Is it time to pilot paying for organs?

Last year the BMJ’s news editor, Annabel Ferriman, had one of her kidneys removed so she could donate it to a friend. Her motivation? “I did it entirely voluntarily and have derived a great deal of satisfaction from it” (doi: 10.1136/bmj.a277). Is this altruistic act, and others like it, the answer to the growing gap between the demand for kidneys and the supply?

Ferriman’s experience was not all plain sailing. From the breezy offer at a party to the operation itself took nearly a year and a half, and although the outcome has been good for both donor and recipient she describes frustrations and delays that made her sometimes wonder why she had ever volunteered. She understands that the needs of sick patients must always take priority over those of a healthy potential donor. But unless the living donor programme is properly resourced, she doubts its chances of scaling up to meet demand.

Yet this is the hope. Ferriman’s nephrologist, B S Fernando, writes that work-up times are falling (doi: 10.1136/bmj.a277) and, according to UK Transplant, the number of living donor kidney transplants is increasing in the UK, from 461 in 2003-4 to 829 in 2007-8, contributing about a third of the total number of kidney transplants performed in the UK.

The remaining two thirds of donated kidneys come from deceased donors—also, it should be remembered, through an act of altruism. John Coggon and colleagues argue that this altruism can and should be enlisted as a factor in the drive to increase deceased donor transplants (doi: 10.1136/bmj.39575.561898.94). Doctors are often constrained by fears that it is unlawful to alter a dying patient’s management solely to protect their organs. In fact a patient’s best interests may be served by ensuring their organs can be donated, in line with their known views and values, even if this means modestly prolonging cardiorespiratory support.

But given that the current shortfall in kidneys runs to several thousand each year in the UK alone, should we be looking beyond pure altruism? Arthur Matas puts the case for paying donors within a tightly regulated system, arguing that legislating against this is paternalistic and that altruistic donation will never meet demand (doi: 10.1136/bmj.a157). But Jeremy Chapman says this would be disastrous: far from increasing the availability of organs it would increase the risks to donors and recipients and cause an implosion in organ donation (doi: 10.1136/bmj.a179). M A Noorani bears witness to the impact in Pakistan of transplant tourism (doi: 10.1136/bmj.39559.489051.94), a term Leigh Turner inveighs against (doi: 10.1136/bmj.39559.626632.94). But one obvious cause is the shortage of organs in the rich world. “It is the moral duty of governments to ensure that enough organs are available for transplantation,” Noorani says.

Many of the arguments against paying donors are based on experience of poorly regulated systems that are vulnerable to coercion and black market trading across borders. In the spirit of evidence based policy making, is it time to pilot payment of donors by the state within a strictly regulated and geographically limited system? Potential benefits of a state payment system as opposed to a commercial market could include allocation by need rather than ability to pay, an increase in the number of unrelated living donors, protection of the poor from exploitation, and an end to transplant tourism. There is room for moral outrage, but we should direct it towards the fact that each year thousands of people’s lives are blighted and cut short for want of a transplant.