what would happen to the supply of kidney transplant donors if the sale of kidneys was legalized?

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Peer-reviewed

Research Article

Would government bounty of living kidney donors exploit the poor? An empirical analysis

• Philip J. Held,
• Frank McCormick,
• Glenn Yard. Chertow,
• Thomas One thousand. Peters,
• John P. Roberts

10

• Published: November 28, 2018
• https://doi.org/10.1371/journal.pone.0205655

Figures

Abstruse

Authorities compensation of kidney donors would probable increase the supply of kidneys and prevent the premature deaths of tens of thousands of patients with kidney failure each year. The major argument against it is that it would exploit the poor who would exist more probable to accept the offers of bounty. This overlooks the fact that many poor patients desperately need a kidney transplant and would greatly benefit from an increased supply of kidneys. The objective of this study is to empirically test the hypothesis that regime bounty of kidney donors would exploit the poor. Exploitation is divers by economists and several noted ethicists as paying donors less than the fair market value of their kidney. Exploitation is expressed in monetary terms and compared with the economical benefit recipients receive from a transplant. Data are from the Scientific Registry of Transplant Recipients and the Us Renal Data System annual data reports. Educational attainment is used as a proxy for income. We estimate that if the government rewards living donors with a packet of not-cash benefits worth $75,000 per kidney, donors would not be exploited. Much more important, this compensation would probable stop the kidney shortage, enabling many more patients with kidney failure to obtain transplants and live longer and healthier lives. The value of kidney transplantation to a U.South. recipient is about $1,330,000, which is an lodge of magnitude greater than any purported exploitation of a living donor (nada to $75,000). Consequently, the aggregate net benefit to the poor alone from kidney transplantation would increase to about $12 billion per year from $1 billion per yr currently. Most of the benefit would accumulate to poor kidney recipients. But poor donors would receive the fair market value of their kidney, and hence would not be exploited. If the government wanted to ensure that donors also received a net benefit, it could easily do so by increasing the compensation above $75,000 per donor.

Citation: Held PJ, McCormick F, Chertow GM, Peters TG, Roberts JP (2018) Would government bounty of living kidney donors exploit the poor? An empirical analysis. PLoS ONE 13(eleven): e0205655. https://doi.org/10.1371/journal.pone.0205655

Editor: Stanislaw Stepkowski, University of Toledo, UNITED STATES

Received: November 21, 2017; Accepted: September 12, 2018; Published: Nov 28, 2018

Copyright: © 2018 Held et al. This is an open admission article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data are available from published sources every bit listed in the References; The only exception are information from the Scientific Registry for Transplant Recipients, (SRTR) an institution funded by the U.s. Government which makes data available to the enquiry customs. (Reference 32). These data are presented in Fig ii of the manuscript. Information from the SRTR may exist requested past going to their website: https://world wide web.srtr.org/requesting-srtr-information/data-requests/.

Funding: The authors received no specific funding for this work. All work was pro-bono.

Competing interests: The authors take alleged that no competing interests exist.

Introduction

Each year well-nigh 125,000 U.S. patients are diagnosed with end-stage renal disease (ESRD) [ane] and must either undergo life-long dialysis therapy or obtain a kidney transplant. Only about 31,000 of these patients are added to the transplant waiting list each twelvemonth, and a little more than than one-half that number really receive transplants because of a serious and growing shortage of transplantable kidneys [2]. Consequently, the number of U.S. patients requiring maintenance dialysis now approaches half a million, and the number on the transplant waiting list has risen to almost 100,000 [one,2]. Waiting fourth dimension for a deceased donor kidney has steadily increased to an average of almost five years, and in many regions await-time now exceeds life expectancy. Most tragically, each year virtually v,000 patients on the waiting list die and another iv,000 are removed considering they are considered too sick to undergo the transplant functioning [2].

At that place is a consensus amidst economists that the main cause of the kidney shortage is the legal prohibition against compensating kidney donors, and that the shortage could be ended if compensation were permitted [3–8]. Moreover, a growing number of physicians and surgeons have concluded that donor compensation should exist seriously considered [9–12]. In May 2014, the American Order of Transplant Surgeons and the American Club of Transplantation published a study calling for the removal of donor financial disincentives and the study of positive incentives to increase organ availability [13]. In November 2015, the House of Delegates of the American Medical Association overwhelmingly passed a resolution to seek regulatory relief and so that financial incentives could exist evaluated in a real-globe airplane pilot report [14].

