Kyle R. Jackson1
Dorry L. Segev- 1Department of Surgery, Johns Hopkins University, Baltimore, MD, United States
- 2Department of Surgery, New York University, New York, NY, United States
A Forum discussing:
Kidneys for Sale: Empirical Evidence From Iran
by Moeindarbari T and Feizi M (2022). Transpl Int 35:10178. doi: 10.3389/ti.2022.10178
Direct financial compensation through organized markets has been proposed as one strategy to increase the number of potential organ donors. However, this controversial practice is legal in only one country in the world—Iran; thus, there are limited data to demonstrate how this type of system might practically function. In a new report, Moeindarbari and Feizi provide granular real-world data on the demographics of kidney vendors and recipients from 2011 to 2018 in the kidney market in Mashhad, Iran [1]. This study provides valuable insights from a direct financial compensation program for organ donation and helps contextualize the debate surrounding this controversial issue.
Most prior attempts to quantify the potential impact of direct financial compensation for donors have been limited to surveys or structured interviews about hypothetical compensation and willingness to donate, rather than the real-world data presented in this article [2–7]. These have generally found that direct financial compensation to donors would likely increase the number of people who would donate an organ. In one web-based survey of members of the Canadian general public, 54% of people who would not consider donation to a relative without any compensation would actually change to being willing to consider donation for a $10,000 payment [3]. Even among people who would already consider donation to a family member or a friend, a payment of $50,000 would make 60% of people even more likely to donate a kidney in a study from the United States [4].
The data presented by Moeindarbari and Feizi confirm that, even in a partially regulated organ sales market, donors are younger than recipients and have fewer years of education. This potentially validates previous concerns of donor exploitation and socio-economic inequalities that have been shown across many countries [8–10]. For example, the Phillipine Organ Donation Program allowed for direct financial payment to donors from 2002 to 2008, and 78% of donors did not have a single follow-up visit post-donation [10]. Importantly, Moeindarbari and Feizi point out that in addition to the market price set by the government for a kidney, the recipients are allowed to pay donors, which seems to undermine the idea of a “regulated” market and further engenders donor exploitation. The authors outlined policy recommendations and improvements moving forward to more fairly consider the market value of a kidney in Iran. However, we would suggest that we are not there yet: before we go down the road of commercial sales, there are many other methods to improve altruistic organ donation that have been underexplored and underutilized.
An increase in altruistic living and deceased donation could eliminate the need for commercial organ sales entirely. After the Israeli government criminalized organ brokering, altruistic living donation rose by 339% over 10 years [11]. Similar results were seen after the Pakistani government banned commercial transplants [12]. Iran has the opportunity to increase deceased donation efforts, given that deceased donors have only increased from 4% to 10% in 30 years [13]. Other ways to improve altruistic donation include the removal of disincentives to donate (such as expenses linked to donation, travel expenses, and lost wages) and removal of HLA, ABO, and other incompatibility barriers to living donation through paired exchange [14]. Other countries have shown these methods can substantially increase the access to living donation without commercial markets.
Even beyond simply removing disincentives to living donation, there are a number of other strategies that have been developed to increase the number of living donor kidney transplants being performed. For example, the Live Donor Champion program trains a friend, family member, or community member to advocate on behalf of a transplant candidate to identify a potential living donor and has been shown to increase the number of potential living donors who come forward to donate [15]. Other focused interventions have been developed to directly increase the number of donors who come forward for people who are racial/ethnic minorities or socioeconomically disadvantaged, although these have not been universally effective [16, 17]. In a randomized controlled trial of 145 African American kidney transplant candidates in the United States, 82% of candidates who received house calls (structured educational sessions delivered to candidates, family, and invited guests in their own home) received at least one donor inquiry compared to 47% of candidates who received traditional individual counseling in the transplant clinic [16]. In another study of 300 African American kidney transplant candidates in the United States, candidates were randomized to receive additional education from a transplant social worker (with or without living donor financial assistance) [TALKS] or to usual care [17]. The TALKS program was designed specifically to address issues precluding living donation raised by African Americans in prior studies. Although the TALKS intervention did not lead to an increase in living kidney donation, 99% of candidates who received the intervention reported a high degree of satisfaction with the intervention. Continued expansion and development of targeted interventions to increase living donation could help avoid the need for direct financial payment of living donors.
In summary, the data provided by Moeindarbari and Feizi shed both positive and negative light on how a regulated system of direct financial payment to organ donors actually functions. While such a system would likely increase the number of transplants performed, major concerns remain, and we would suggest that expanding systems designed to support and compensate donors for actual incurred expenses could substantially expand the number of donors without needing to directly provide payments for living donors. Additionally, continuing to innovate and expand the utilization of targeted interventions to increase living donation could also help avoid the need for direct financial compensation for living donors. Ultimately, we agree with the authors that careful study of this controversial topic is critical to ensuring protection of living donors.
