A 2017 paper co-written by Sally Satel outlines safeguards such as built-in waiting period and delayed compensation. A payment of, say, $50,000 could take the form of tax-credit spread over 10 years, school vouchers, or other long-term government benefit for generous Kidney Donor.
There is a wide consensus, however, that the surest way to substantially alleviate the shortage of kidneys is through an increase in living donors. But there is fierce disagreement on how to achieve this.
One prominent contributor to the debate is Sally Satel. A scholar at the American Enterprise Institute (AEI), a Washington think tank, she has an intense personal interest in the subject. She said the reason so few kidneys are available for transplant, is that under the National Organ Transplant Act of 1984, paying for organs is illegal.
- 37mhave chronic kidney disease but 90% may not know
- 726,000suffer from end-stage kidney disease
- Almost 90,000people on dialysis die every year
Iran is the only country that allows such transactions and it has no kidney shortage. Satel is not advocating an Iranian-style market for body parts. But she believes that well-designed financial incentives can extend the pool of donors while addressing concerns over paying cash for organs.
“They’re afraid people will rush in to do this not knowing what they’re doing because the rewards are so appealing,” she says. “There are a million ways to approach that.”
Her ideas are fiercely resisted by those who want to maintain donations on a purely charitable basis. One common objection, outlined in this Los Angeles Times piece, is that financial incentives would crowd out altruistic giving.
Satel rejects that notion as illogical and argues that financial incentives would not just improve the length and quality of life for kidney patients, but also save a huge amount of money. Half a million Americans are on dialysis, and caring for each one costs $100,000 (£77,000) a year. Medicare, the US federal programme that picks up most of the bill, spends 7% of its budget on it, while dialysis patients account for just 1% of its recipients.
If you add disability benefits and tax forgone, the costs of dialysis dwarf those of transplantation and post-transplant care.
Studies have tried to quantify the benefits US society would derive from various levels of compensation. One paper found that that offering $45,000 for every donated kidney would result in a net gain of $46bn for America as a whole through lower medical costs and patients living more normal working lives.
Polls have suggested that a majority of US voters would favour non-cash payments for organs if this saves lives. But those who want to keep donations on a purely charitable basis take a dim view of such calculations and stand on principle.
The National Kidney Foundation (NKF) – a powerful voice in shaping public policy in the field -opposes any radical review of the 1984 ban. “Any attempt to assign a monetary value to the human body,” it says, risks “devaluating the very human life we seek to save”.
Many contributors to bioethics – the study of the rights and wrongs of medical research – also regard financial incentives as potentially exploitative. David Gortler, a former Federal Drug Administration official and onetime member of Yale University’s Center for bioethics, is concerned that people could make reckless decisions because they need the money.
“I have no confidence that people are going to spend [any tax credit] any more intelligently than a teenager with a blank check,” he says.
Deep-seated misgivings about paying donors mean that the 1984 law will not face a frontal challenge anytime soon.
A number of US states are now providing tax breaks worth up to $10,000 to cover the costs of donating organs – such as travel, accommodation and lost wages. But such measures may have limited impact, as research suggests the total value of the disincentives faced by donors is much higher
There have been federal moves to tweak the 1984 act, but they are unlikely to go very far either. A bill to study the effect of non-cash compensation on the organ supply has been stuck in Congress since 2016.
Things may change in due course, but not fast enough for Duane Oates. He is pinning his hopes of finding a kidney not on politicians, but on the inner strength he derives from his family and his god. “You can allow things to pull you down and go crawl underneath a rock, or you can make something else happen for yourself,” he says.
“The wind underneath my wing is my daughter and my wife. When it seems I’m getting depressed I think about them, and I come out of it. We’re strong on faith belief.”(BBC HEALTH)