Although many ethicists appear to be against compensation of kidney donors (run across Greasley [15], Kerstein [sixteen], Rippon [17], Sandel [xviii], and Satz [xix]), many others are in favor (see Erin and Harris [20], Richards and colleagues [21], Wilkinson [22], Taylor [23], and Fabre [24]). Prof. Wilkinson has provided a useful survey of the ideals of donor compensation [25].

Those opposed to donor compensation argue that poor people would be more likely than others to accept offers of compensation, then the more than flush would finish up ownership kidneys from the poor, thereby exploiting them. A 2015 letter to the U.S. Secretary of Health and Human Services, signed by many distinguished members of the transplant community, stated that principles adopted by the World Health Organization "drew on decades of global feel which shows that paying for organs inevitably exploits the poor" [26]. Delmonico et al. [27] make similar arguments. Although this criticism is frequently made, opponents of compensation overlook the stiff likelihood that government compensation of living kidney donors would increase the supply of kidneys and enable many more than patients with ESRD, including those who are poor, to relish longer and healthier lives.

Methods

The objective of this written report is to empirically test the hypothesis that authorities compensation of living kidney donors would exploit the poor. Exploitation is divers and expressed in monetary terms, and is compared with the estimated benefits received by kidney transplant recipients. Nosotros have appended iv supplements (S1 File…S4 File) to meliorate explain some of our assumptions and calculations.

Economic benefit of a kidney transplant to a recipient

Held-McCormick et al. [8] accept estimated the discounted present value of the economic do good of a kidney transplant over a recipient'due south lifetime in two situations. The start is for electric current conditions in the U.S. in which donor compensation is prohibited and as a effect at that place is a serious shortage of transplant kidneys. Consequently, transplant recipients are able to obtain, on average, simply one transplant, the value of which is approximately $937,000 ([8] Table three). In the second state of affairs, donors are compensated for the fair market value of a kidney, which would likely end the kidney shortage. With kidneys readily available, transplant recipients would be able to obtain, on average, two transplants, with a total estimated value of $1,330,000 ([eight] Tabular array 3). (The average waiting list patient who receives a showtime transplant has a life expectancy of 19.3 years, simply the boilerplate graft lasts only 12.half-dozen years. And then the average recipient would receive ii transplants. Some recipients would receive more and some less.)

The exploitation of kidney donors

The term exploitation is defined as paying less than the fair market value of the good or service being sold. This definition is well grounded in the economics literature [28] and is often employed past respected ethicists [29]. However, the off-white market value of a kidney from a living donor is not known because the National Organ Transplant Act prohibits the buying and selling of human being organs for transplantation.

To gauge the fair market value (run into S1 File), we begin with the fact that Medicare pays organ procurement organizations (OPOs) about $55,000 for a kidney from a deceased donor [7]. Merely a kidney from a living donor is worth more than one from a deceased donor because the expected functional life of a graft from a living donor (for a person on the kidney waiting list) is about 43% longer [8]. This lone would boost the value of a living donor kidney by $23,650. In addition, when a kidney transplant fails, a patient typically incurs costs totaling about $233,000 ($88,000 for the price of graft failure plus $145,000 for a second kidney transplant [viii]). For a living donor kidney, this cost occurs four.2 years later than for a deceased donor kidney. So using a real discount charge per unit of iii%, the filibuster in incurring this expense makes a kidney from a living donor more than valuable by $twenty,665.

On the other hand, it costs almost $20,000 to remove a kidney from a living donor [30] and about $v,000 for the tests of the donor beforehand, both of which reduce the value of a donated kidney. So taking all of these factors into consideration, the estimated value of a kidney from a living donor is roughly $75,000 ($55,000 + $23,650 + $xx,665 - $25,000 = $74,315).

