COMMENTARY

Everyone Should Be Presumed to Be a Willing Organ Donor

Arthur L. Caplan, PhD

Disclosures

May 06, 2014

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Hi. I'm Art Caplan, from the Division of Medical Ethics at the NYU Langone Medical Center. Politicians say that there is no rationing in American healthcare and there never should be. That just shows that they don't know very much about American healthcare. There are certainly areas where rationing goes on every single day and every single hour. None is more obvious than transplants.

If we look at the kidney transplant waiting list today, we would find maybe 100,000 people listed who are waiting for transplants. Each year we do about 10,000 transplants of kidneys. That means 90,000 people who could benefit do not, and every day many people die because there is no kidney to give them. Some of these people can go with kidney dialysis for a while, but eventually they get too sick from it. It gets difficult to use dialysis on them if they had been on it for many years, so they must have a kidney transplant. It's the therapy of last resort.

Things are only going to get worse. If you look at the reasons that kidneys are failing at such a high rate, you will see high blood pressure, diabetes, and many chronic illnesses that are fueling the epidemic of kidney failure. I wouldn't be surprised if, 10 years from now, we had 200,000 people on waiting lists.

We get our kidneys from people who die -- cadaver donors. I think all physicians should encourage their patients to be organ donors. I am one, and I think it's a good thing to do. Even if you have 2 kidneys to donate, unfortunately most of us will die under circumstances where we're not going to be donors, even if we want to be, because we didn't die on life support after a head injury. That is where cadaver organs come from.

The other option is living donation. About half of the organs in the United States come from family members who donate a kidney and a few people who are strangers who donate a kidney. Still, we only have roughly 10,000 kidneys. The demand is increasing every day. Rationing is a horrible dilemma. Many people who deal with kidney disease are getting more and more frustrated that they can't offer anything to their patients who are patiently waiting. So ideas are floating around. What do we do?

One idea that keeps coming back is giving people financial incentives. I think the problem with financial incentives is that they are not likely to work. In a rich country like the United States, you would have to pay a huge sum of money to get the average person to go out and sell a kidney. Remember, you're talking about having a major operation with some risk for death and more risk for complications. It is not usually risky but it's still significant enough that I think very few people are going to say, "Yeah, I think I'm going to go sell my kidney for $5000 or $10,000." You would have to get the payment up to huge amounts to get anything near the number of people we need to meet the demand for kidneys.

Other people say that it is not going to work for a different reason. Major religious groups oppose kidney sale. The Catholic Church, evangelical Christians, and many, many other religions say that you cannot buy or sell the body. It's not yours to sell, and we can't support a system of organ donation if there is going to be a market. Some of you who are watching may be saying, "What do I care? They don't have to participate." But remember that hearts, livers, and other organs are always going to come from altruistic donation. If one part of the system becomes a market -- for example, kidneys -- and everybody else withdraws from the rest of organ donation, we may wind up killing more people than helping them benefit.

Another problem with markets is pretty simple: The doctor has to be willing to take a kidney out just so that the person can make some money. That is a dubious practice relative to the "do no harm" principle of medical ethics. It is one thing to take out a kidney because it has a disease or a cancer. It's a different thing to say, "Okay, you're healthy. I'm going to remove a kidney so you can make money." I think that would strike many physicians as wrong.

So, what could we do? What are some other options? One option is to change the default for kidney donation. Today we have to opt in to become a donor of a kidney or any other organ. You have to sign a card. You have to go on a computer registry when you go to the Department of Motor Vehicles. But we could change that around. We could presume that you want to be an organ donor. Most surveys show that. Indeed, a recent study that just came out from the Department of Health and Human Services shows that more than 80% of Americans say they want to be organ donors, and they do show significant support for what is sometimes called "presumed consent" or "default to donation." That is, we presume that you are a donor. You can carry a card that tells us that you are not. We presume that you are a donor. Your family could veto that and say that they don't want that to happen, or you could put your name in a computer registry and say that you don't want to donate.

There are a couple of bills, most recently in the state of Pennsylvania, to try to push this idea through the state legislature. Would it really solve all of our problems with respect to the need for more kidneys? No, but I think it could make a bigger dent than trying to fight the fight that would break out if we tried to go to a market. In the long term, neither of these ideas -- markets or default to donation -- is going to solve our problem. If we don't get a handle on the obesity epidemic and on increasing compliance with respect to managing high blood pressure and other chronic diseases that lead to kidney failure, almost nothing that we do is going to get us enough kidneys for those who are going to need them. We need to take that primary care obligation much more seriously. That is the best weapon we have with which to fight the shortage of kidneys today. I'm Art Caplan, from the Division of Medical Ethics at the NYU Langone Medical Center. Thanks for watching.

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