Compassionately Logical: Part II

This is the second part to Compassionately Logical: Part I.

Regulated kidney trade in Iran

In all developed countries, most living kidney donors are family members or spouses of the recipient. Commercial transactions involving the trade of human kidneys are strictly illegal and there is no compensation of any kind to the donor. Hence, it is extremely rare to find altruistic unrelated kidney donors apart from those with very strong unconventional religious convictions like the Jesus Christians in Australia. Because the pool of potential donors is effectively restricted, there are long lists of ESRF patients waiting for an available kidney. In America, about 3500 people on the waiting list die before receiving a kidney while only 16500 kidney transplants were performed in 2005. In a system which only allows kidneys from cadavers and related living donors, it is quite unlikely that the number of available kidneys will increase significantly to cover the shortfall.

In contrast, in Iran, there is no waiting list for kidneys. This is because most transplanted kidneys are taken from living donors, the majority of whom are unrelated to the recipient. Iran has a regulated system in which people can trade their kidneys - the recipient and the regulatory agency compensate the donor for his/her kidneys. According to this article,

"There are no private agencies or middlemen involved in the process of organ donation in Iran and all volunteer donors present themselves to the National Association for the Support of ESRD Patients. The sale of organs is legally and ideologically forbidden, but the concept of compensated donation is accepted."

In Iran, the middleman is a non-profit charitable organization, called the Dialysis and Transplant Patients Association (DATPA), which refers the donor to state hospitals where experts screen the donor physically and psychologically to ensure that the health and welfare of the donor is not compromised by the operation. It arranges for potential sellers to meet potential buyers. The donor receives a sum of US$1200 from the DATPA as well as health insurance coverage from the government for donating his/her kidney. The donor also receives a monetary 'gift' from the recipient, the quantum of which is agreed on by the two transacting parties. For more details, please see this article on the Iranian model of paid and regulated living-unrelated kidney donation.

For emphasis, I like to repeat this: there is no middleman, no risk of getting hepatitis from the transplanted kidney or surgical complications (unlike in India where the medical screening is dodgy), no coercion, etc. The donors are counselled about the risk and assessed for suitability in terms of physical and psychological health. I should also mention that both the donor and the recipient have to Iranian nationals. For foreign patients, the donor has to have the same nationality as the recipient.

As for concerns that the scheme might exploit the poor, I quote from the article:

"All transplant candidates who are poor receive renal transplantation. The elimination of renal transplant waiting lists means that all patients with ESRD, either rich or poor, have equal access to renal transplant facilities; otherwise, many poor patients would remain on the renal transplant waiting list. The main reason for this equal access is the active role of charitable organizations that pay for many expenses of renal transplantation that the poor patients cannot afford. One of the arguments against paid kidney donation is that the kidney donors are almost poor and illiterate, whereas the majority of recipients are educated and wealthy. We previously conducted a study on 500 renal transplant recipients and their living-unrelated donors to determine which socioeconomic classes are receiving transplants more from paid kidney donors (16). All of these donors and recipients were grouped according to their level of education, which showed no significant differences. In this study, 6.0% of living-unrelated donors were illiterate, 24.4% had elementary school education, 63.3% had a high school education, and 6.3% had university training. Corresponding levels in their 500 recipients were 18.0, 20.0, 50.8, and 11.2%, respectively. Then they were grouped according to whether they were poor, rich, or middle class. The results showed that 84% of paid kidney donors were poor and 16% were middle class, and of their recipients, 50.4% were poor, 36.2% were middle class, and 13.4% were rich. So >50% of kidneys from paid donors were transplanted into patients from poor socioeconomic class. This finding is a clue against commercialism in the Iranian model renal transplant program."

Of course, the Iranian model is not without its problems. Again, I quote:

"Because the amount of governmental donor award (approximately $1200 USD) is not enough to satisfy the majority of kidney donors, recipients provide rewarding gifts to donors. If the recipient is poor, then the rewarding gift is provided by charitable organizations. This also results in directed paid kidney donation, meaning that the transplant candidate and the volunteering kidney donor meet each other in a DATPA meeting for arrangement of rewarded gifting to be paid to the donor after transplantation. Providing sufficient financial incentives and some social benefits to each living-unrelated donor by the government will eliminate rewarding gifts and will make the Iranian model a nondirected paid kidney donation program whereby the donors and the recipients will not see and know each other at least before transplantation. All transactions for financial incentives will be carried out by organ procurement organizations (OPO). The OPO will receive all governmental donor award budgets as well as all charitable donations. The donor will donate a kidney to the OPO and will receive all defined financial incentives from the OPO. Because of lack of administrative expertise in health authorities, this approach has not yet been tested in the Iranian kidney donation model.

Unfortunately, the financial incentives to kidney donors in the Iranian model neither has enough life-changing potential nor has enough long-term compensatory effect, resulting in long-term dissatisfaction of some donors. However, providing adequate financial incentives to kidney donors and awarding some social benefits to them will eliminate almost all long-term dissatisfaction. Some opponents have sensationalized that the majority of Iranian paid kidney donors have been poor and have remained poor after kidney donation. As mentioned, in the Iranian model of paid kidney donation, not only the majority of donors (84%) but also the majority of transplant recipients (50.4%) also are from poor socioeconomic class. This national program is not adopted to upgrade the socioeconomic class of kidney donors and is very different from commercial transplants that are carried out in other countries."

Kidney transplant in Singapore

In Singapore, like most developed countries in which only deceased and living-related donors are allowed, there is a long waiting list and the average waiting time for kidney is roughly 7 years, despite the 'opt-out' system (as legislated in The Human Organ Transplant Act or HOTA) currently in place. We should also bear in mind that, as mentioned before, the longer the patient spends on dialysis, the lower the effectiveness of the renal transplant. The Ministry of Health acknowledges here that donor availability is a problem. Actually, what it is implicitly saying is that we don't have enough living donors.

Possible paid kidney transplant system in Singapore

I could envisage a system in Singapore similar (but not identical) to the Iran model in which living-unrelated kidney donors are paid for donating their kidneys. No point in reinventing the wheel. Such a system would have the following features:

1. A national regulatory body which screens potential donors physically and psychologically to assess their suitability for donating their kidneys. Potential donors are counselled about the risks.
   
2. Donors are paid a fixed sum by the government, say $20000, as compensation for the risk and loss of personal time. The exact quantum can be worked out later. This money would come from the patient or from charitable organizations. If the patient cannot afford the full amount, then we can have in place some kind of financial assistance to help him/her pay. The idea is that everyone pays the same amount for a kidney so that the wealthy have no advantage over the poor. There is no need for the recipient to know whom the donor is.
   
3. Priority in receiving the transplant is determined by the regulator body based on medical condition.
   
4. The donor receives free health insurance coverage/additional medical benefits from the government in recognition of his contribution. The national regulatory body should maintain a high level of post-operative care and the health of the donor is to be monitored over 10 years. Again, the duration of post-surgery monitoring is not set in stone.
   
5. The patient and the donor have to be Singaporeans.
   

I believe if we have such a system in place, donor availability will increase tremendously and the waiting list in Singapore will be eliminated.