Doing Well By Doing Good

The Wall Street Journal, March 16, 2007

By Sally Satel

March is National Kidney Month. The House of Representatives celebrated by passing the Charlie W. Norwood Living Organ Donation Act last week, a law intended to increase the number of patients receiving kidney transplants. Named for the late congressman from Georgia who underwent a lung transplant, the new legislation makes it easier for so-called paired-kidney exchanges to take place. It passed 422-0 and is expected to sail through the Senate.

Any mechanism that increases the supply of kidneys is a blessing. Today, over 70,000 people need a kidney. If they cannot get one from a friend or relative they must wait on the national list for a deceased donor organ. Last year, only one-fourth of all candidates got lucky.

The Norwood Act is specifically designed to help patients who already have a willing donor but cannot receive the kidney because of biological incompatibility. If this couple can trade with another mismatched couple, the transplants can take place: the donor from couple A gives his kidney to the compatible recipient of couple B, and vice versa.

The virtue is that two lives are saved instead of none. Without the exchange, both patients would languish on dialysis. With wait times of five years or more they would face a 50-50 chance of dying or becoming too sick to get a transplant before their names were called. Also, every individual who gets a transplant is taken out of the queue and helps those behind him move up a slot. Thus, the more exchanges, the less suffering.

Congress stepped in because many transplant centers will not perform exchanges. Administrators fear violating the 1984 National Organ Transplant Act (NOTA) which makes it a felony to give or receive something of worth — or “valuable consideration” — in exchange for an organ. Their anxiety stems from a years-old memo from Department of Health and Human Services that gave confusing guidance as to whether a kidney itself was “valuable” under the law. The Norwood Act ensures that the federal law intended to prevent the sale of organs by living donors does not inadvertently prohibit paired donations.

How many additional transplants could result from more such swaps? Estimates range from between a 14% and 30% increase over the volume of live kidneys — between 6,000 and 6,500 — donated annually over the last five year. Needless to say, more kidneys would be hailed as a windfall, saving many lives. But it is no panacea: There won’t be nearly enough for the 70,000 people now waiting.

Now that Congress is poised to clarify NOTA through Norwood — an excellent beginning step — the next move must be bolder: to change the prohibition against rewarding people who donate. Our current system demands altruism as the sole legitimate motivation for organ donation. Surely, it is a beautiful virtue that will continue to inspire thousands to donate, but, in the end, altruism is not enough. We should reward individuals who relinquish an organ to save a life because doing so would encourage others to do the same. A growing chorus of voices is urging us try.

At the annual meeting of The American Society of Transplant Surgeons this winter a straw poll revealed that 80 to 85% were in favor of studying incentives for living donors, according to society president Arthur Matas. In 2003, the American Medical Association testified on behalf of legislation that would have permitted pilot studies of incentives for deceased organs.

The public seems receptive as well, according to a new Gallup poll on attitudes toward donation of organs after death. The most striking results were among 18 to 34 year olds wherein an impressive 34% said that incentives would make them “more likely” to donate while 6% said less likely. Incentives were even discussed during the formulation of NOTA in 1983. Former Rep. Al Gore, who spearheaded the legislation, suggested that incentives should be considered if generosity proved insufficient.

It has. So what to do? A reasonable first step might be to offer all donors lifetime Medicare coverage. This is medically responsible and could serve as an inducement. Other ideas include tax credits, tuition vouchers for a donor’s children, a deposit in a retirement account and charitable contributions in the donor’s name. These would be offered in a regulated environment overseen by the federal government. The prodigious savings from dialysis could be used to underwrite the various types of compensation. According to the Congressional Budget Office, the Norwood Act alone will save almost $500 million in Medicare costs over 10 years.

The idea of combining organ donation with material gain can make people queasy. Yet the mix of financial and humanitarian motives is commonplace. No one objects, for example, to a tax credit for charitable contributions — a financial incentive to complement the “pure” motive of giving to others. The great teachers who enlighten us and the doctors who heal us inspire no less gratitude because they are paid. An increase in the supply of kidneys will ameliorate suffering and prevent needless death. This is more important than whether an organ has been given freely or for material gain. Norwood is an admirable start. It is time for the next step.

Dr. Satel is a resident scholar at the American Enterprise Institute.