For several years, Dr. Arthur Matas, director of the renal transplant program at the University of Minnesota's Department of Surgery, has been advocating for a fundamental shift in the country's kidney donation program. To address a significant and growing gap between the number of people waiting for a kidney transplant and the number of kidney donors, Matas, the immediate past president of the American Society of Transplant Surgeons, says we should create a system to compensate donors for kidneys on a trial basis. Why do we need a compensation program for kidney donors?
In 1980, if you went on the waiting list for a kidney, we could tell you that if you were a straightforward case, we would probably get you a transplant within a year. Now, I tell new patients that it's a five- or six-year wait. People who are acceptable candidates when they are put on the list are dying now before they can get a transplant. On average, more than 8 percent of people on the waiting list are dying. And in some parts of the country, there is close to a 10-year wait.
Doesn't paying people for donations seem a bit unseemly?
People are concerned that if there is compensation you'll hurt the dignity of the person who is the compensated donor as opposed to the person who is the altruistic donor. I don't believe that. I think if you create a culture of dignity around the whole process, we'll be fine. We have paid heroes in our society -- policemen, firemen, soldiers, etc. Donors can be compensated heroes just as well.
So how would a compensation system work?
First, you have to change the law. Second, you have to decide the context of a trial. Would you do it regionally and only allow parts of the country to do it, or would this be something overall in the country? We currently have an allocation system for deceased donors that runs through an organ-procurement organization, which in our area is LifeSource, so you could run this trial through organ-procurement organizations like LifeSource.
This is a hypothetical model and anyone could come up and tweak the details, but a potential compensated donor would call up LifeSource and you would have a screening interview. If they passed that, they would undergo a full evaluation as organized. And then have a panel at LifeSource consisting of, say, a surgeon, nephrologist, social worker, donor advocate, etc., who would review the overall evaluation, and we would have national criteria, and they would approve or disapprove the potential donor. Then run the list the same way that we would do for a deceased donor.
So what kind of evaluation would you need for this?
You would do a detailed psycho-social evaluation, but we do that for a lot of donors already as well. Informed consent is really the basis for all of this. You want to make sure that the potential donor knows all of the risks of surgery, that the donor doesn't have unrealistic expectations about what the benefits would be in terms of the package of compensation.
But it would be the poor who primarily would donate under a compensated donor program, right? I can imagine that not sitting well and that that would be a hurdle that people have to get over.
But I think that's an attitude hurdle. The poor do all sorts of things that the rich don't do for money. They take all sorts of jobs for risks that the rich don't do. Poor and rich make all sorts of decisions about risks like smoking, hang gliding, mountain climbing. We allow people to make all those decisions for themselves.
The real answer to this is that you're just giving the poor another choice. They can choose to do it or not to do it. Poverty may put you in a situation where your choices are somewhat limited, but that doesn't mean that you're not capable of making a good decision about what's in your best interest.
So where does the compensation package come from?
Right now the government and insurance companies pay for dialysis forever, and transplantation is extremely cost-effective compared to dialysis. So it would be, at worst, cost-neutral to them to provide a package of compensation to the donor, and it would probably lead to a cost savings.
So what are the next steps?
The real steps in moving forward would be to get groups of like-minded people together to try and influence Congress. There's been a big change in the transplant community. Five years ago you would find most people against the concept of compensated donations. As the waiting list has gotten longer and people see that other potential solutions are baby steps in the context of the huge need, more and more people are willing to consider a trial of compensated donations.