This is the corporeality the government would initially offering for a kidney from a living donor. Over time, the regime would likely adjust this amount to balance the quantity of kidneys supplied and demanded. In any event, we will run across below that our conclusions practise not depend crucially on the exact magnitude of this value because it is compared to the benefit that poor kidney recipients receive from a transplant, which is more than than an club of magnitude larger.

Thus, at the current time when donor bounty is prohibited, a living donor is paid nil for a kidney that has a value of nearly $75,000, so the amount of exploitation (equally we have defined it) is $75,000 (Table 1, row 4). On the other paw, if regime compensation of living kidney donors were increased to $75,000, exploitation would fall to cypher (Table 1, row 5). If compensation were increased to $100,000, exploitation would refuse to a negative $25,000, i.e., the donor would receive a net benefit of $25,000 (Table one, row six). Thus, exploitation can exist reduced, eliminated, or turned into a net benefit by increasing the amount of compensation.

Indeed, if policymakers conclude (or pilot studies suggest) an even greater sum is needed to ensure that donors are not exploited, the regime could hands afford to increase compensation above $75,000. The savings from stopping dialysis later transplantation are so great that bounty could be increased to as much equally $320,000 per kidney [eight] before the taxpayer would no longer salvage money by having the government compensate donors.

Information technology is clear that exploitation of kidney donors, as nosotros have defined it, applies to kidney donors of all income levels. Notwithstanding, since the distinguished critics of donor bounty focus on the exploitation of the poor, we volition address that criticism.

Data on the income levels of kidney donors and recipients is non readily bachelor, but data on educational level, a recognized proxy for income (see S4 File), is available for kidney recipients. Therefore, we volition define the poor as adults who have non graduated from high school, which is about 12% of the U.S. population. (According to the U.Due south. Census Bureau, 13.5% of the U.S. population lived in poverty in 2015 [31].)

In addition, we present data showing poor patients are: (a) less likely to qualify for (or be assigned to) the kidney transplant waiting list and receive a transplant from a deceased donor, and (b) less likely to receive a transplant from a living donor.

Results

Given these definitions and preliminary calculations, the exploitation of poor kidney donors was compared with the benefit that poor kidney recipients receive from a transplant to estimate the net result on the poor in 3 different situations. The kickoff is the current situation in the U.S. where bounty of kidney donors is prohibited. In the second, the government compensates living kidney donors the $75,000 fair market value of a kidney nether realistic (simply conservative) assumptions about the response of poor donors and recipients. The third state of affairs is a sensitivity analysis to show how robust the conclusions of Situation 2 are—the authorities once more compensates living kidney donors $75,000, merely under assumptions that are very pessimistic for the welfare of the poor. Tabular array 2 and Fig 1 summarize the calculations and results for the three situations.

Situation 1: Current weather in the U.S.

1. Compensation of kidney donors is prohibited,
2. Partly every bit a event, just most 17,500 transplants accept place each year (using kidneys from both living and deceased donors),
3. The poor receive only 6% of these transplants [32] (much less than their 12% share of the general population and their 34% share [33] of patients newly diagnosed with ESRD),
4. The poor provide an estimated iv% of living donor kidneys (close to the 3% share of living donor kidneys they receive) [32].

Since donor bounty is prohibited, the exploitation of an private living kidney donor is the maximum amount: $75,000. And if nosotros make the conservative simplifying supposition that the level of exploitation of deceased kidney donors is the same every bit for living donors (meet S2 File), then the aggregate exploitation of all poor kidney donors is $0.1B/yr. [= 17,500 transplants/yr. Ten 4% of transplant kidneys donated by the poor Ten exploitation of $75,000 per donor]. Nonetheless, even this slight over-gauge is still an social club of magnitude less than the amass benefit to all poor kidney recipients, which is $1.0B/yr. [= 17,500 transplants/yr. X 6% of transplant kidneys received past the poor X $937,000 do good per recipient from one transplant]. Therefore, nether current conditions, the net do good to the poor every bit a grouping from transplantation is $0.9B/year. (Run into Table 2, row 1, columns 6–8.)

