The AJT Report
News and issues that affect organ and tissue transplantation
Is the system of paid donation in Iran a success? It depends on whom you ask. “The success of the Iranian system is well beyond its failures,” says Ahad J. Ghods, MD, FACP, head of the Transplantation Unit at Hashemi Nejad Kidney Hospital, Iran University of Medical Sciences, Tehran. He points to Iran's elimination of a kidney transplant waiting list, an effective ban on transplant tourism, and a regulated system of donation coordinated by a charitable organization.
Nasser Simforoosh, MD, professor and chair of the Department of Urology and Kidney Transplantation, Shaheed Labbafinejab Medical Center, Tehran, says that 25 years of hard work and a lot of personal sacrifices have produced a system that decreases patient suffering.
But Gabriel M. Danovitch, MD, medical director for the Kidney Transplant Program at the University of California, Los Angeles, thinks that “people tend to forget about the donors.” He mentions a report on poor donor quality of life from Iranian urologist Javaad Zargooshi, MD, associate professor of urology at Kermanshah University of Medical Sciences in Kermanshah, Iran. Dr. Zargooshi is an outspoken critic of the Iranian system. In an article titled “Quality of Life of Iranian Kidney Donors” published in The Journal of Urology, he reported that most of the 310 donors interviewed did not believe the financial reward compensated for what they had lost.1“None were able to remove themselves from poverty and debt or change their lives radically. Quality of life was impaired in all aspects,” he reported.
Francis Delmonico, MD, director of medical affairs for The Transplantation Society and an advisor to the World Health Organization, says that “once you put cash payments in the issue, it brings brokers and different prices that have to be borne by families. That's something that is unavoidable in their system and is something that we wouldn't want to foster for the rest of the world.”
Some critics question the morality of a system that provides financial compensation to encourage donors (most of whom are poor) to undertake a serious medical procedure that does not benefit them. Proponents of the Iranian system argue that ethical considerations should include the needs of society as a whole, especially when altruistic donations don't meet the urgent demand for kidneys.
Basics of the Program
The Iranian system includes the following components:
- • Potential recipients and donors are referred to the Dialysis and Transplant Patients Association (DATPA), a charitable organization that arranges medical evaluation and referral to transplant centers.
- • Donors must have next-of-kin consent.
- • The government provides the equivalent of $1,200 U.S. dollars and one year of medical insurance to each donor. In addition, DATPA arranges for a private meeting between donor and recipient, at which the recipient offers an additional cash reward to the donor. If the recipient is poor, an Iranian charitable organization provides the donor reward.
- • Iranian law requires that transplantation can only be carried out between citizens of the same country.
- • Most transplants are performed in university transplant centers, with the surgeon's fee paid by the government, which allows people of all socioeconomic levels to be accommodated. Medical teams and hospitals are not involved in the financial rewards for donation.
SOURCE: IRANIAN MINISTRY OF HEALTH.
According to 2006 statistics from the Iranian Ministry of Health, 75% of kidneys came from living unrelated donors, 13% from deceased donors, and 12% from living related donors.
The Iranians have not been shy about discussing their system in professional circles, and some proponents and critics have pointed out the benefits and shortcomings of what the Iranians call their model of rewarded gifting.2 But there is a shortage of publications in the peer-reviewed international literature. As Tehran University of Medical Sciences nephrologist Mitra Mahdavi-Mazdeh, MD, notes, “We are assigned to introduce it openly and show the important regulation which exists, and to call for necessary upgrading. The international community can objectively show their concerns, which may help us to convince decision makers to make necessary changes.”
Flaws in the System
At a 2006 meeting of the International Forum on Organ Donation and Transplantation in Madrid, Spain, Iranian Ministry of Health senior expert Alireza Heidary Rouchi, MD, described the benefits of the rewarded-gifting model and also noted some of the disadvantages, such as no long-term donor follow-up and no pre-surgical psychiatric evaluation.
Dr. Ghods, a well-known proponent of the Iranian system, admits that the exchange of money between recipient and donor is a problem. “The government should increase the amount of donor award,” he says. “There should be sufficient financial incentives and social benefits to each paid donor by the government or by charity donations in order to eliminate the rewarding gift. Unfortunately, the health authorities do not pay attention and do not give priority to [the resolution of] this very important ethical issue.”
Regarding donor health, most Iranian transplant professionals acknowledge that a lack of long-term donor follow-up is one of their biggest problems.
Arthur Matas, MD, director of the Renal Transplant Program at the University of Minnesota, Minneapolis, and a long-time proponent of paid donations in the United States, notes that the problem isn't limited to Iran. “We need to realize that America has not done a very good job of donor follow-up either,” he says. “This is something that should be established for all countries, including our own.”
And then there's the question of deceased donations. Critics claim that the Iranian system discourages donation of deceased organs, while others contend that a 2000 law legalizing and defining brain death criteria has led to a slow but steady increase in deceased donor organs.
Based on his conversations with Iranian colleagues, Dr. Danovitch says that Iran has only a rudimentary deceased organ donation system with no impetus for family members to give permission for donation.
However, Dr. Rouchi stresses that Iran's deceased donor transplantation program is growing. From 2000 to 2006 there were 338 liver, 122 heart, 20 lung, seven pancreas, 28,838 cornea, 1,380 heart-valve, and 1,366 bone transplants.
Finally, there's the question of the Iranian waiting list. Some proponents of the Iranian system claim that the waiting list was abolished in 1999, but Dr. Ruchi notes that there are more than 14,000 patients on dialysis in Iran, and “for half of these patients, transplantation is indicated.” Dr. Ghods offers an explanation for possible discrepancies, saying that many patients are from villages and small towns where they do not receive a diagnosis, are not referred for dialysis therapy, and therefore aren't on a waiting list.
So, is the Iranian paid donation system a success? There's no doubt that Iranian citizens receive desperately needed kidney transplants, transplant tourism has been eliminated, and proponents report public acceptance of the rewarded-gifting model. However, debate continues over the ethics of paid donation from poor Iranians and the well-being of donors who are not followed over the long term.