Ng Jun Heng Rayson, 20

Topic: Should we incentivise organ donation to increase supply?

Award: First Place, Open Category, 2022

Incentives for Life

1. Introduction

Hearts and livers give life; corneas bestow sight; bones can repair bodies in reconstructive surgery; and skin provides grafts for burn victims. The impact of an organ donor is immense, yet in Singapore, there are over five hundred individuals on the waiting list for an organ transplant, and the average waiting time for a deceased donor kidney transplant is eight to nine years.

Despite existing public education efforts such as the “Live On” Campaign and the Human Organ Transplant Act (HOTA) that operates on presumed consent, the number of organs procured by the current system falls short of present-day demands. The acute shortage is likely to persist unless Singaporeans open their minds to a third state action: boosting organ donation with incentives.

In Singapore, the purchase or sale of human organs is outlawed. Presently, the only form of compensation allowed is reimbursement for the expenses of living donors. Admittedly, incentives could be ethically taboo as they raise concerns about the commercialization of transplantation. While these concerns hold some validity, most of them can be assuaged through regulation rather than blanket prohibition. This essay aims to deconstruct the foremost arguments against the incentivisation of organ donation and outline the form such a system can take in Singapore.

2. What could an incentivised donation system look like in Singapore?

First, two types of incentives exist: non-financial and financial. Non-financial incentives primarily include priority as an organ recipient. Preference is given to individuals in need of organs who have earlier expressed their consent to donate their organs after death.

This ‘preferential access’ model would not suit the opt-out HOTA but could complement the Medical (Therapy, Education and Research) Act (MTERA), which requires expressed consent. Compared to the former, the latter allows a person to donate a greater variety of organs and tissues for not only transplants, but education and research purposes too. Hence, it would only be fair if donors who voluntarily register under the MTERA received benefits for their larger contributions. To address the risk of people registering as donors only after they have realised that they are at high risk of needing an organ, priority status should only be conferred after a period of time has elapsed following registration.

Financial incentives are another form of incentives. These can be distributed directly through a direct payment for the organ as the donation is made. However, such a measure is unlikely to be feasible in Singapore, where vital organs and money lie in distinct moral territories and society adopts a firm normative stance against the commercialisation of organs.

Instead, indirect financial incentives that dissociate economic advantages from the act of donation might be employed. For instance, deceased donors registered under the MTERA could have funeral reimbursements or charitable contributions made under their names. Alternatively, living donors can be granted coverage for any future stays in A or B1 class wards or receive prioritised medical appointments with reduced waiting times in public hospitals.

As with any untested proposal, incentivised donation has spawned vehement objections. These critiques can be categorised as such: the commodification of the body, the undermining of altruism, and the exploitation of vulnerable groups.

3. Commodification of the body

Those who rail against offering incentives cite that the practice deprecates the human body and desecrates the sanctity of life. However, this assertion conflicts with the facts of the 21st-century capitalist economic system, where the human body is increasingly transformed into an object of economic value. Team Singapore athletes are financially rewarded for medal-winning displays of their physical attributes¹ and social media influencers are paid for promoting products with their natural beauty or charisma². Do these people defile their bodies when they profit from their use of them?

In contemporary times, because of the ubiquity of the profitable application of various parts of the human body, there is an underlying contradiction in the contention that incentivised donation clashes with present-day moral standard.

Even if incentivised donation passes the ethics test, it is currently constrained by national laws, which indiscriminately forbid the profitable utilisation of the human body and its parts. In Singapore, egg or sperm donors cannot receive payment, and the provision of surrogacy services is illegal. However, incentives for organ donation are not akin to paying for a gamete or the use of a womb. Incentives should not be misconstrued as a payment for an organ, but rather recognised as a reward to the donor for selflessly donating it. As incentives do not place a price tag on organs, they remain within Singapore’s legal boundaries.

4. Undermining of altruism

Naysayers of incentivised donation fear that permitting it would extinguish the fires of altruism. They argue that the personal element in the act of donation would be forsaken, diminishing the intrinsic emotional gain of the donor or their family. Yet, incentives and altruism do not necessarily exist on either side of a dichotomy.

In Singapore, men spend about two years of their lives catering to the nation’s defence needs. Servicemen receive compensation for National Service and most would agree that their service, despite its mandatory nature, possesses altruistic components.

Moreover, in Singapore’s arsenal of public policies, incentives are an established and well-accepted tool to reward individuals for promoting communitarian interests. For example, Singaporeans can claim tax reliefs by attending courses³ and receive lump sums of money for having children⁴.

Through the symbolic reward of incentives, the government conveys the gratitude and appreciation of the organ recipient and society for the donor’s gesture of donation. Incentives do not thwart altruistic intents, but instead champion organ donation as an exemplar of altruism.

5. Exploitation of vulnerable groups

Another scenario conjured by cynics of incentivized donation is that of a cardboard granny selling her organs for survival. They claim that incentives impair an individual’s ability to freely consent to organ donation. Yet, societal imbalance is not an occurrence unique to donation incentives.

