Portal de Periódicos da CAPES

Promotion of Altruistic Donation: A Reply

2010; Wolters Kluwer; Volume: 89; Issue: 7 Linguagem: Inglês

10.1097/tp.0b013e3181cf503c

1534-6080

Benjamin Hippen, Arthur J. Matas,

Blood donation and transfusion practices

We were pleased to read the letter (1) by Tilney et al. with regard to the advisability and potential pitfalls of a regulated trial of incentives for organ procurement. By shifting the debate regarding incentives for organ procurement from a discussion about whether such a system of incentives could every be ethically defensible, to a critical request for details as to how a regulated trial of incentives might be structured, we believe that this letter represents a substantive step forward in a debate that many believed had reached an impasse. The questions raised by Tilney et al. as regards the methodologic structure and potential unintended consequences of a regulated trial of incentives are well reasoned and reasonable. Although a detailed response to these questions is beyond the scope of this letter, we favor a government-sponsored request for applications and subsequent funding of several trials of incentives in different regions throughout the United States. In each instance, the study group would design a methodology with explicit inclusion and exclusion criteria, and a means of documenting demographic, psychosocial, and clinical characteristics of participants. Each study would include a menu of incentives, each with limited fungibility, from which potential donors could choose. Donors and recipients would then be followed up prospectively for a fixed time frame. Each study would require approval by an institutional review board with a relevant jurisdiction, a data safety monitoring board to identify adverse unintended consequences in follow-up, and any such study would require both unique approval from the Secretary of Health and Human Services and a specific exemption from the relevant section of the National Organ Transplant Act, not unlike the exemption conferred on paired donation by the Norwood Act. Control arms would need to be individually designed but might include both historical controls (living and deceased organ donation trends before the institution of the study) and measurement of similar trends both within a study institution and surrounding institutions, which are nonparticipants in the study. We deny that Iran represents a “regulated trial,” in any meaningful sense of the term, of financial incentives for organ procurement. Iran does not have a single system, but rather a patchwork of systems which are organized differently in different parts of the country. Nearly every study of the Iranian system is center specific, retrospective, and lacks long-term follow-up of donors. It should be observed that of the alleged failings of the Iranian system cited by Tilney et al., one (failure to “fix” the price of an organ) is not a self-evident “failing,” and two (failure to eliminate Internet solicitation, outlaw brokers) are not addressed, much less substantiated, by the study they cite by Nejatisafa et al. (2). Underground organ brokering and Internet solicitation are not generally recognized as problems in Iran in any of the published literature on the subject. What has been achieved in Iran is an elimination of the waiting list for kidneys (3), and in at least one center, 10-year graft outcomes which rival those noted in the United States (4), an outcome which is in sharp contrast with typical reported outcomes from recipients of trafficked organs. However, the study by Nejatisafa et al. does reinforce existing (though incomplete) evidence (5, 6) that those in Iran who sell an organ tend to disproportionately labor under a variety of significant stressors, including low socioeconomic status, which increase the risks of adverse outcomes. We might do well, even if we reject the Iranian “systems,” to do what we can to discover what there is to learn from the Iranian approaches, whether the lessons are positive, negative, or both (3). We are, respectfully, less impressed by the concern that a system of regulated incentives ignore the “important realities” of the waiting list. It is true that incentives for kidneys will not solve the shortage of hearts, lungs, and livers. But, it may well solve the problem of the shortage of kidneys, and we find that prospect, however humble, to be sufficient warrant for serious consideration. As to the inactive list, we are rather more morally impressed by the recent study by Schold et al. (7), demonstrating that there are an additional 80,000 to 130,000 dialysis-dependent patients in the United States that meet demographic criteria for benefit from a kidney transplant compared with remaining on dialysis, but are never even referred for evaluation. Even if the least sanguine estimates for inappropriate listings are correct, the hidden demand for kidney transplantation makes the “inactive” problem irrelevant by comparison. We stand in solidarity with those, here and abroad, who oppose the practice of illegal, underground organ trafficking from the poorest denizens of developing countries. However, we believe that the clearest solution to organ trafficking is the recognition that the central source of economic support for organ trafficking in developing countries is from desperate recipients of means in developed countries who suffer from a system, which continues to fail to address the ongoing and growing disparity between the demand for and supply of organs. Unless and until this problem is meaningfully addressed, organ trafficking will continue unabated. Declarations, however well intentioned, are no longer enough. Benjamin Hippen1 Arthur Matas2 1 Metrolina Nephrology Associates, PA Charlotte, NC Carolinas Medical Center Charlotte, NC 2 Department of Transplant Surgery University of Minnesota Minneapolis, MN