Financial Neutrality in Organ Donation
Authors: Alexander M. Capron, Francis L. Delmonico, Gabriel M. Danovitch
Journal: Journal of the American Society of Nephrology (2019)

In their recent Perspective article on “Removing Disincentives to Kidney Donation,”1 McCormick et al. begin by noting the “widespread agreement” existing among physicians and policy makers that removing financial disincentives to kidney donation would increase the number of donors and be fairer. The article’s quantitative analysis, however, extends far beyond removing such disincentives to items that proponents—who include the article’s authors—have cited as reasons to pay for organs.2–4 The principle of financial neutrality “means that donors and their families neither lose nor gain financially as a result of donation.”5 It is a long-standing component of The Transplantation Society’s ethical standards, of the “Guiding Principles” of the World Health Organization (from 1991 and reiterated in 2010), and of the US National Organ Transplant Act of 1984. We agree with McCormick et al. that it is important to reconsider the current policies of the National Living Donor Assistance Center that restrict which donors are eligible. Providing reimbursement for donors’ “reasonable and verifiable expenses”6 is laudatory, but McCormick et al. propose much more. Drawing on estimates from past studies of lost income and of the costs of dependent care, the authors recommend giving organ donors tax credits of up to $6000, as a fixed amount for reasons of “administrative simplicity.” But, like any payment not based on an actual expense, this lump sum will serve as a financial incentive, especially for poorer and younger donors. A tax credit is equivalent to a cash payment. Additional “disincentives” that the authors propose to cover have previously been more accurately described as “incentives” by organ market proponents.7 For example, they would give donors a $6500 tax credit for the pain and discomfort of the nephrectomy. But the physical burdens of donation cannot be quantified in fixed financial terms. Should they eventuate in economic costs, such as for medical care or income replacement, then financial neutrality dictates that these costs are covered.8 But paying a lump sum for pain and discomfort, the degree of which is highly variable, would undercompensate those donors who experience complications while providing a substantial windfall to the great majority who do not. More importantly, the reason that donating a kidney is regarded as an admirable act is precisely because it creates some burden and risk for donors. Paying $6500 for something that is inherent in the donation turns the kidney from a gift into a market commodity, a commodity whose “value” has no fixed determinant and would no doubt vary from country to country. The authors also attempt to transform things that might discourage donation, such as a fear of dying or diminished quality of life, from general decisional factors into economic disincentives. For example, they propose to overcome donors’ possible concerns about experiencing a decrease in the long-term quality of life. They use the 0.9% chance of developing ESKD plus the smaller risk of other less-serious consequences to produce a “total disincentive” of “about $7910.” But they offer no reason to think that a dollar figure based on a remote risk would operate the same way in donors’ decision making as do out-of-pocket costs and lost income. Fairness to donors does require that health care be provided to those who suffer adverse side effects as part of assuring donors that “financial neutrality” will continue to cover future costs. This is the appropriate way to address any concerns on the part of potential donors, not a fixed dollar figure that claims to neutralize a hypothetical disincentive effect. The authors admit that it is “challenging” to calculate the dollar equivalent of the concern felt by a donor that a kidney donated today will not be available to be given to “a relative or close friend [who] might need a kidney in the future.” The manner in which they set the “magnitude of [this] disincentive” at $7728 is speculative, and the result will not be helpful in the decision-making potential donors. The “voucher” system already described in detail by Veale et al.9 (and successfully implemented by the National Kidney Registry) gives individuals designated by the donor priority for a transplant if needed, without paying money to incentivize the donor. McCormick et al. conclude that their total estimate of “almost $38,000” is “much larger than the numbers usually mentioned.” This is not surprising because they propose reimbursing far more than actual costs and do not apply the term disincentives in the manner used in prior efforts to achieve financial neutrality.10 If policy makers accept their definition of disincentive—namely, any reason why people may decline to donate—then the amount becomes untethered from donors’ financial costs. An organ donation is financially neutral when the donor has received no material reward for the organ as such but has been reimbursed for actual, documented out-of-pocket expenses and lost earnings, and has been assured that future medical expenses and lost income resulting from the donation will be covered. Financial neutrality is just and fair whether it increases the rate of donation or not. It does not involve creating hypothetical donors with theoretical average costs and providing that amount as a lump sum. Neither does it involve treating “pain and discomfort” or other noneconomic adverse consequences of being a donor as though they were financial costs. Monetizing such items becomes a way of paying donors for their organs. Disclosures None.