The U.S. faces a widening gap between the need for, and the supply of, transplantable organs. The waiting list for transplants increased 150% in the past decade; last year, about 6,000 people died awaiting a transplant. This need has rekindled debate about the morality and feasibility of using incentives to encourage posthumous organ donation. This Issue Brief explores attitudes of the public and health professionals in the transplant community about using financial and nonfinancial incentives to increase the supply of cadaver organs for transplant

Asch, David A

Jasper, John D

English

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsIssue Briefs Leonard Davis Institute of Health Economics3-16-2004Professional and Public Attitudes TowardIncentives for Organ DonationJohn D. JasperDavid A. AschUniversity of Pennsylvania, asch@wharton.upenn.eduFollow this and additional works at: http://repository.upenn.edu/ldi_issuebriefsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/44For more information, please contact repository@pobox.upenn.edu.Jasper, John D. and Asch, David A.. Professional and Public Attitudes Toward Incentives for Organ Donation. LDI Issue Briefs. 2004; 9(5). http://ldi.upenn.edu/brief/professional-and-public-attitudes-toward-incentives-organ-donationProfessional and Public Attitudes Toward Incentives for Organ DonationAbstractThe U.S. faces a widening gap between the need for, and the supply of, transplantable organs. The waiting listfor transplants increased 150% in the past decade; last year, about 6,000 people died awaiting a transplant.This need has rekindled debate about the morality and feasibility of using incentives to encourageposthumous organ donation. This Issue Brief explores attitudes of the public and health professionals in thetransplant community about using financial and nonfinancial incentives to increase the supply of cadaverorgans for transplant.LicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/44Leonard Davis Institute of Health EconomicsLDI Issue BriefVolume 9, Number 5March 2004John D. Jasper, PhDAssistant Professor of PsychologyUniversity of ToledoDavid A. Asch, MD, MBALDI Senior Fellow; Co-Director,VA Center for Health EquityResearch and Promotion;Robert D. Eilers Professor ofMedicine and Health CareManagement and Economics,University of PennsylvaniaDemand for cadaverorgans far exceeds supplyContinued on next page.Professional and public attitudes towardincentives for organ donationEditor’s note:  The U.S. faces a widening gap between the need for, and the supplyof, transplantable organs. The waiting list for transplants increased 150% in the pastdecade; last year, about 6,000 people died awaiting a transplant. This need hasrekindled debate about the morality and feasibility of using incentives to encourageposthumous organ donation. This Issue Brief explores attitudes of the public andhealth professionals in the transplant community about using financial and non-financial incentives to increase the supply of cadaver organs for transplant.Although the public generally expresses favorable attitudes toward organ donation,relatively few individuals agree to donate before they die or consent to have familymembers’ organs donated upon their death. The current system, which relies onaltruism and good will, has not been effective in procuring enough organs to meetthe demand. One suggested alternative approach would offer incentives to familiesof deceased or dying individuals to encourage their consent for organ donation.• Those in favor of offering incentives contend that they will encourage donation,citing longstanding and successful practices of payment for blood, bloodproducts, sperm, and eggs.• Opponents claim that incentives are unethical and that health professionals donot want to be in the position of offering incentives to the bereaved family of thedonor.  They also claim that incentives would undermine the altruistic appeal ofthe current system and ultimately discourage donation.• In 2002, the American Medical Association and the United Network for OrganSharing endorsed the idea of limited trials of financial incentives for posthumousorgan donations.• The National Organ Transplant Act of 1984 prohibits the purchase of organs fortransplantation.  This federal law would most likely need to be changed beforeany financial incentives could be tried, even on a limited basis.Dr. Jasper and colleagues examined the attitudes of 3 groups of health careprofessionals—transplant surgeons, transplant coordinators, and critical carenurses—toward current policies of altruistic donation and alternative policiesoffering incentives to the donor family.Mailed survey exploresattitudes of transplantcommunity towardincentivesTransplant communityjudges nonmonetaryincentives and indirectmonetary incentivesmorally acceptable• The investigators surveyed 400 transplant surgeons, 200 transplant coordinators,and 200 critical-care nurses.  Response rates for these groups were 64%, 74%, and69%, respectively.