Regulated payments for living kidney donation: an empirical assessment of the ethical concerns

Abstract

Background: Although regulated payments to encourage living kidney donation could reduce morbidity and mortality among patients waiting for a kidney transplant, doing so raises several ethical concerns.

Objective: To determine the extent to which the 3 main concerns with paying kidney donors might manifest if a regulated market were created.

Design: Cross-sectional study of participants' willingness to donate a kidney in 12 scenarios.

Setting: Regional rail and urban trolley lines in Philadelphia County, Philadelphia, Pennsylvania.

Participants: Of 550 potential participants, 409 completed the questionnaire (response rate, 74.4%); 342 of these participants were medically eligible to donate.

Intervention: Across scenarios, researchers experimentally manipulated the amount of money that participants would receive, the participants' risk for subsequently developing kidney failure themselves, and who would receive the donated kidney.

Measurements: The researchers determined whether payment represents an undue inducement by evaluating participants' sensitivity to risk in relation to the payment offered or an unjust inducement by evaluating participants' sensitivity to payment as a function of their annual income. The researchers also evaluated whether introducing payment would hinder altruistic donations by comparing participants' willingness to donate altruistically before versus after the introduction of payments.

Results: Generalized estimating equation models revealed that participants' willingness to donate increased significantly as their risk for kidney failure decreased, as the payment offered increased, and when the kidney recipient was a family member rather than a patient on a public waiting list (P < 0.001 for each). No statistical interactions were identified between payment and risk (odds ratio, 1.00 [95% CI, 0.96 to 1.03]) or between payment and income (odds ratio, 1.01 [CI, 0.99 to 1.03]). The proximity of these estimates to 1.0 and narrowness of the CIs suggest that payment is neither an undue nor an unjust inducement, respectively. Alerting participants to the possibility of payment did not alter their willingness to donate for altruistic reasons (P = 0.40).

Limitation: Choices revealed in hypothetical scenarios may not reflect real-world behaviors.

Conclusion: Theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence. A real-world test of regulated payments for kidney donation is needed to definitively show whether payment provides a viable and ethical method to increase the supply of kidneys available for transplantation.

Primary funding source: None.

Conflict of interest statement

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2133.

Figures

Figure 1. Study flow diagram

*Participants with any of the following criteria were considered clinically ineligible to donate: age >65 years; current kidney disease; congenital solitary kidney; family history of polycystic kidney disease; or history of heart disease, high blood pressure requiring more than 1 medication, diabetes, cancer, or hepatitis.

Figure 2. Adjusted proportions of participants willing to donate a kidney to family members and to patients on the waiting list as functions of payment and risk

Scenarios in which donors would receive payment of $100 000, payment of $10 000, or no payment are illustrated. As evident from the roughly parallel nature of the lines within each recipient group, no interaction between risk and payment occurred when the recipient was a family member (odds ratio, 0.99 [95% CI, 0.94–1.04]) or when the recipient was the next patient on the waiting list (odds ratio, 0.97 [CI, 0.93–1.01]).

Figure 3

Adjusted proportions of participants willing to donate a kidney to a patient on the waiting list as a function of income and payment. Participants whose annual household incomes were ≤$20 000 through >$100 000 are illustrated. The plotted proportions have been adjusted for risk for renal failure, donor age, donor sex, version of the survey packet received, and interval of participant recruitment. Error bars represent 95% CIs around each adjusted proportion. As evident from the roughly parallel nature of the lines, no interaction between payment and income occurred (odds ratio, 1.01 [95% CI, 0.99 –1.03]).