Bao Xiyin, 18

School: Dunman High School

Topic: Should we incentivise organ donation to increase supply?

Award: Second Place, Open Category, 2022

Incentivising organ donations – Is It Truly The Solution?

The immense lack of organ donors to complement organ transplantations is a morbid problem that plagues the world far and wide. In Singapore, the wait time for a kidney transplant averages at a decade.

The expansion of the organ donor pool with the enactment of the Human Organ Transplant Act (HOTA) proves insufficient to fulfil the burgeoning demand for organ transplantations which prompts the need for more efficient and effective methods that can increase the pool of organs available for transplantation. In which, policies centering on incentivising organ donations has brought about its own share of support and controversies.

The ethics of incentivising organ donation

Organ Transplantation is no stranger to the convoluted world of ethics and morality. The very act of allowing one person to enjoy life on the basis of another’s organs is an ethics question in itself. The elevation of organ donation into an altruistic act of human solidarity is a direct response to this question. It paints organ donation as an act that is highly noble and one that stems from nothing but pure good will. The notion of sacrifice underpins the justification of organ donation as one cannot argue upon the harm it inflicts upon the donor’s body as it is permissible and fully authorised by the donor themselves. This makes incentivising organ donation morally dubious as it is seen to taint the motives of the action.

However, to devalue the altruistic aspect of organ donation merely due to incentives being involved can be a dangerous dichotomy. The coexistence of altruistic and interest based motivations behind organ donations should be recognised. The downward cascade of stigmatising and demeaning organ donations that involve incentives is unwarranted as based on the concepts of bodily autonomy, the donor has every right to state their own conditions for consenting to donating their organs within the boundaries of law. The involvement of incentives should not undermine the fact that as of any other organ transplantation, a life is saved with the donation.

Of all manners of incentivising organ donation, direct payments and financial benefits cause the most controversies as economic gain seems to turn the nature of organ donations into trade of resources. In this case, the altruism of the act is diminished and the organ itself is reduced from “a gift of life” to a mere commodity. The idea of organ donation being a sale trade between the donor and the recipient or rather, the buyer and the seller, is seen to trample upon human dignity. The act of isolating the value of the organ itself from the person donating it seems dehumanising to some.

However, it is important to re-calibrate the relationship between donors and recipients to understand what justifies and what devalues the morality of organ donation. Donation is not to be conceived as unidirectional, reciprocity in some form is often expected. The potential tyranny elements in the relation between the donor and the recipient incurred as a result of the recipient not being in the right position to express their gratitude by giving something of the same value in return can lead to severely disparate gift relations. This gift-relations can be moderated by states should they choose to incentivise the donations and therefore be the ones to judge what is “sufficient” a reward for organ donors as a reciprocation for their acts of common good.

Aside from the aforementioned controversies, should incentives be extended towards posthumous donors is another difficult question to tackle. The ethical dilemma comes in when the purpose of the incentives should be seen as a reward towards those who have displayed altruism by opting to be an organ donor. However, as a posthumous donor they will be unable to enjoy the incentives and whether or not if the act itself can be considered altruistic is a debate of its own due to the difference in which the donation affects the donor compared to living donors. While society accepts consent by proxy for organ donations, is it fair for the proxies to benefit from the incentives as well? The idea of members aside from the donors themselves benefiting from the donation seems harder to stomach than incentives for living donors as it seems to dehumanise and devalue the posthumous donor from a family member or spouse to a commodity to donate and profit from.

The Practicality of Incentivising Organ Donations

The incentivisation of organ donations is proposed to increase the availability of organs in order to meet the growing need for organ transplantation across the world. It has the potential to widen the pool of organ donors, increase conversations on organ transplantation and increase the number of organ transplantations. This helps alleviate the long line of waiting list of patients in need of an organ they have minimal chances of receiving. While the innate appeal of incentives cannot be denied, it has been observed that incentivising such acts associated with altruism might actually cause the decrease of such acts as when incentives are involved, donors no longer feel the same degree of altruism or emotional appeal as when incentives are not involved. For example, blood donations rates in some countries were observed to drop after financial compensations were no longer outlawed.

The main concern surrounding implementing incentives for organ donation seems to be the Pandora’s box it opens as to the types of incentives which are acceptable and the risk of it escalating into organ sales trade.