Situation ii: Donor compensation of $75,000 nether realistic assumptions

1. Now assume the government increases the compensation of living kidney donors from zero to the $75,000 off-white market value of a kidney.
2. This causes the number of kidney transplants to increase to more than 31,000 per twelvemonth (plenty to supply the yearly additions to the kidney transplant waiting listing).
3. With the kidney shortage ended, poor patients would receive 30% of these kidney transplants (but slightly less than their 34% share of the ESRD population as explained in the Word section).
4. The poor provide l% of living donor kidneys (more than 4 times their 12% share of the general population).

Then the exploitation of individual kidney donors would be zero (since donors would be compensated for the off-white-marketplace value of their kidney). And so the amass exploitation of all poor donors would likewise be zero, while the amass benefit to poor kidney recipients would be $12.4B/yr. [= 31,000 transplants/year. 10 thirty% of transplant kidneys received by the poor Ten $1,330,000 benefit per recipient from ii transplants]. Therefore, the net benefit to the poor as a group would also be $12.4B/yr. This is about 13 times the $0.9B/yr. cyberspace benefit to the poor in the current situation.

It is clear from Table 2 and Fig 1 that the conclusions of Situation two are robust. The estimated value of kidney transplantation to a poor kidney recipient is then big ($ane,330,000), and the purported exploitation of a poor kidney donor is so small (nix to $75,000), that any reasonable alternative assumptions would probable yield the same decision—that the poor every bit a grouping would be far better off if donors were compensated.

Situation 3: Donor compensation of $75,000 nether pessimistic assumptions

This point is illustrated by the following sensitivity analysis in which the assumptions are deliberately skewed to produce a effect unfavorable to the poor.

1. (a) The government again compensates kidney donors $75,000, and
2. (b) This over again results in more than than 31,000 kidney transplants per year.

But at present, for purposes of analogy only, the post-obit pessimistic assumptions are fabricated:

1. (c) The poor provide 100% of the donor kidneys, but
2. (d) They receive only 17% of kidney transplants (half of their 34% share of the kidney failure population).

Then under these pessimistic assumptions for the welfare of the poor, the aggregate exploitation of poor kidney donors would again be cipher, and the aggregate benefit to poor kidney recipients would exist $vii.0B/twelvemonth. [= 31,000 transplants/yr. Ten 17% of transplant kidneys received past the poor X $ane,330,000 benefit per recipient from two transplants]. Therefore, the cyberspace benefit to the poor from transplantation would also exist $7.0B/twelvemonth., which is seven times the $0.9B/year. internet benefit in the current situation.

Other ways government compensation would affect the poor

Government compensation of living kidney donors would also alleviate two other serious issues currently facing poor patients in need of a transplant. These patients are: (a) less likely to be added to the kidney transplant waiting list and receive a transplant from a deceased donor, and (b) less likely to receive a transplant from a living donor.

These ii problems are illustrated in Fig 2, using data from a census of all U.South. kidney transplants in 2014 (SRTR [33]). The columns indicate the percent of unlike patient groups who accept attained four different levels of education: (a) less than loftier school graduate, (b) high school graduate, (c) attended some higher (only no degree), and (d) higher degree (associate, bachelors, or graduate).

For instance, the tan columns testify that, among patients starting dialysis, 33% have not finished high schoolhouse, 35% are high school graduates, 17% accept some higher, and 15% have college degrees (percentages sum to 100%). Patients starting dialysis are concentrated in the lowest ii educational groups.

The hatched columns betoken the percent of new dialysis patients who are added to the kidney waiting list. Note that only 7% are not high school graduates. Similarly, the blue columns evidence the percent of new dialysis patients who receive a transplant from a deceased donor; again simply seven% are not loftier school graduates.

The ruby-red columns indicate the percent of new dialysis patients who receive a transplant from a living donor; an even smaller three% are not high school graduates.

Thus, fifty-fifty though the least educated (poorest) patients are over-represented amidst those diagnosed with ESRD, they are under-represented on the kidney transplant waiting list and amongst those who receive a kidney from either a deceased or living donor.

