What Can Be Additionally Helpful for Donor and Recipient?
With respect to the donor risks, it is of utmost importance to give the donor and the recipient the best possibility for informed consent, in other words, they should be given information in such a way that both can make the decision on their own terms.
As the transplant physician may have his own agenda and is likely to be in favour of donation, and the potential donor may feel some emotional pressure, the pure exclusion of a commercial donation does not seem to be enough.
It may be advisable to involve an ombudsman or donor attorney. This person should have a substantial medical background in the field of nephrology without active past or present involvement in transplantation other than the special education required to become a nephrologist. He should not be a member of a transplant centre but rather a private practitioner or nephrologist from a hospital not involved in transplantation. Further, this person should have no connections to donor or recipient. He can then advise both recipient and donor of the risks and benefits of transplantation. In some cases, he may refrain from transplantation based on poor recipient condition or likely problems after transplantation in other cases, he may protect the donor based on individual risks despite emotional stress.
In a number of countries, this issue is taken up by a local or regional ethics committee which may be independent from the transplant centre or part of it. But it remains rather difficult to fathom the depth of the human hearts. What kind of pressure is put on the potential donor by emotion or stress within the family? Can we really be sure of a decision of the free will of the donor even though there may be no money involved? If donor and recipient both want the transplantation, the ethics committee will not be able to exclude commercial donation.
It could be considered to donate some kind of gift to the donor who is taking a small but somewhat unforeseeable risk from which the society profits immensely, although this is not an advocation of commercial donation. For certain, we have to exclude donation in the form of 'bread for kidney', in other words, the recipient needs the donation to survive or to support his otherwise disabled family. However, there are examples for state-controlled donation such as in Iran. While this is illegal in Europe so far, it is worth considering.
In such a model, the donor receives a defined amount of money or other forms of reimbursement for his donation. The obvious risk is that younger people in particular may be inclined to buy a car or a small house or to pay off debts, in other words to gain an immediate benefit from the donation. This bears the risk that the potential donor may reevaluate his decision a few years later as the time for immediate reflection may be too short.
Other ideas could be a better retirement fund, an earlier age of retirement or free health insurance. Such a model has increased the number of living donors in Israel, for example. This model has the clear benefit of no immediate effect of donation. It is a way to demonstrate the worth of donation to the society; it should be seen as a reward rather than a payment.
At present, there is not even a public acknowledgement of the society to demonstrate the worth of donation. In all these models, the recipient should not pay the donor. The donor should be rewarded by the society or a special health fund. Such a reward should not be immediate in order to protect the donor from donation to pay his consumer credit or buy his car 1 month earlier than without donation. Therefore, a better retirement fund seems to be the best option as it gives no immediate benefit.[13,18,19]
Nephrol Dial Transplant. 2012;27(6):2166-2170. © 2012 Oxford University Press