Views & Reviews Personal View

We should consider paying kidney donors

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d4867 (Published 02 August 2011) Cite this as: BMJ 2011;343:d4867
  1. Sue Rabbitt Roff, senior research fellow, University of Dundee, Dundee DD2 1LR
  1. s.l.roff{at}dundee.ac.uk

At least three people died today in the United Kingdom because they couldn’t get a kidney transplant. Several thousand more will attend dialysis units. There are increasing numbers of patients, usually young, whose doctors would like to give them “pre-emptive” kidney transplants instead of starting dialysis, which is harsh on the patient and expensive for NHS resources. A transplanted kidney will “pay for itself” within 18 months. Although kidneys obtained within minutes of cardiac death or during the process of “neurological death” are usable and a boon to the recipients, those from living kidney donors give the recipient a better and longer lease of life.

The increase in diabetes and hypertension in the community puts further pressure on the need for kidney transplantation. But the rate of donation of kidneys from deceased and living donors has never kept pace with the need, and has plateaued at about 2000 a year in the UK. At present we have a reimbursement model whereby donors’ costs are covered for several weeks by the NHS, insurers (who well know the cost savings), and employers. Kidney donation is about equivalent to an elective caesarean section in terms of its immediate and long term health risks for the patient.

But there are other models that it’s time we looked at. We have the wage payment model, for services supplied by participants in medical research, who often are admitted to hospital for a fortnight or more and undergo unpleasant, sometimes risky procedures. We have compensation models, for criminal, worker, and military injuries, which have agreed tariffs, such as £2500 for a fractured coccyx and £22 500 for the loss of one kidney.

It would not be such a big step to move towards regulated paid provision for live donors’ kidneys. This would be far different from the illegal organ market that exists now in several countries, and we must not make the mistake of ruling out a properly regulated system because of the depredations of the current illegal market. The standards of care before and after operation would be as good as they are now for kidney donors in the UK. The kidneys would be allocated in the same fair way as they are now.

One reservation that many people express about such a proposal is that it might exploit poor people in the same way the illegal market does now. But if the standard payment were equivalent to the average annual income in the UK, currently about £28 000, it would be an incentive across most income levels for those who wanted to do a kind deed and make enough money to, for instance, pay off university loans.

We have recently moved to allowing donation of strangers’ live kidneys, in which an individual decides to give to someone whom they will never meet and with whom they have no emotional or genetic relationship. That is a huge shift from the approach of last century, when it was largely assumed that genetically related members of families would want to donate among themselves. It isn’t always as straightforward as that. As one potential donor told me, “When my brother was diagnosed my mother went ape because he is her favourite child. She dragged us all down to the hospital to get tested, and I am the only one who is compatible. One day I will get the call and have to do it.”

When I served as a non-medical member on the Unrelated Live Transplants Regulatory Authority we had to look at the motivation to donate of spouses and friends. They were asked to write statements about “what was in it for them.” Many said that giving the kidney would improve the quality of family life, reinvigorate a marriage, or make possible the retirement travel plans they had made together. If we couldn’t see sufficient incentive in this form we had to consider the possibility that the person was being persuaded, or coerced, into giving the kidney. Yet we shy away from other forms of social good, which can be manifested in monetary payments, as incentives for live kidney donation.

Oddly enough, it is not clear in law who owns our body parts even while we are using them. But a 2009 Court of Appeal decision by the Lord Chief Justice in favour of two men whose sperm had perished while it was in the care of an NHS trust could have important parallels for the legal issues around our rights to be paid for the supply of a kidney. Transplant chains, in which matches are found for two or more patients by virtue of donors “exchanging” their kidneys in simultaneous operations, can be viewed as a version of payment.

So it’s time to begin to explore how to pilot paid provision of live kidneys in the UK under strict rules of access and equity. We need to extend our thinking beyond opt-in and opt-out to looking at how we can make it possible for those who wish to do so to express their autonomy in the same way as current donors are encouraged to do by making available a healthy kidney for a fee that is not exploitative.

Notes

Cite this as: BMJ 2011;343:d4867

Footnotes

  • Competing interests: None declared.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.