Purpose: Proposals to increase the supply of transplantable kidneys through government-regulated payments to living kidney donors have not been seriously considered by policymakers due to ethical concerns. We sought to determine the extents to which the three main ethical concerns with paying kidney donors might manifest if regulated payments were legalized.
Methods: We recruited a representative sample of Philadelphia County residents by interviewing consecutively encountered regional rail passengers. We used conjoint analysis to elicit participants’ willingness to donate a kidney while systematically varying (1) the amount they would be paid, (2) their risk of subsequently developing kidney failure themselves, and (3) who would receive their kidney. We determined whether payment represents an “undue inducement” by evaluating participants’ sensitivity to risk as a function of the payment offered; whether payment represents an “unjust inducement” by evaluating participants’ sensitivity to payment as a function of their annual income; and whether introducing payment would reduce altruistic donations by comparing the proportions of participants who would donate altruistically (for free) when this condition was presented up front versus after participants were exposed to payments.
Results: Among 342 encountered rail passengers, 260 completed the questionnaire (response rate = 76.0%), and 222 were medically eligible to donate. Clustered logistic regression revealed that donation rates increased significantly as risk of developing kidney failure decreased, as the payment offered increased, and when the kidney recipient was a family member rather than the next patient on the public waiting list (p < 0.01 for each). Despite greater than 90% power to detect statistical interactions, none was found between payment and risk (p = 0.80) or between payment and participants’ income (p = 0.20), suggesting that payment is neither an undue nor an unjust inducement, respectively. Alerting participants to the possibility of payment did not alter their willingness to donate for altruistic reasons (p = 0.77).
Conclusion: Theoretical concerns with paying people for living kidney donation are not corroborated by empirical evidence. We cannot recommend establishing a kidney market based on these results because choices revealed in hypothetical scenarios may not reflect real-world behaviors. However, these results suggest that it is time to conduct a real-world test of regulated payments to determine whether they may reduce the kidney shortage ethically.
Candidate for the Lee B. Lusted Student Prize Competition