Discussion

The barriers the poor confront in obtaining transplants

Fig 2 clearly indicates the biggest barrier poor patients confront in obtaining a deceased donor kidney is being placed on the waiting listing, not getting a transplant one time on the list (where the current system seems to work reasonably well in allocating deceased donor kidneys to the poor). This wait list admission trouble does non necessarily reflect deliberate bigotry against the poor. Instead, given the astringent kidney shortage under the electric current system, admission to the waiting list must be limited by some criteria, and these criteria favor the healthier candidates with the best prospects for a successful transplant—who happen to exist the more affluent.

With regard to kidneys from living donors, the problem for poor recipients is that most of their relatives and friends are likewise poor and hence less able to carry the burden of being a living donor (lost wages, etc.).

Both barriers for the poor could be circumvented by authorities bounty of kidney donors because that would end the kidney shortage. Enough kidneys would be available for all who needed one, rich or poor.

Annotation, yet, that even if the kidney shortage is ended, poor patients may not receive kidney transplants in full proportion to their 34% share of the ESRD population because of other factors. For example, many non-elderly Medicare patients lose all Medicare coverage including immunosuppressive therapy 36 months after a transplant [34]. That policy creates an incentive for patients, specially the poor and young, to not even apply for a transplant. Likewise, the poor are more probable to live in rural areas, far from a transplant center, making it hard for them to travel to a center to use for the waiting list or to receive a transplant.

The opponents and proponents of donor bounty have very dissimilar perspectives on the relation between bounty and exploitation. Opponents usually cite the weather in illegal markets (commonly referred to as "black" markets) for kidneys in poor countries every bit testify that compensation leads to exploitation [27,35]. Proponents usually refer to a proposed legal allocation procedure in the U.S. that would be controlled past the government and would be specifically designed to forestall exploitation [3,viii,12,36]. Table 3 summarizes the differences between the two views. Compensation for living donors would be paid in a delayed not-cash grade—such as tax credits, health insurance, tuition assistance, retirement funds, etc.—so people who are drastic for cash would not be tempted to sell a kidney. Before adopting this proposal, the authorities should sponsor pilot programs to test the various features and discover whatsoever unintended consequences (see S3 File for the details of our specific proposal).

Limitations of the study

Many ethical concerns have been raised about government compensation of kidney donors. In this paper, we have chosen to focus on just one of them—that donor bounty would exploit the poor—considering (a) that is the main argument made by many distinguished opponents of donor compensation, and (b) that hypothesis can be empirically tested.

Oxford ethicist Janet Radcliffe Richards has as well extensively critiqued the exploitation argument [37]. With regard to the contention that poor people would not donate a kidney if they had enough money, she points out that this reasoning would apply to much paid work. This reasoning does not differentiate organ selling from innumerable other activities (e.yard., rubbish removal, clearing sewers, etc.) that people would not do if they had enough money. Also, if we say the rich are exploiting poor donors, then, according to Richards, nosotros tin can equally say that all persons in a weaker position are being exploited by people in a stronger position. For example, those who supply a kidney in return for bounty tin be said to be exploiting those who are in desperate need of a transplant kidney.

Some of the other ethical concerns about compensating kidney donors have been expertly addressed by other researchers:

Nobel Laureate Alvin Roth [38] wrote the seminal article on this subject, noting that some transactions are not repugnant as gifts or in-kind exchanges, but become repugnant when money is involved. These transactions are considered repugnant because they (a) care for people similar objects, (b) could be coercive, leaving some poor people open to exploitation, and (c) could lead to a slippery slope of even more repugnant transactions.

Sandro Ambuehl, Muriel Niederle, and Alvin Roth [39] surveyed the general public to see how their views on the ethical appropriateness of paid participation in medical experiments inverse as the level of bounty changed. They found that the public generally thought some form of payment was more than ethical than purely voluntary participation, and that in-kind compensation was most ethical. But some participants thought very high amounts of bounty were less ethical.

Julio Elías, Nicola Lacetera, and Mario Macis [forty] found that support for a market-based solution to the organ shortage increased when people were presented with documented and verifiable information well-nigh its potential benefits. This shows that empirical testify can bear on what society considers to exist ethically adequate.

