No Ethical Free Lunch in Organ Donation Policy

Jennifer Chandler points to the ethical trade-offs in any policy to increase organ donation.


The suggestion that we should pay people to donate a kidney is raised from time to time as a possible solution to the shortage of donated organs that leaves many suffering from the consequences of kidney failure.  Detractors characterize the payment for organs solution as the “whack-a-mole of transplant policy.”   In their view, this “solution” to the organ shortage is rediscovered every other year by commentators who fail to provide a convincing answer to the real ethical concerns raised by organ markets.  One of these real concerns is that in a system of paid donation, it is the least well-off who will disproportionately end up supplying the kidneys for transplant.

Barnieh et al. surveyed a sample of Canadians in 2011, finding that 45% of the public were comfortable with a cash payment for a kidney.  Recently, they calculated that a $10,000 payment for a kidney would be cost-effective if this payment produced a five percent increase in donations.  They noted the concern that cash payments would lead to a system that exploits the poor, but reported that among those initially uncertain or unwilling to donate, roughly similar proportions of both poorer and wealthier survey respondents said that they would consider donation for a cash payment.  Of course, one cannot be sure that what people say in a survey is what they would actually do in real life.

The First Kidney Transplant - Medical Team & Patients - From left: Recipient Transplant Surgeon Joseph E. Murray, Recipient Patient Richard Herrick, Nephrologist John P. Merrill, Donor Patient Ronald Herrick and Donor Transplant Surgeon J. Hartwell Harrison (Boston MA, 1954)

The First Kidney Transplant – Medical Team & Patients – From left: Recipient Transplant Surgeon Joseph E. Murray, Recipient Patient Richard Herrick, Nephrologist John P. Merrill, Donor Patient Ronald Herrick and Donor Transplant Surgeon J. Hartwell Harrison (Boston MA, 1954)

However, we do have some evidence from “real life,” albeit not in Canada.  Evidence from the government-regulated system of payment for kidneys in Iran, as well as evidence from illegal markets in countries like Pakistan suggests that the bulk of paid donations tend to come from those who are the least well off.

Ghods and Savaj studied a sample of 500 paid live kidney donations in Iran in 2001, finding that 84% were poor, 16% were middle class and none were rich.  (In their view, this was acceptable as long as the recipients were roughly comparable in terms of wealth.  In fact, 50% of Iranian recipients were poor, 36% were middle class and 13% were rich).  In a more recent sample of nearly 500 Iranian donors reported by Malakoutian and colleagues, 62% were below the poverty line and 70% fell within the lowest 20% by income in Iran. The disparities are worse in unregulated illegal markets, such as in Pakistan where Naqvi and colleagues documented donations from a group of largely illiterate bonded labourers in Pakistan, where the majority of recipients are foreign and relatively wealthy.

Although there are truly remarkable people who donate a kidney to a stranger without any reward, shouldering the risks and inconvenience to benefit a fellow in dire need, the fact of the matter is that few of us do this.  It seems intuitively likely that paid donation will bring forth donations from less well off rather than wealthier people, and the evidence from abroad bears this out.  This is a troubling flaw in systems of paid kidney donation.

That being said, there is also a credible argument that our current system is ethically flawed.  We have obligations of solidarity to those in our communities whom we could easily help at nearly zero cost to ourselves (e.g. through registering as willing to donate our organs after our death), and we have obligations to reduce the desperation that drives the international black market in organs.

Our obligation to our fellows is all the more striking when we consider that if we were to need an organ transplant, I suspect that most of us would want one.  The observation that few register as posthumous donors but most would accept a transplant has led to another form of donation incentive in two countries so far:  the so-called reciprocity system.  Under such a system, those who register to donate after death have preferential access to an organ for transplant if, during their lifetimes, they need one.  So far, both Singapore (in the late 1980s) and Israel (in about 2010) have adopted this system. Although this type of system is unlikely to close the gap between the need for transplants and the supply, it may improve matters.  Note also that while this system creates a donation incentive, it is one that is equally valuable to all.  Therefore, unlike financial compensation, it is unlikely to create a situation where the bulk of donations come from the poorest.

However, there is no ethical free lunch, and there are objections to reciprocity systems.  One such objection is that they represent a form of organ allocation based on moral judgment.  In other words, the preference reward is akin to giving organs preferentially to those we think are good people.  This is a dangerous way to allocate scarce life-saving resources – who gets to say who the “good people” really are?  It may also ignore the fact that some members of society may have greater reason to be reluctant to donate (e.g. where some minorities have greater mistrust in the medical system).  Our recent research suggests that Canadians are divided on whether a reciprocity system is appropriate for Canada.

What then should we be doing?  At a minimum, we should all take the small step of registering to donate after our deaths, and we should also inform our loved ones of our desire to donate in order to encourage them to consent to organ donation if asked as next-of-kin (this will also reduce the burden of choice that they will otherwise bear).  We may also need to accept the ethical trade-offs in other policies to increase donation, although it is far from clear that we should do so in the case of paid kidney donation.

Jennifer Chandler is Associate Professor, Faculty of Law, University of Ottawa


  1. Roxanne Sperry · · Reply

    The title of this article attempts to sound clever, but leaves me without a chuckle. I believe the author is stating that we must sacrifice ethics if we are going to expand the donor pool through paid donation.

    To start, the author has done what many others have done, and that is to try to apply the Iran experience and the ILLEGAL UNREGULATED markets in Pakistan to Canadian and North American transplant programs. It is unlikely that in any transplant program thoughout North America that the poorest of the poor or illiterate bonded labourers woud be deemed as a suitable donor. It is clear that the author fails in understanding that in North America living donors are intensley scrutinized to be an appropriate donor medically and phsycologically with considerable attention given to their social circumstances. I don’t know what is done in Iran to evaluate a potential donor. I am sure in the illegal unregulated markets the bar is set extremely low if any evaluation of donor suitability takes place at all. If we are going to have meaningful discourse and advance the discussion about paid donation in North America we should stop using Iran and especially illegal markets as examples for paid donation.

    Second, I take issue with the value of the kidney ($10,000). The real monetary value of the kidney becomes apparent in the very rare event the donor suffers a loss of life or encounters other devastating circumstances as a result of donation. To that end, I suggest that a direct pay out upon donation model may no be in the best interest of society or the donor. I suggest that a national trust should be established for when things go wrong. We need to ask, do living donors have a safety net that will pay off the mortgage or put a child through university if they are harmed by the act of donation. I doubt that any religious organization would have a problem with supporting and protecting the donor’s assets in thier time of need.

    Finally, the author tells us what we should do, this goes against the principle of donation. Organ and tissue donation occurs because we ASK not because we tell people what to do.

    Unfortunately, I feel this article will do very little to help advance organ donation and may have done more harm then good.

  2. Rudolf García-Gallont · · Reply

    Objective, clear, well stated. Difficult issue, but very well presented.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: