Between Scylla and Charybdis: Charting an Ethical Course for Research Into Financial Incentives for Living Kidney Donation

Abstract

New approaches to address the kidney scarcity in the United States are urgently needed. The greatest potential source of kidneys is from living donors. Proposals to offer financial incentives to increase living kidney donation rates remain highly controversial. Despite repeated calls for a pilot study to assess the impact of financial compensation on living kidney donation rates, many fear that financial incentives will exploit vulnerable individuals and cast the field of transplantation in a negative public light, ultimately reducing donation rates. This paper provides an ethical justification for conducting a pilot study of a federally regulated approach to providing financial incentives to living kidney donors, with the goal of assessing donors' perceptions.

Financial donor incentives: Problems with pilots

“…They argued for (a) a regulated system of government-based payments, thus ruling out direct sales and free markets, and endorsed (b) a regulated system of fair allocation according to existing principles. Succeeding debates did embrace this framework, but many questions remained unanswered [15]: payments directly to donors to cover donor costs of travel [2], which implies that not all costs are covered and/or conceptualized as costs. Often gifts are allowed as an expression of gratitude, e.g.…”

“…As described, one can benefit donors in many ways [15]: directly-"cash", indirectly-"in kind", through the level of payment, and/or conditions, e.g. a "cooling off period" in months between the decision to donate and the operation [2,9].…”

“…Whereas one proposal suggests amounts up to $50.000 [9], another proposal seeks to find the middle ground by "not giving too much and not giving too little" [2]. Often, in-kind rewards are advocated [15], but some proposals favor only health-related benefits, whereas others suggest alternative rewards, such as a retirement fund, income tax credit, a tuition voucher [9,15] or contribution to a charity [15].…”

“…Fisher et al [2] have elaborated their objectives and endpoints in more detail. The authors mention the risks of exploiting vulnerable individuals and a negative public reaction toward payment.…”

“…Several researchers have advocated pilot studies to study the effects of financial incentives, including Schold and Reed [1], Fisher et al [2], Matas et al [3,4,5], the Working Group on Incentives [6], Gill et al [7], Hays et al [8], and Satel and Cronin [9]. The general claim of such studies is that real-life experiments can address speculations regarding the impact of incentives.…”