Promotion of Altruistic Donation (2009)

Altruistic donation of organs and tissues, “the gift of life,” has been the linchpin of clinical transplantation since its inception. Grieving relatives originally introduced the concept, wanting to ensure that the sudden and tragic death of their loved one could be meaningful in saving the life of another. Healthy individuals, desirous of giving all or a part of a vital organ to a relation, a friend, or even a stranger in need reinforced this altruistic gesture. The nobility of these acts has set the field of organ transplantation uniquely apart from all other areas of medicine. But with demand for organs persisting, and despite the generosity of willing donors and donor families, rampant commercialism for organs (first noted by transplant professionals in the 1980s) has attracted increasing public notoriety and ethical objections. In direct response to such activities, the National Organ Transplant Act was drafted in the United States to prohibit specifically the commercialization of human organ donation. Strengthening an international chorus of objections, the Istanbul Declaration states plainly that transplant commercialism is inevitably associated with organ trafficking, because it targets the indigent and impoverished and leads to inequity and social injustice (1). The guiding principles of the World Health Organization object to organ sales for similar reasons. As an alternative to such untoward practices, Hippen and Matas (2) proposed a regulated trial of financial incentives to increase both the number of organs available from live donors and preserve the well being and dignity of the donors and their families. Although the idea of reimbursement of donor expenses is endorsed by most professionals in the field, the proponents of a regulated trial unfortunately provide no organizational details (3). What would be its control group? How would the impact of financially incentivized donation on “altruistic” donation be measured? The possibility of a trial of payment for organ donors in the United States could set into motion an unregulated national patchwork of schemes that could vary between individual states and regions. Will transplant programs in neighboring states be vulnerable to competitive “regulated” trials? Surely, if we wish to have such a trial, we should first measure the impact of systematically removing financial and other disincentives to donation and by defining and systematizing living donor “best practices.” It is important to note that a regulated trial of financial incentives has been attempted already and has been long underway in Iran. However, the experiment has been unsuccessful even in that most controlled society. Despite stringent regulations, the government has failed to fix the price for an organ, outlaw brokers, prevent Internet solicitation for vendors, and ensure the financial and personal integrity of the donors. Indeed, the Iranian investigators themselves have recently reported the experience and concluded that the “Iranian model” should not be considered for the rest of the world (4). Important realities concerning the wait list need to be addressed. A substantial proportion of those who die “while waiting” may not be active candidates; these ineligible or inactive individuals would not be helped by a trial of financial incentives. In addition, approximately 40% of those who are dying on the wait list would not be affected, because they are in need of extrarenal organs that cannot be purchased by a living donor. At the same time, potential support for live donors must be encouraged. Federal protections could be enacted for job security, assured donor leave, and the provision of health and life insurance for donation-related events that would provide donor care and remove obstacles for those who wish to be organ donors. The international community is calling its professional colleagues in the United States to continue to pursue the gains we have collectively achieved in combating organ trafficking through the tenets of the Declaration of Istanbul and other global statutes. It is critical that the concept of the altruistic donor be preserved and encouraged. Nicholas Tilney Joseph Murray Richard Thistlethwaite Doug Norman Francis Delmonico Douglas Hanto Alan Leichtman Gabriel Danovitch Mohamed Sayegh Ron Shapiro William Harmon Oscar Salvatierra Dan Brennan Sue McDiarmid Peter Stock Liz Pomfret William Bennett David Conti Bob Metzger Minnie Sarwal A. Benedict Cosimi Brigham and Women's Hospital Boston, MA