As we draw observations from the world around us, the desperation of patients in dire need of organ transplantation and the proportion of affluent patients willing to spend their life savings to bypass the wait list for their organ transplant has fuelled the organ trafficking pandemic, these global trafficking chains are built off exploiting lower income communities such as those in India and Brazil. In Singapore, although the sale of organs is outlawed under HOTA, prominent businessman Tang Wee Sung was jailed and fined for attempting to purchase a kidney from an Indonesian man in 2008, an illustration of how patients are willing to trespass the boundaries of law in order to earn themselves the “gift of life”.

Should incentivisation of organ donation be allowed, the ethics principles that hold organ sales at bay no longer apply. The call for a legal organ market is not unheard of even when the majority of the countries today ban the use of incentives altogether. By legalising the incentivisation of organ donations, the lines between willing living donors and those who are coerced and exploited is easily blurred and it leads to a downward spiral that transcends closer to organ sales which violates the equity of organ donations and thrives off exploitation of communities that are lower in socioeconomic status. If states can provide incentives, who is to say that corporations or individuals are not to involve themselves in this incentivisation of organ donation? On what grounds can the legal systems condemn those who choose to donate their organs at a marked price should they fully consent to it as of those who choose to donate their organs to receive government incentives? The answer is none, once the ethical barriers between organ donations and organ trades are diminished, the legislative systems do not have proper reasoning to continue outlawing organ trades. This opens the doors to a multitude of problems. The richer are more likely to be able to afford organ transplants despite not necessarily being those who are in the most critical need for the organs, those who are of lower socioeconomic status are more likely to coerced into donating their organs and without proper legal knowledge they are susceptible to being exploited by middlemen, law enforcers will find it more difficult to establish the clear distinctions between consenting living donors and victims of organ trafficking which makes it much more arduous to protect the rights of living donors. The list is non-exhaustive.

Conclusion

The incentivisation of organ donation is plausible ethically but it will require strict moderations and policies to ensure that the thin line of respecting the donor’s wishes and reducing the donor into a commodity is not compromised. Incentivisation of organ donation should not be proposed as a standalone solution as it is superficial to see it as merely a tool to increase the pool of organ donors in the country. Legalising incentives for organ donations has more implicit effects on other legislations regarding organ donations and reflects on where the country stands on the ethics of organ donations.

Hence, I believe that countries should only offer incentives for organ donation should they be well-equipped to implement policies that are able to ensure the integrity of organ donations. It should also be considered subservient to other policies that are meant to promote organ donations within current legislations. It is a solution that may not yield substantial results that complement the efforts and investments on the part of the state required to ensure its feasibility.

In essence, organ donations should not be incentivised.

References

1. Shaikh, S. S., & Bruce, C. R. (2016). An Ethical Appraisal of Financial Incentives for Organ Donation. Clinical Liver Disease, 7(5), 109–111. https://doi.org/10.1002/cld.v8.1

2. Kishan, P. (2019, January 3). Organ trading in Singapore – is it time to lift the ban? Asia Law Network Blog. Retrieved May 20, 2022, from https://learn.asialawnetwork.com/2019/01/03/living-organ-donation/

3. Kishore, R. R. (2005). Human organs, scarcities, and sale: morality revisited. Journal of Medical Ethics, 31(6), 362–365. https://doi.org/10.1136/jme.2004.009621

4. Stephanie Zwerner, A Small Price to Pay: Incentivizing Cadaveric Organ Donation with Posthumous Payments, 18 MINN. J.L. SCI. & TECH. 273 (2017). Available at: https://scholarship.law.umn.edu/mjlst/vol18/iss1/5

5. Sadie-Anne Jones, A. (2020, December 16). A Legal Organ Market: Should it Exist? – UAB Institute for Human Rights Blog. UAB Institute for Human Rights Blog. https://sites.uab.edu/humanrights/2020/12/16/a-legal-organ-market-should-it-exist/

6. Incentives for Organ Donation: Proposed Standards for an Internationally Acceptable System. (2011). American Journal of Transplantation, 12(2), 306–312. https://doi.org/10.1111/j.1600-6143.2011.03881.x

7. Levy, M. (2018). State incentives to promote organ donation: honoring the principles of reciprocity and solidarity inherent in the gift relationship. Journal of Law and the Biosciences, 5(2), 398–435. https://doi.org/10.1093/jlb/lsy009

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