Sandro Ambuehl and Axel Ockenfels [41] in a survey virtually human egg donation showed that when the acquisition of information is costly, individuals with higher marginal costs of data oft respond more than to higher compensation. Thus, every bit compensation increases, people who find it more hard to be well informed contain an increasing fraction of participants. Consequently, policy makers should go to some lengths to ensure participants take a thorough understanding of possible negative outcomes.

Undue inducement is a term originating in police which means improper influence that deprives a person of freedom of choice or substitutes another'due south pick or desire for the person's ain (Merriam-Webster Dictionary). In an article describing persons interviewed on the regional runway and urban trolley lines in Philadelphia, Halpern et al. [42] "… found no prove that whatever of the 3 main concerns with a regulated organization of payments for living kidney donation would manifest if such a market were established. Providing payments did not dull persons' sensitivity to the risks associated with donor nephrectomy, suggesting that payment does not represent an undue inducement—one that would make rational choice difficult. Furthermore, providing payments did non preferentially motivate poorer persons to sell a kidney, suggesting that payment does non represent an unjust inducement—one that would put substantially more pressure on poorer persons than on wealthier persons."

Also, Gordon et al. [43] say in that location is a range of compensation between get-go to consider donation and start to experience undue inducement to donate, suggesting elbowroom for offering acceptable amounts of financial compensation earlier exerting an undue inducement on people to donate.

Fisher et al. [44] say: "Despite repeated calls for a pilot study to assess the impact of financial bounty on living kidney donation rates, many fear that financial incentives will exploit vulnerable individuals and cast the field of transplantation in a negative public lite, ultimately reducing donation rates."

Note that we took many of these ethical concerns into business relationship when designing (a) our proposed legal regulated allocation procedure in the U.Southward. in Tabular array 3, and (b) our specific proposal to compensate kidney donors in the S3 File.

There are some limitations to the analyses and values calculated in this study.

This paper used educational attainment as a proxy for income. A great deal of enquiry shows a close correlation betwixt the two (see S4 File). To establish the off-white marketplace value of a kidney from a living donor, estimates from published research were used. Actual marketplace prices would be preferred but are unavailable due to a federal constabulary that prohibits the selling of human organs for transplantation.

Nothing in this paper should exist construed as advocating that poor people should take bounty for their kidneys. Indeed, if the poor were completely prohibited from accepting compensation—a simple policy alternative—it would simply strengthen the case for our bones determination that government compensation of living kidney donors would greatly benefit the poor. Poor kidney recipients would nevertheless receive the benefits of transplantation, but there would be no chance poor donors might be exploited.

Conclusion

The purpose of this study was to empirically test the hypothesis that government compensation of kidney donors would exploit the poor. We ended that if the regime rewards living kidney donors with a package of not-greenbacks benefits worth about $75,000 per kidney, donors would not be exploited.

Much more of import, compensation would likely end the kidney shortage, enabling many more patients with kidney failure to obtain transplants and alive longer and healthier lives. The value of transplantation to a U.Southward. recipient is about $1,330,000, which is an guild of magnitude greater than any supposed exploitation of living kidney donors (nix to $75,000 per donor). Indeed, compensating kidney donors would increase the aggregate benefit to the poor from transplantation about 13-fold to $12.4 billion per year from $0.ix billion currently.

Note this is not a case of 1 group of poor people benefiting from government compensation of kidney donors while another group of poor people is fabricated worse off. Rather, poor kidney recipients are greatly benefited, simply poor kidney donors are no worse off considering they are compensated for the fair market value of their kidney. Moreover, if the government chooses to recoup kidney donors more than $75,000—which information technology could easily afford to exercise and still save coin for the taxpayer—it could ensure poor donors would likewise be ameliorate off, i.e., they would also receive a cyberspace benefit.

Supporting information

Acknowledgments

The authors thank Robert Heller PhD, Heywood Fleisig PhD, Ronald Pisoni PhD, Friedrich Port K.D., Sally Satel M.D., and Philip Simon J.D., for providing important reviews and insight. The data and statistics reported hither have been supplied past the Scientific Registry of Transplant Recipients (SRTR) [32] and the U.S. Renal Data System (USRDS) [1]. The interpretation and reporting of these data are the responsibility of the authors and in no style should be seen as an official policy or interpretation of the U.Due south. authorities.

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Source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205655