Vouchers and incentives can increase kidney donations and save lives

Surgical team working on a patient in operating theater (iStock)

The chronic organ shortage in this country is a well-known scourge, so any good idea for recruiting more organ donors is always welcome. Bravo, then, to the Ronald Reagan UCLA Medical Center and its voucher plan for kidney donors. It basically lets an individual donate a kidney to a stranger now and get a certificate for a future kidney transplant for a loved one.

This idea was the brainchild of retired judge Howard Broadman, who feared he would be too old to donate a kidney when his grandson, Quinn, needed one in a few years. The concept has since been adopted at other medical centers and has been formalized under the umbrella of the private National Kidney Registry’s advanced donation program.

The registry tries to leverage the impact of these donations by placing the donor within a chain of transplants. So-called never-ending altruistic donor chains are created using a complex algorithm involving detailed biological data. Donors like Judge Broadman can kick off such a chain by donating to a stranger waiting for a transplant. That stranger, who already has a willing but incompatible donor in the wings, asks that donor to give to another person waiting for a transplant, and so on. Each living donor in this system gives to a stranger, and the chain of donors is kept going as long as possible.

Another way to generate more kidney donors, I believe, would be to offer a different kind of voucher. It would be for prospective donors who ultimately decline to give a kidney to a friend or even a distant relative because they want to be able to assist a closer member of their family or inner circle should the need arise. I call this the peace-of-mind voucher. It is already legal under the federal Organ Procurement and Transplantation Network for a living donor to get priority for a kidney under the rare but not unheard of chance that he or she develops kidney failure down the line. Why not expand this option to all living donors?

I wish such a program had been in place when I needed a kidney back in 2006. I discovered my kidneys were failing after a routine blood test came back with off-the-chart results. I actually felt fine at the time because, unbeknownst to me, my kidney function had been insidiously deteriorating over a long period of time. As a physician, I knew I had to find a donor — or spend years tethered to life-sapping dialysis.

But finding a living donor was a hellish experience. A number of people told me they wanted to help but were reluctant to do so because they worried their child might need a kidney in the future. Although this concern is understandable, it is surely overblown. Unless an individual has diabetes, chronic hypertension, collagen vascular disease (such as lupus), or polycystic kidney disease, the odds of an otherwise healthy person developing renal failure over a lifetime are slim. Even so, it’s easy to understand a parent’s reluctance. After 18 months — thankfully, I was able to stave off dialysis until the very last minute — I was rescued by a fond acquaintance turned dear, dear friend who heard through the grapevine that I needed a kidney.

If the federal organ transplant network, which operates under the Department of Health and Human Services, were to provide peace-of-mind vouchers for living donors, specified family or friends of those donors could redeem them at any transplant center. (Selling the voucher would, of course, be against the law). Unlike the UCLA program, where the certificate is earmarked by the donor for a specific person at high risk for a transplant in the future, peace-of-mind vouchers aren’t likely to ever be redeemed because healthy people don’t usually develop kidney failure.

No voucher program will erase the organ backlog — there are now more than 100,000 people waiting for kidneys. Last year, less than one-fifth of those on the waiting list received a transplant — the average wait is almost four years, with some people waiting much longer. Every day, 12 people on the national waiting list die; they simply couldn’t survive the wait. But “paying an organ forward” in the service of a loved one known to need a kidney in the future is an excellent option for interested prospective donors and will surely save a number of lives. It is hard to know how many prospective donors would take advantage of peace-of-mind vouchers, but it seems worth implementing them on a pilot basis.

Here’s an even bolder idea for increasing the supply of kidneys: give prospective donors an incentive to serve as the kick-off donor in a chain. This approach would create never-ending compensated donor chains. Benefits to such donors could be tax credits, contributions to retirement plans, a contribution to a charity designated by the donor, and other options. To avoid situations with outsize appeal to poor individuals who might impulsively rush to donate and later regret it, no one would receive an outright lump sum of cash.

A bill currently in Congress — the Organ Donor Clarification Act introduced in May by Representative Matt Cartwright (D-Pa.) — would let researchers study the potential effects of various incentives. The bill aims to clarify that pilot studies would not violate Section 301 of the 1984 National Organ Transplant Act, which bans the commercialization and private sale of organs.

Incentives have enormous potential. The White House recently offered social media and cutting-edge medical technology as ideas for reducing the wait list. Technology could some day make organ donation obsolete, but until we can make kidneys or kidney stand-ins in a lab, such as with 3-D printed kidneys, implantable microdialysis machines, genetically modified transplantable pig kidneys, and the like, we must rely on organs from humans. Kidneys from deceased donors certainly help. But those from living donors are in far greater supply and generally function longer in recipients.

It’s imperative that we take advantage of every new idea. Vouchers don’t require an act of Congress and are an obvious next step for increasing the supply of much-needed kidneys.