Making Sense of Bioethics: Column 158: Can We Pay Others to Donate a Kidney

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Often we envision donating our organs after we are dead, but we can also choose to become an organ do­nor while we are alive if we share part of our liver or donate one of our kid­neys. The proposal to give one of our two kidneys away, though, does raise some ethical and safety con­cerns. There can be long-term risks for the donor. Donating a kidney, moreo­ver, would not be therapeutic for us — only for someone else — and in fact might slightly increase our own risk for experiencing renal fail­ure in the fu­ture. 

Clearly we have a general duty to respect the integrity of our body. This means we shouldn’t cause in­jury to it, or damage it, for example, through surgeries or treatments that are not necessary to preserve our health or save our life. In light of these considerations, donating one of our kidneys would seem to run coun­ter to our responsibility to main­tain bodily integrity. 

Yet the notion of integrity can also be understood in a broader sense, namely, as functional integrity, so that if one of our kidneys were re­moved without imposing undue risk, and without a significant loss of blood filtering function, then we could say that the functional integ­rity of our renal system was pre­served. In that case, the removal of one of our kidneys, as a sacrificial act and for a proportionate rea­son, such as saving or improving an­other person’s life, could be justi­fied. This is what the Church af­firms. 

A further ethical concern, how­ever, centers on the fact that the decision to donate must be made freely by the donor, and con­sent should be given without any undue pressure. This means that offering payments for organs is fundamentally coercive and un­ethi­cal. 

We face a serious shortage of availa­ble kidneys for transplant in the U.S. Average wait times for a kid­ney are approaching five years, and about 15-20 people die each day while waiting for an or­gan — the majority for a kidney. In Au­gust of 2018, I participated in a conversa­tion with some of the health policy team at the White House as they considered possible strate­gies for increasing the supply of live donor kidneys. We dis­cussed the ethical, legal, economic and health implications of some pro­posed solutions, in­cluding the pro­posal to reward organ dona­tion by providing various non-cash benefits.

During the White House meet­ing, some parties to the dis­cus­sion offered recommenda­tions that the government provide life­time guaranteed coverage of all fu­ture medical expenses, or lifetime health insurance, to every person who be­comes a living kidney donor. I empha­sized that we should not be “encourag­ing” donation by offering “incen­tives” to donors as a direct bene­fit at all. Offering lifetime health insur­ance or similar proposals would, in my view, constitute a form of pay­ment or “valuable consideration” of­fered to the donor, and would again raise the problem of improperly in­centiviz­ing the donation of organs, pressur­ing someone to consider do­nat­ing as a way to secure lifetime health insurance coverage. 

When Congress passed the Na­tional Organ Transplant Act in 1984, this concern about incentivizing do­na­tions was directly addressed. This law prohib­its the purchase of organs or any exchange of “valuable consid­era­tion.” This same law, however, clearly per­mits reimbursement of various ex­penses associated with the transplant, such as travel costs to get to the hospi­tal in order to have the kidney re­moved, temporary housing at the time of surgery, lost wages in­curred in connec­tion with the dona­tion of the or­gan, etc.

Providing reimbursement of ex­penses should not be viewed as en­courag­ing or incentivizing the dona­tion itself, but rather as “eliminating disincen­tives,” or “removing hin­drances or roadblocks.”  An organ do­nor should not have to assume extra per­sonal expense or take on other heavy burdens to be able freely to help out another patient who would benefit from receiving his or her kidney.

From the ethical point of view, our ultimate goal should be not so much to “incentivize donation,” as to “sup­port or encourage personal gen­eros­ity” on the part of those individu­als who may desire to donate freely one of their kidneys. The distinc­tion is an important one. At the end of the day, we want people to be­come organ donors, not organ vendors. Hu­man or­gans and tissues, because of their close proximity and connection to our human identity, cannot be re­duced to commodities to be acquired or sold on an open market.  We must do what we can, legally and other­wise, to safeguard the generosity of the or­gan donor’s freely chosen act and pre­vent others, especially the poor and disadvan­taged, from being exploited be­cause they need money, health care, or other “incentives.” 

 Copyright © 2020, The National Catholic Bioethics Center, Philadelphia, PA. All rights reserved.

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