Fiscal incentive weighed to boost US organ supply

By Carey Goldberg, Globe Staff, 10/8/2003

With more than 6,000 Americans dying each year while they wait for organ transplants, medical and political leaders are considering a desperate experiment long viewed as taboo: rewarding the families of brain-dead donors with thousands of dollars in hope of increasing the organ supply.

The American Medical Association, which represents nearly 300,000 doctors nationwide, and the United Network for Organ Sharing, the national group that oversees the organ supply, have endorsed the idea of a test on whether offering financial incentives will lead to a rise in donations.

Earlier this year, a group of academics, doctors, clerics, and others created The Ad Hoc Committee for Solving the Intractable Organ Shortage, the first group organized expressly to lobby for the idea of payment to encourage organ donations.

Now, a bill in Congress proposes overturning a section of the current law that bars payment for organs. Some advocates say its chances appear better than similar attempts in the past. "The number of deaths is so much more glaring, now that people who were once against the idea now recognize that it might have merit," said Dr. Thomas Peters, director of the Jacksonville Transplant Center in Florida and a member of the ad-hoc committee.

Peters, who has been following the issue in Congress, said he believes that the bill, sponsored by Representative James C. Greenwood, a Pennsylvania Republican, is the first to have a real chance of attracting broad support.

The idea of mixing money into heart-wrenching decisions about organ donation is repugnant to many and prompts fears that sinister organ farms could traffic body parts or that the bodies of the poor could be exploited to supply the rich.

But proponents' central argument has gained strength with each passing year: The waiting list for organs, now at about 82,000 people, keeps growing, and nothing has succeeded in significantly increasing the number of donations. Almost 60 percent of those on the list are expected to die waiting.

Research indicates that the families of less than half of possible donors agree to donate. The transplant community has tried various initiatives, from public awareness campaigns to donor registries, that have helped some.

But the gap keeps growing.

Overall, the waiting list has been increasing by about 12 percent a year, while the number of brain-dead donors has been rising by under 3 percent, to about 6,000 a year.

A recent study estimated that the number of potential donors each year is about 17,000.

Proponents of financial incentives emphasize that they are not proposing the buying and selling of organs and that the incentives would not be offered to "live donors," those who plan to go on living after they volunteer an organ.

Rather, members of the ad hoc committee and other advocates propose that the federal government finance carefully controlled pilot studies to determine whether donation rates rise when families of brain-dead donors receive a standard sum, perhaps $5,000, as thanks for public service.

They say the payment is comparable to the money given to families of soldiers who die in the line of duty. Another suggestion would give a $10,000 tax credit to the donor's estate.

The AMA has not endorsed a specific figure, and the United Network for Organ Sharing endorses legislation that could carefully study the effect of incentives, whether financial or nonfinancial.

For more than a decade, advocates have been pushing for such financial incentives, said Harold Kyriazi, a neuroscientist at the University of Pittsburgh and the founder of the ad hoc committee. "But it's always been sort of a fringe voice," he said. "Now, I'd call it a vocal minority."

Opposition from groups including the American Society of Transplant Surgeons remains broad and strong. Dr. Francis L. Delmonico, a Massachusetts General Hospital transplant surgeon who is active in the National Kidney Foundation, said financial incentives inevitably raise many of the same ethical problems inherent in the outright buying and selling of organs."Any attempt to assign a monetary value to the human body or its body parts, even in the hope of increasing organ supply, diminishes human dignity and devaluates the very human life we seek to save," he testified at a congressional hearing on increasing organ donation in June. He also warned that payments could "undermine the integrity of the donor pool" and would give relatives incentives to cover up flaws in a potential donor's medical history to get the money.

Other opponents argue that some families who would have donated a patient's organs out of altruism may be turned off by the money and that donations could actually drop or that some families could pull the plug more quickly on their relatives.

The AMA was closely divided over endorsing the incentive experiment, initially shelving the proposal before the organization finally endorsed it last year.

Ultimately, supporters say the only way to determine whether money works as an incentive is to test the ideas -- whether they are gifts that go straight to the family, cash to cover funeral expenses, or tax benefits for the estate of the donor.

"The point is to say, `Look, let's set up a few demonstration projects,' " said Alan Eisenberg, an adviser to Greenwood.

Without knowing the effects that those financial incentives would have on donations, proponents say, it is impossible to assess the balance between harm and good.

If the proposal is approved, the United States would apparently be the first country to try an official program using financial incentives, said Lloyd Cohen, a member of the ad hoc committee and a George Mason University School of Law professor who has written extensively on organ markets.

The economic principles involved in such incentives are elementary, he said. "If you pay for something, you're more likely to get it than if you don't."

Eisenberg said Greenwood has not yet been trying to sign up cosponsors for the bill, which was introduced in July.

But the measure has been drawing support across party lines, he said, and, in general, editorial boards and national groups such as the AMA "are starting to build up this swell of pressure to say, `Let's try to do this.' "

He also said that Tommy G. Thompson, US secretary of health and human services, would probably support trying the idea. Thompson's office did not respond to a request for his position.

John M. Newmann, an economist and two-time kidney recipient, opposes the sale of organs from live donors, but said he strongly supports careful research to test financial incentives.

"Everyone seems to have a very strong opinion on one side or the other," he said. But "no one offers any objective data to support these opinions, because there are none."

Carey Goldberg can be reached at goldberg@globe.com.