It is no longer controversial that renal transplantation is the best therapeutic modality for most patients with advanced (Stage 5) chronic kidney disease: over 70% of those who have lived 10 years or more with end-stage renal disease (ESRD) have functioning allografts. While more than 65 000 patients are now awaiting suitable kidneys, this represents only 20% of those undergoing dialysis, many more of whom are likely acceptable transplant candidates. Overall, less than 5% of the ESRD population is transplanted annually (1). With projections of a doubling in demand for transplantation by 2010 (2), the consequences for individuals needing kidneys are foreseeable: extended waiting times that exclude all but the youngest and healthiest of recipients. Unfortunately, even these patients will have accumulated the morbidities of prolonged dialysis. No matter the allocation scheme, the increasingly common endpoint will be the equal opportunity to die on a waiting list (3).
In the current issue of the American Journal of Transplantation, Rothman and Rothman speculate regarding the ‘hidden costs’ of moving toward an incentive-based solution to the kidney shortage: ‘crowding out’ of altruism, altered social interactions and compromised integrity of the medical profession. Indeed, in the context of this editorial, it might seem strange to the uninitiated reader that an article documenting ‘hidden costs’ should be so dismissive of the conspicuous costs of the current system, characterized by the Rothmans as “…moral incentives now very well-established in federal and state law…” in homage to which some 3500 American citizens died last year. We believe that a “…full consideration of the implications of such a system for medicine and for society..” called for by the Rothmans should also include consideration of the extent of suffering (personal and economic) among those without a living donor in the current system, as well as the broader consequences for medicine and society of an erosion of trust in a paradigm that fails so many it was designed to serve (4). Since there is a vast economic benefit of transplantation compared to dialysis (5), and given an estimated charge of $28 billion to Medicare alone for ESRD by 2010 (2), consideration should also be given to the propriety of distributing the escalating financial costs of the current policy across several future generations.
While it would be possible, and perhaps desirable, to rebut each point of the Rothmans' essay, that is not our goal here. To do so risks reducing the debate to the sort of exchange that confuses debating, points with deliberation. Others (including one of us) have offered compelling arguments for the opposite side elsewhere (3,6–8). Most caregivers involved in transplantation occupy neither pole of this debate, but are increasingly haunted by the growing sense that we have lost the wherewithal to address the needs of our patients. At times, it seems easiest to retreat to the assurance that the National Organ Transplant Act of 1984 makes organ markets illegal anyway. We palliate our discomfort over the current dynamic with comfortable bromides about altruism as a prerequisite for respecting human dignity, maintaining that we are ‘protecting’ the interests of donors and recipients alike. We as a transplant community must move beyond intellectual debate and toward realistic and implementable solutions to the current impasse. If financial incentives can be ethically woven into a practical system that respects the moral agency of individuals (including physicians), we should proceed to develop such a system. If not, we should move forward on other fronts.
Our fundamental concern is of participating in (or promoting) an endeavor that coerces organs from otherwise unwilling persons. Yet, with the rise in importance of living donation, we are forced to reflect on whether the actions of a living donor, told that their acquiescence is the only way to prevent the suffering (or death) of a loved one, is really the apotheosis of altruism (3). This concern, that such pressures on donors can generate an amalgam of fear, resentment and other un-selfless motives is poignantly described by Fox and Swazey as the ‘Tyranny of the Gift’ (9). Given the manifest moral and economic costs of the current system, it is becoming less and less clear what we are protecting donors, recipients, or the public at large, from. Since it is not reasonable to expect that human beings will continue to voluntarily suffer and die for precepts to which they do not subscribe, those with the means to pursue transplantation outside the officially sanctioned system will increasingly act on their collective desperation. Indeed, the unintended consequence of the current system of mandated altruism is the unprecedented growth in the underground trade in organs. It is worth emphasizing that this despicable practice would not exist but for the fact of the growing disparity between the demand for and supply of transplantable organs.
Is it plausible to seriously consider incentivizing donor nephrectomy as a solution to the organ shortage? Might such incentives improve the outlook not only for those in desperate need of kidneys, but also for the donors of whom we ask so much and to whom we offer so little? Perhaps. Opponents of such measures will have to concede that not all financial incentives necessarily equate with open markets, nor culminate in exploitation, avarice or a withering of the social fabric (10). Proponents should acknowledge that the ends do not justify the means. There are potential hazards in any new system, and the moral permissibility of financial incentives should be judged by whether they can be implemented in a manner that is demonstrably safe, transparent and respectful of the moral agency of all participants (3).
Reducing the shortage in transplantable kidneys is but the latest iteration of cutting-edge challenges that the transplant community has effectively addressed many times in the last half century. To be sure, technical success does not entail moral progress. Leon Kass asks “How, in this matter of organs for sale, as in so much of modern life, is one to conduct one's thoughts if one wishes neither to be a crank nor to yield what is best in human life to rational analysis and the triumph of technique? Is poor reason impotent to do anything more than recognize and state this tragic dilemma?” (11) Fortunately not. We support efforts to explore all reasonable options to increase the availability of organs for transplantation. At the same time, we believe the transplant community, now more than ever, must renew fundamental ethical commitment to those who provide organs for transplantation, and those who receive them. Perhaps the Rothmans' concerns can be understood as a needed ‘canary in the coal mine’ in regard to the integrity of these commitments. But, the least defensible position is to cling to our discomfort concerning hidden costs, or to tragically shrug our shoulders as a means of avoiding moral hazard. If that becomes our choice, by action or inaction, we need not rely on thought experiments or on heavily qualified examples from social science to realize the repugnant future consequences of more of the same.