Date Published: November 28, 2018
Publisher: Public Library of Science
Author(s): Philip J. Held, Frank McCormick, Glenn M. Chertow, Thomas G. Peters, John P. Roberts, Stanislaw Stepkowski.
Government compensation of kidney donors would likely increase the supply of kidneys and prevent the premature deaths of tens of thousands of patients with kidney failure each year. The major argument against it is that it would exploit the poor who would be more likely to accept the offers of compensation. This overlooks the fact that many poor patients desperately need a kidney transplant and would greatly benefit from an increased supply of kidneys. The objective of this study is to empirically test the hypothesis that government compensation of kidney donors would exploit the poor. Exploitation is defined by economists and several noted ethicists as paying donors less than the fair market value of their kidney. Exploitation is expressed in monetary terms and compared with the economic benefit recipients receive from a transplant. Data are from the Scientific Registry of Transplant Recipients and the United States Renal Data System annual data reports. Educational attainment is used as a proxy for income. We estimate that if the government rewards living donors with a package of non-cash benefits worth $75,000 per kidney, donors would not be exploited. Much more important, this compensation would likely end the kidney shortage, enabling many more patients with kidney failure to obtain transplants and live longer and healthier lives. The value of kidney transplantation to a U.S. recipient is about $1,330,000, which is an order of magnitude greater than any purported exploitation of a living donor (zero to $75,000). Consequently, the aggregate net benefit to the poor alone from kidney transplantation would increase to about $12 billion per year from $1 billion per year currently. Most of the benefit would accrue to poor kidney recipients. But poor donors would receive the fair market value of their kidney, and hence would not be exploited. If the government wanted to ensure that donors also received a net benefit, it could easily do so by increasing the compensation above $75,000 per donor.
Each year about 125,000 U.S. patients are diagnosed with end-stage renal disease (ESRD)  and must either undergo life-long dialysis therapy or obtain a kidney transplant. Only about 31,000 of these patients are added to the transplant waiting list each year, and a little more than half that number actually receive transplants because of a serious and growing shortage of transplantable kidneys . Consequently, the number of U.S. patients requiring maintenance dialysis now approaches half a million, and the number on the transplant waiting list has risen to nearly 100,000 [1,2]. Waiting time for a deceased donor kidney has steadily increased to an average of almost five years, and in many regions wait-time now exceeds life expectancy. Most tragically, each year almost 5,000 patients on the waiting list die and another 4,000 are removed because they are considered too sick to undergo the transplant operation .
The objective of this study is to empirically test the hypothesis that government compensation of living kidney donors would exploit the poor. Exploitation is defined and expressed in monetary terms, and is compared with the estimated benefits received by kidney transplant recipients. We have appended four supplements (S1 File…S4 File) to better explain some of our assumptions and calculations.
Given these definitions and preliminary calculations, the exploitation of poor kidney donors was compared with the benefit that poor kidney recipients receive from a transplant to estimate the net effect on the poor in three different situations. The first is the current situation in the U.S. where compensation of kidney donors is prohibited. In the second, the government compensates living kidney donors the $75,000 fair market value of a kidney under realistic (but conservative) assumptions about the response of poor donors and recipients. The third situation is a sensitivity analysis to show how robust the conclusions of Situation 2 are—the government again compensates living kidney donors $75,000, but under assumptions that are very pessimistic for the welfare of the poor. Table 2 and Fig 1 summarize the calculations and results for the three situations.
The purpose of this study was to empirically test the hypothesis that government compensation of kidney donors would exploit the poor. We concluded that if the government rewards living kidney donors with a package of non-cash benefits worth about $75,000 per kidney, donors would not be exploited.