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The National Kidney Foundation’s Bizarre Logic

Thursday, June 11, 2009

The public is receptive to the idea of rewarding organ donors. It’s time to leverage that receptivity.

For the last several years, I have been working with other physicians, legal scholars, economists, ethicists, and organ donors to promote the idea that generous souls who give a kidney to a stranger should be rewarded. You can read the basic prescription here.

You would think the National Kidney Foundation (NKF), the nation’s largest advocacy group for people with kidney disease, would applaud our efforts. After all, the foundation laments that thousands “die while waiting for that ‘Gift of Life.’” But instead of locking arms with us, the foundation tries to sabotage any attempt to explore the possibility of rewarding organ donors.

The foundation’s logic is bizarre. When I spoke with Dolph Chianchiano, senior vice president for health policy and research at the NKF, he told me that “compensating donors would cheapen the gift.”

We want to incentivize people to donate to needy strangers so that more transplants will take place.

As a kidney recipient, I find this hard to fathom. When I was facing years on dialysis, any healthy kidney, paid for or not, would have been precious to me. What about would-be donors? Won’t some of them be more likely to donate one of their kidneys or the organs of their family members at death, because of the prospect of a financial reward? And will a grieving mother really say to herself: “I’d love to donate my son’s organs; it would give his tragic death some positive meaning. But wait, a kidney donor somewhere in the country is getting a tax credit for saving a stranger’s life, so forget it.”

Rarely does NKF appeal to reliable data to support their opposition to even pilot trials of incentives (a proposal the foundation actually endorsed in the 1990s). But when they do, they bungle it.

Here is late NKF chairman, Charles B. Fruit, writing in USA Today in 2006:

Payment stands as an affront to those families that have already donated organs of loved ones out of charity. There is evidence to suggest it might prove similarly offensive to future donors. In 2005, the National Survey of Organ Donation found that 10.8% of those polled would be less likely to grant consent for the organs of a deceased family member to be used for transplant if they were offered payment; 68% said they would be neither more nor less likely to grant consent. Thus, there is little data to show that financial incentives would increase donation rates.


The astute and altruistic Virginia Postrel called attention to Fruit’s “misleading math exercise,” as she called it: “to round the figures a bit, 70 percent would be unaffected, and 11 percent would be less likely to grant consent. What happened to the other 19 percent? They were, ahem, conveniently left out—because they would be more likely to grant consent. That’s what’s called a net increase,” she wrote.  

Asked in a poll whether ‘payments’ would affect their willingness to give a family member’s organs, 19 percent answered ‘more likely,’ while 9 percent said ‘less likely.’

Last week, the NKF conveniently disclosed only part of a new study from a nephrology journal. Its “E-Kidney Newsletter” ran an item with the headline “Social Connection Far Outweighs Compensation in Motivating Kidney Donors.” It elaborated: “A potential kidney donor is far more motivated to donate a kidney based on a close relationship with the recipient than on a monetary incentive, according to new research published this summer in NKF’s Journal of Nephrology Social Work.”

Here is the abstract of the full article by Harry L. Humphries and colleagues at Pittsburg State University:

We surveyed a sample of 73 individuals to assess the relationship between social distance, increasing material incentives, and donor motivation. Our results suggest that altruism is significantly related to donor motivation only for donations to immediate family members and that limited material incentives . . . may be important in enhancing donations among individuals unrelated to kidney transplant recipients [italics mine].

First, the article is not about kidney donors, as the NKF implies. It is about attitudes of college students. Second, and key, is that Humphries’s findings actually support our proposal. “The findings of this research,” the authors say, “suggest that altruism alone is not a significant motivating factor for non-directed donations to distant others.” We favor offering rewards to stranger donors. We do not particularly seek to reward the admirable friends and relatives who plan to donate to loved ones. We want to incentivize people to donate to needy strangers so that more transplants will take place.

In 2008, the number of living kidney donors was the lowest it has been since 2000. The number of people in the queue for a kidney, 80,000, is a new high.

There is a modest literature on polls and surveys on attitudes toward donor incentives and it reveals a general receptivity to rewards. One of the larger polls, published by Gallup in 2005 and commissioned by the U.S. Department of Health and Human Services, asked respondents whether “payments” would affect their willingness to give a family member’s organs. Nineteen percent answered “more likely,” while 9 percent said “less likely.” That margin favored donation. Young people were especially receptive. One-third of 18-to-34-year-olds said the offer of incentives would make them “more likely” to give a family member’s organs, compared with 7 percent who said “less likely.” 

We need to leverage the public’s receptivity to the idea of rewarding donors. The picture is bleaker than ever. In 2008, the number of living kidney donors was the lowest it has been since 2000. Even more striking, 2008 was the first year in the history of the waiting list, which began in 1988, when the number of deceased donors was lower than the preceding year. Presumably, the NKF knows this depressing news yet it announced recently that it is revving up implementation of “proven and tested strategies which can end the wait in ten years.”

Proven? Just the opposite: after years of deploying those “tested strategies” the waiting time to transplantation is now longer than ever—five to eight years in major cities. And the number of people in the queue for a kidney, 80,000, is a new high. At least half of them will survive the wait for a transplant. As it is, 4,400 people died in 2008 while waiting for a kidney, according to the United Network for Organ Sharing.

My colleagues and I have our work cut out for us. The NKF has a posse of lobbyists on call and is high profile on the Hill. As the vigilant opposition we will be busy exposing the foundation’s specious arguments, bad facts, and half-truths. And, unlike the NKF, we will continue advancing a pragmatic alternative to more of the same.

Sally Satel is a resident scholar at the American Enterprise Institute. She is the editor of When Altruism Isn’t Enough (AEI Press).

FURTHER READING: Satel wroteWhen Altruism Isn't Moral,” arguing for a regime of donor compensation, and “The Human Factor” on ditching the ‘brain disease’ model that is popular with scientists and focusing on treating drug addicts as people with the power to reshape their own lives.

Image by Darren Wamboldt/Bergman Group.

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