Author Contributions
All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References
1. Moeindarbara, T, and Feizi, M. Kidneys for Sale: Empirical Evidence from Iran. Transpl Int (2022).
2. Barnieh, L, Gill, JS, Klarenbach, S, and Manns, BJ. The Cost-Effectiveness of Using Payment to Increase Living Donor Kidneys for Transplantation. Clin J Am Soc Nephrol (2013) 8:2165–73. doi:10.2215/cjn.03350313
3. Barnieh, L, Klarenbach, S, Gill, JS, Caulfield, T, and Manns, B. Attitudes toward Strategies to Increase Organ Donation: Views of the General Public and Health Professionals. Clin J Am Soc Nephrol (2012) 7:1956–63. doi:10.2215/cjn.04100412
4. Peters, TG, Fisher, JS, Gish, RG, and Howard, RJ. Views of US Voters on Compensating Living Kidney Donors. JAMA Surg (2016) 151:710–6. doi:10.1001/jamasurg.2016.0065
5. Elías, JJ, Lacetera, N, and Macis, M. Paying for Kidneys? A Randomized Survey and Choice Experiment. Am Econ Rev (2019) 109:2855–88. doi:10.3386/w25581
6. Halpern, SD, Raz, A, Kohn, R, Rey, M, Asch, DA, and Reese, P. Regulated Payments for Living Kidney Donation: an Empirical Assessment of the Ethical Concerns. Ann Intern Med (2010) 152:358–65. doi:10.7326/0003-4819-152-6-201003160-00005
7. Held, PJ, McCormick, F, Ojo, A, and Roberts, JP. A Cost-Benefit Analysis of Government Compensation of Kidney Donors. Am J Transpl (2016) 16:877–85. doi:10.1111/ajt.13490
8. Gill, J, Dong, J, Rose, C, Johnston, O, Landsberg, D, and Gill, J. The Effect of Race and Income on Living Kidney Donation in the United States. J Am Soc Nephrol (2013) 24:1872–9. doi:10.1681/asn.2013010049
9. Zhang, Y, Gerdtham, U-G, Rydell, H, and Jarl, J. Socioeconomic Inequalities in the Kidney Transplantation Process: A Registry-Based Study in Sweden. Transplant Direct (2018) 4:e346. doi:10.1097/txd.0000000000000764
10. Padilla, BS. Regulated Compensation for Kidney Donors in the Philippines. Curr Opin Organ Transpl (2009) 14:120–3. doi:10.1097/mot.0b013e328329256f
11. Kurleto, P, Skorupska-Król, A, Broniatowska, E, and Bramstedt, KA. Exploring the Motives of Israeli Jews Who Were Living Kidney Donors to Strangers. Clin Transpl (2020) 34:e14034. doi:10.1111/ctr.14034
12. Rizvi, AHS, Naqvi, AS, Zafar, NM, and Ahmed, E. Regulated Compensated Donation in Pakistan and Iran. Curr Opin Organ Transpl (2009) 14:124–8. doi:10.1097/mot.0b013e328326f6ef
13. Malekshahi, A, MortezaNejad, HF, Taromsari, MR, Gheshlagh, RG, and Delpasand, K. An Evaluation of the Current Status of Kidney Transplant in Terms of the Type of Receipt Among Iranian Patients. Ren Replace Ther (2020) 6:66. doi:10.1186/s41100-020-00314-8
14. Segev, DL, Gentry, SE, Warren, DS, Reeb, B, and Montgomery, RA. Kidney Paired Donation and Optimizing the Use of Live Donor Organs. JAMA (2005) 293:1883–90. doi:10.1001/jama.293.15.1883
15. Garonzik-Wang, JM, Berger, JC, Ros, RL, Kucirka, LM, Deshpande, NA, Boyarsky, BJ, et al. Live Donor champion: Finding Live Kidney Donors by Separating the Advocate from the Patient. Transplantation (2012) 93:1147–50. doi:10.1097/tp.0b013e31824e75a5
16. Rodrigue, JR, Paek, MJ, Egbuna, O, Waterman, AD, Schold, JD, Pavlakis, M, et al. Making House Calls Increases Living Donor Inquiries and Evaluations for Blacks on the Kidney Transplant Waiting List. Transplantation (2014) 98:979–86. doi:10.1097/tp.0000000000000165
17. Boulware, LE, Sudan, DL, Strigo, TS, Ephraim, PL, Davenport, CA, Pendergast, JF, et al. Transplant Social Worker and Donor Financial Assistance to Increase Living Donor Kidney Transplants Among African Americans: The TALKS Study, a Randomized Comparative Effectiveness Trial. Am J Transpl (2021) 21:2175–87. doi:10.1111/ajt.16403
Keywords: kindey, transplant, organ donation, compensation, Iran, debate
Citation: Jackson KR, Haugen CE and Segev DL (2022) Kidneys for Sale: Are We There Yet? (Commentary on Kidneys for Sale: Empirical Evidence From Iran). Transpl Int 35:10635. doi: 10.3389/ti.2022.10635
Received: 11 May 2022; Accepted: 12 May 2022;
Published: 24 June 2022.
Copyright © 2022 Jackson, Haugen and Segev. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Dorry L. Segev, dorry@jhmi.edu