In a society undergirded by meritocratic principles, Singaporeans triumph and advance based solely on their ability. Often, individuals with more “merit” undertake better-paying blue-collar jobs while those with less “merit” perform more risky, dangerous, and unpleasant tasks. By juxtaposing the earlier image of the impoverished cardboard granny with that of the retired and pensioned elderly, it is obvious that the engagement in risky activities by those motivated by economic goals is not only already legal, but common in Singapore. To alleviate the inescapable imbalance, financial incentives could be paid in instalments, shutting out individuals desperate for money. Alternatively, they could be disbursed only to donors above a specified income threshold.

Regarding non-financial incentives, a ‘preferential access’ system risks exploiting people who are most at risk of needing an organ, since they are more likely to register as donors.

To prevent their exploitation, the provision of long-term follow-up is paramount. For example, kidney donors should attend yearly tests for their urine, blood pressure, and kidney function. Additionally, donors, alongside their yearly follow-up, can be granted a free general screening for common conditions such as diabetes and high cholesterol. Since individuals that are most likely to need an organ are also more vulnerable to chronic diseases, they would disproportionately benefit from such incentives, thereby correcting the imbalance.

6. Living donation

Most patients in Singapore choose to wait for a kidney from a deceased donor instead of from a living one. Although the Singapore General Hospital receives between ten and fifteen referrals for living donor transplants monthly, most of them are unfruitful as their patients are disinclined to bother their loved ones. This belief stems from the rule of reciprocity, which requires that people repay in kind what another has done for them. Perhaps if organ recipients gained a way to perceive organ donation as a mutually beneficial exchange, they might embrace the idea of it more warmly.

Incentives consider the concept of reciprocity, which is salient to the act of donation. By likening organ donation to a gift exchange, incentives fulfil the obligation of recipients to reciprocate the selfless act of the living donor and allay decision-making pressures.

7. Moving forward

Against the backdrop of a greying demographic and shortages of manpower and acute hospital beds, the issue of whether incentives are preferable to other ways of encouraging donation remains urgent and complex. A categorical ban on all such efforts does nothing to clear the fog shrouding the legal and ethical feasibility of incentives. Boasting strong regulatory governance, a multilayered financing framework, and transparent registries, Singapore’s healthcare system is uniquely poised to adopt a system of incentives where variables can be adjusted to minimise harm and maximise benefits.

While society can endlessly critique incentivised donation, such cynicism is not where progress lies. There can be no progress without change, no change without discussion. The public and lawmakers alike must look beyond the barrier of moral panic and view the bigger picture of the future of transplantation. Will we only give a second glance at incentivizing organ donation when it is us on that hospital bed, our names on a list with five hundred others?

¹Swimmer Yip Pin Xiu won two gold medals at the Paralympic Games in Tokyo. Each win earned her a $200,000 reward.

²According to Get Kobe (a social marketing agency), Instagram influencers can receive $75 and upwards per post while bloggers can receive $175 and upwards for every blog they upload.

³Course Fees Relief can be claimed up to a maximum of $5,500 each year for the attendance of a course of study, seminar or conference for the purpose of gaining an approved academic, professional or vocational qualification or that is relevant to the individual’s current employment, trade, business, profession or vocation.

⁴The Baby Bonus Cash Gift of between $8000 and $10,000 is given out in five instalments over 18 months, after the child’s birth.

References

1. NCBI (2012, February 12). Incentives for Organ Donation: Proposed Standards for an Internationally Acceptable System https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3350332/

2. Singapore Legal Advice (2021, January 22) Hiring a Surrogate: 6 Legal Issues for Singaporean Couples https://singaporelegaladvice.com/law-articles/surrogacy-singaporean-couples#:~:text=1.,its%20 licence%20 suspended%20or%20revoked.

3. Eugenia Liew (2019, May 16) How Do Influencers Make Money & How Much Do They Earn? https://blog.moneysmart.sg/career/how-do-influencers-vloggers-make-money/

4. Thomas A. Callender (2010, May 6). Incentivising Organ Donation: is there an ethical way forward? https://www.bmj.com/rapid-response/2011/11/02/incentivising-organ-donation-there-ethical-way-forward

5. Mélanie Levy (2018, May 19). State incentives to promote organ donation: honouring the principles of reciprocity and solidarity inherent in the gift relationship https://optn.transplant.hrsa.gov/professionals/by-topic/ethical-considerations/financial-incentives-for-organ-donation/

6. Live On (2021, December 31) Statistics information booklet https://www.liveon.gov.sg/docs/info_booklets/LiveOn_stats.pdf

7. Singapore Legal Advice (2018, October 26) Organ Donation in Singapore (under HOTA, or For Science) https://singaporelegaladvice.com/law-articles/organ-donation-in-singapore/

8. Sally Satel (2018, June 24) How to provide better incentives to organ donors https://www.aei.org/articles/how-to-provide-better-incentives-to-organ-donors/

9. Virtus Fertility Centre Sperm & Egg Donation Programme https://www.virtusfertilitycentre.com.sg/en/sperm-egg-donation-programme

10. Sazali Abdul Aziz (2022, February 16) Team Singapore honoured in Parliament; work being done to increase cash rewards for para-athletes https://www.straitstimes.com/singapore/team-singapore-honoured-in-parliament-work-being-done-to-increase-cash-rewards-for-para

Disclaimer: Please note that the views and opinions expressed in the essays for the Live On Festival 2022 are those of the participants and are not endorsed by the National Organ Transplant Unit (Ministry of Health). To learn more about organ donation and organ transplantation in Singapore, please visit www.liveon.gov.sg