By Daniel Rodger and Bonnie Venter.

The problem

The demand for kidneys required for transplant cannot be satisfied by the existing supply and this deficit continues to increase annually. This is a worldwide phenomenon that is being driven by steady increases in kidney disease and the comorbidities that can cause it. Globally, more than 850 million people have some kind of kidney disease and it is projected to increase from the 16th to the 5th leading cause of years lost by 2040.

In England, patients will wait on average around three years to receive a kidney transplant. Recipients will acquire a kidney through one of two avenues—a deceased donor or a living kidney donor, with the latter associated with the best long-term outcomes for the recipient.

In recognition of this problem, in 2020, England adopted an opt-out system of organ donation, which means adults are presumed to consent to donate their organs when they die unless they register a decision not to. Living donation rates have also been increased by relying on non-directed altruistic donors, where an individual donates a kidney to someone they do not know, as well as the sharing scheme which allows donor-recipient pairs who are difficult to match to donate to others in a similar position. Whilst 2023 saw a 2% increase in both deceased and living donors, the supply still falls significantly short of the demand.

This shortfall means that hundreds of people in England die each year waiting for a kidney transplant and hundreds more become too sick and are removed from the waitlist. Whilst addressing the causes of kidney disease is important, attention should also be given to alternate means of ethically sourcing more kidneys for donation. The current approach is not sufficient to address this issue, and past alternatives that were quickly dismissed should be reconsidered.

Financial compensation

Proposals have been put forward to reward living kidney donors, but this solution is often heavily criticised or seen as immoral. As the law stands in the UK, as in most of the world, it is considered a crime if a donor receives any sort of payment for their kidney. This, however, does not mean that donors may not be remunerated for costs associated with their donation, such as travel, accommodation, or loss of earnings. In fact, the NHS provides remuneration for up to £5000 to ensure that the donation is cost-neutral. Despite this initiative, research has shown that the expenses continue to act as a disincentive for donors.

We recommend that the time has come to revisit the debate of paying the donor. It is plausible that the shortfall and disincentives can be addressed by providing donors in England with the option of receiving financial compensation—perhaps around £35,000.

Our proposal would operate within a monopsony system, a market structure where there is only one ‘buyer’—in this case the NHS. Patients would continue to receive a kidney transplant based on clinical need; however, they would likely wait much less time for a transplant, perhaps a year rather than three. It is well established that an earlier transplant carries significant short- and long-term health benefits and is associated with notable cost-savings that can be reinvested in addressing the causes of kidney disease.

We believe that this approach could increase the number of living kidney donors and would result in a reduced burden on dialysis services, increase awareness of living donation, and result in long-term cost savings. Importantly, we do not believe that accepting compensation should be the default, but rather an option donors could opt in to receive. This way, those opposed to the proposal do not have to accept compensation.

Fairness and autonomy

Financial compensation would be a much fairer way of acknowledging the risks—i.e. the low health and psychological risks—that a living kidney donor willingly accepts. The surgical removal of a kidney has been practised for several decades and is considered a safe surgical procedure. However, like any other invasive procedure, it can involve risks and complications. How fair is it for an individual to undergo surgery with no therapeutic benefit to them and yet it remains illegal to reward them for doing so? There are also hidden costs that are not captured by the reimbursement scheme, such as a partner’s travel expenses to the hospital on the day of donation.

Most people may believe it is better to donate a kidney with no expectation of reward, and while it might be considered less good to be rewarded for donating, it does not make it bad. It is difficult—even in principle—to see how the good of the benefits experienced by the recipient would be outweighed or diminished by a donor being financially compensated.

Restricting compensation for living kidney donation may be seen as paternalistic, limiting informed individual choices. The current system with its safeguards and processes is already designed to identify donors that are being coerced or exploited through an independent assessment that is done by the Human Tissue Authority. Importantly, when more kidneys are available it would likely remove the incentives and motivations to coerce or exploit a donor.

Concerns

Objections to financially compensating living kidney donors include concerns of exploitation, coercion, and that it will ‘crowd out’ or reduce the number of altruistic living donors. However, these concerns are dependent on compensation being tested in practice. We believe that all of these concerns can be mitigated through careful implementation and have addressed these concerns in our article. For example, there is evidence that paying living donors paradoxically makes a reduction in ‘altruistic’ donors less likely. The only way to really assess the feasibility of compensating living donors in England would be to trial it, however, as things stand—it remains illegal. We explore some of these objections in greater detail in our article here.

Authors: Daniel Rodger and Bonnie Venter

Affiliations: 

DR: Institute of Health and Social Care, School of Allied and Community Health, London South Bank University, London, UK; Department of Psychological Sciences, University of London, Birkbeck, UK

BV: Centre for Health, Law, and Society, Bristol Law School, University of Bristol, Bristol, UK

Competing interests: None declared

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