Cheow Jun Wei, 21

Topic: Should we incentivise organ donation to increase supply?

Award: High Distinction, Open Category, 2022

The Donor Paradox

The shortage of organs for organ donation has been a medical issue that plagues virtually every society in the world since time immemorial. It is easy to think that this shortage is not as dire in Singapore due to its relative small population compared to the rest of the world, however such thinking is nescient and in fact, it is not an understatement to claim that the waiting time for an organ in Singapore is much longer than in other countries. Despite Singapore’s healthcare system being reputed as medically advanced and being one of the best globally, the sheer reality is that Singapore has an incredibly dense and ageing population which amplifies the demand for organs, while abysmal birth rates will further strain the already scarce supply of healthy organs down the road. Fortunately, medical advances have made it possible to address the problem of organ shortage in the coming decades but these are neither immediate solutions nor is it free from ethical concerns. Some feel that incentivisation is the best approach moving forward to encourage people to step forward to donate their organs while others feel that this very act itself may be considered coercive. Personally, while I feel that organ donation should be incentivised to address the unavailability of organs for transplant, it should not be a measure that is lightly taken or relied upon in the long term.

To begin, organ donation should be incentivised to encourage people to step forward and offer their organs such that people who need them can be given a second chance to lead fulfilling lives, rather than being succumbed to their respective illnesses. As more societies face the problem of an ageing population today, a surge in people contracting illnesses is inescapable. However, no one deserves to undergo the awful experience of replacing their failed organs, and above all else, not die waiting to get one. In reference to the death statistics by cause in Singapore, the percentage of individuals dying from heart-related causes has been increasing in recent years, amounting to a quarter of a total of 22054 deaths in 2020. Individuals who passed on due to lung-related causes accounted for 18.8% of deaths, highlighting the number of lives that could have been saved if there were a hypothetical higher availability of organs for transplantation. Despite Singapore’s best efforts to alleviate this unfortunate scarcity of organs by rolling out policies such as the HOTA 1987 and MTERA, there are still more than 400 patients waiting to receive a life-saving transplant every year. In fact, most patients have to wait five to seventeen years before a suitable organ is found. The incentivisation of organ donation, not limited to monetary incentives, has been pilot tested in other countries with some degree of success. For instance, Zhejiang Province in China saw an increase from 23 donors to 43 donors within a short span of four months by covering basic funeral expenses such as body transportation, cremation, ash urn storage and providing deceased donor’s families with cash allowance from the government - the extent of which is generous but dependent on the families’ incomes. On top of that, a good Samaritan regulation was introduced to protect altruistic donors who lend a hand. This success is not only unique to China but also applicable to Pennsylvania in the US during its own pilot programme in 2000. Although a twenty increment seems barely sufficient, it does not change the fact that donation rates doubled in Zhejiang and it shows that incentivisation, when carefully calibrated, can be utilised to increase the availability of organs for transplantation.

However, while incentivisation is a possible way to increase availability of organs as mentioned above, it may cause undesirable outcomes such as temptations and coercion. lncentivisation, monetary and other immediate benefits in particular, can indeed influence and thus interfere with the decision making process of individuals. As such, individuals may overestimate the benefits of organ donation and underestimate the huge risks involved, therefore making an ill-informed decision. The judgement made in the spur of the moment may in fact be impulsive and breach their respective belief and value systems. In a study by EJ Gordon, it was found that the median lowest amount of financial compensation for individuals to begin considering donating a kidney would be 5,000 USD for family and friends and 10,000 USD for people who are unknown to them. Similarly, the median monetary value to spur the same group of individuals to accept the offer without hesitation was at 50,000 USD for family and friends and 100,000 USD for people who are unknown to them. This study effectively shows that if the amount of incentivisation were to be intentionally scaled at a point where the incentives become irresistible to potential donors, it may cause an unhealthy surge in people offering their organs. While this may solve the shortage of organs at hand, it poses health risks to potential donors and may breed other issues such as exploitation.

Additionally, incentivisation is a double-edged sword that may create unimaginable consequences and cause divides in societies. lncentivisation can always be a weapon for anyone to take advantage of, regardless of their socio-economic statuses. The poor can use it to relieve their financial constraints while the rich can exploit it to gain unequal access. For instance, in regions with impoverished conditions such as India, people sell organs for commercial gains. A black market exists for the purchase and selling of organs in India despite the Transplant of Human Organs Act (1994) in place which bans the trading of organs. Even after the law went into effect, a study showed that 96% of donors sold their kidneys to pay off their financial debts with an average earning of 1,070 USD. Furthermore, it was found that most traders were labourers and street vendors with an annual income of 660 USD, highlighting that these people sacrificed their organs for nearly two years of income to pay off their debts. As such if incentivisation would be rolled out by governments to encourage organ donations, people living in poor conditions would not hesitate to do so. On the other hand, the wealthy can easily access the black market and offer organ donors more attractive incentives than what was offered by the government and healthcare system. Consequently, the wealthy would have greater and unequal access to organs, making it unfair for people who are not as privileged. As such, the organ donation system would transform into one that is dependent on income brackets, favouring the wealthy and acting against the poor. Moreover, the emergence of black markets could diminish the number of altruistic donors in society and the very essence of organ donation.

In conclusion, while incentivisation can encourage people who are hesitant to step up, it can breed a multitude of problems such as exploitation and undue inducement. As such, I believe that incentivisation should only be utilised when carefully calibrated with legislations in place to eliminate any undesirable outcomes that arise. In view of the global shortage of organs and the millions of people who have died waiting to get one, governments and scientists around the world should come to a unanimous agreement to collaborate and work towards an ethical-friendly solution to tackle the catastrophic issue, such as increasing research on organ cloning by using stem cells. The world has learnt about the immense power of global collaboration from the Covid-19 pandemic where vaccines, which typically take at least a decade to produce, were developed in less than a year without compromising standards. And with that spirit, the low availability of organs for transplant can also become a problem of the past.

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 ↗ (opens in new tab)