

Compensation Now Legal for Bone Marrow Donation

Excellent news; yesterday the Ninth U.S. Circuit Court of Appeals issued a unanimous opinion stating that compensation for bone marrow donation, specifically peripheral blood stem cell apheresis, is legal because such donation does not fall under the National Organ Transplant Act (NOTA).

The case was simple and it’s outrageous that the government fought. In brief, a bone marrow donation used to require inserting a very big needle into the donor’s hip bone, a painful hospital-procedure often requiring general anesthesia. Today, however, donors typically do not donate marrow but hematopoietic stem cells which can be harvested directly from blood in a procedure that takes a little longer but is essentially similar to a standard blood donation. Compensation for blood is legal (blood is excluded as an organ under NOTA). The plaintiffs, led by the Institute for Justice, argued and the court agreed that there is no rational basis for outlawing one type of blood donation when a similar donation is legal.

I was shocked by the utter boneheadedness of one of the government’s arguments:

…the government argues that because it is much harder to find a match for patients who need bone marrow transplants than for patients who need blood transfusions, exploitative market forces could be triggered if bone marrow could be bought.

In other words, markets are forbidden just when they are most useful. It was in fact the patients with rare matches who brought this case. As the court noted:

…a physician and medical school professor…says that at least one out of five of his patients dies because no matching bone marrow donor can be found, and many others have complications when scarcity of matching donors compels him to use imperfectly matched donors. One plaintiff is a parent of mixed race children, for whom sufficiently matched donors are especially scarce, because mixed race persons typically have the rarest marrow cell types.

The patients with the most common cell types can afford to rely on the kindness of strangers. You don’t need a lot of kindness when there are a lot of strangers. The patients who are most difficult to match need to leverage altruism with incentive. It’s a lesson with many applications.

CA Organ Donor Law

California has a new law creating a live donor registry for kidney transplants and requiring California drivers to say yay or nay on whether they want to be organ donors when they renew their drivers' licenses.  The law was passed with the prodding of Steve Jobs who last year had a liver transplant.

The live donor registry is very good. The required declaration is mixed but I hope it works.  I see it as follows.  The benefit is that if a potential donor has said yes to organ donation then next of kin almost always agree to their wishes so if more people positively affirm that is good.  The cost, however, is that now "no" really means "no" and next of kin will presumably agree to that as well.  Previously, next of kin might have said yes to non-signatories.  Let's use some back of the envelope figures:

100 potential donors
20 signed organ donor cards
80 do not sign but, among these, half the families say yes so 40.

Total: 60 donors.

So with declaration you need more than 60 to agree to be organ donors, i.e. a huge increase in those saying yes.  It could happen if what people say on surveys about supporting organ donation is true but I would have been much happier with even a small incentive to sign.  How about a free iPhone for signatories?  Or at least some more minutes!

See here for more on incentives and organ donation.

Addendum: Nudge blog has some helpful comment–the law appears to be closer to mandated ask than mandated choice.