• The survey asked about the moral appropriateness, likely success, and decision toimplement six alternative policies.• Incentives included 1) priority on the waiting list should a family member everneed a transplant; 2) a $1500 contribution to a favorite charity; 3) a $1500payment toward the donor’s funeral expenses; 4) $1500 in cash; 5) a  $1500rebate or premium reduction on health insurance; and 6) recognition such as thedonor’s name on a plaque or memorial.• A value of $1500 was selected because it was in the middle range of paymentproposed by others, and seemed large enough to act as an incentive but smallenough not to be coercive.Although some differences among the professions exist, the transplant communitygenerally agrees on the moral appropriateness of nonmonetary incentives (such asdonor recognition or preferred status) and indirect monetary incentives (such as$1500 toward funeral expenses or to a charity).• When rating the alternatives, all 3 professions made clear and very similardistinctions among policies.  The current policy and a policy offering donorrecognition had the highest ratings of appropriateness, and a policy of $1500 incash had the lowest rating.• All 3 professions believed the current policy and a policy offering donorrecognition to be morally appropriate; a policy offering $1500 toward funeralexpenses to be morally neutral, and a policy offering a $1500 cash or a $1500health insurance rebate to be morally inappropriate.• Surgeons believed a policy offering a $1500 contribution to charity to be morallyappropriate; coordinators and nurses believed this policy to be morally neutral.Surgeons and coordinators believed a policy offering preferred status to be morallyneutral; nurses believed this policy to be morally inappropriate.All 3 professions believed the current policy to be at best only moderately successfulin recruiting organ donors, and nearly 50% of all respondents suggested changes tothe current policy.  Most thought that all of the incentives described would increaseorgan donation relative to the current policy of altruistic donation.• Providing incentives to the family or potential donor was the change mostfrequently suggested by surgeons and coordinators, followed closely by providingbetter education to health professionals and the public; the latter change was mostfrequently suggested by the nurses.• Surgeons and nurses believed that each alternative policy would increase thelikelihood of donation.  With one exception (a policy offering a $1500contribution to charity), coordinators also believed each alternative wouldincrease the likelihood of donation.  All professions believed that a policy offering$1500 in cash or funeral expenses would be most successful, and a policy offeringa $1500 contribution to charity would be the least successful at increasing thenumber of organs donated.Most respondents thinkalternative policies wouldincrease organ donationsContinued on back.Professional attitudestoward incentives fororgan donation consistentwith public’s attitudesPOLICY IMPLICATIONSFor respondents in all 3 professions, the decision about whether each policy shouldbe implemented  was more frequently related to its moral appropriateness than tothe perceived likelihood of success in increasing donations.• A policy offering donor recognition had a significantly higher percentage ofadvocates than did any other alternative policy, with at least 75% of respondentsin each profession believing that the policy should be implemented despite itsrelatively low likelihood-of-success rating.• Only 7%-16% of respondents in each profession thought that a policy of $1500in cash should be implemented, despite its relatively high likelihood-of-successrating.• About half of the surgeons and half of the coordinators advocated implementing apolicy of $1500 toward funeral expenses, with a somewhat lower percentage ofnurses advocating implementation.  Policies offering preferred status, a $1500contribution to charity, or a $1500 health insurance rebate were favored by 24%-45% of each profession.The transplant community’s attitudes toward incentives are similar to those of thepublic. In an earlier study, Jasper and colleagues surveyed 300 prospective jurors inPhiladephia County and asked them about the moral appropriateness of incentivesfor organ donation, and about what effect incentives might have on their intentionsto donate. They asked about the same six incentives used in the transplantcommunity survey, plus three others: a $1500 payment for uninsured medicalexpenses, a $1500 federal income tax credit, and free drivers’ licenses and tags.• None of the policy alternatives was considered morally inappropriate by themajority of respondents.  In other words, the majority of respondents rated eachpolicy as morally “neutral” or “appropriate.”• In general, indirect monetary incentives (such as a $1500 payment toward funeralexpenses or uninsured medical expenses) were considered more appropriate thanpolicies offering more direct monetary incentives (such as $1500 in cash or a$1500 income tax credit.).• To gauge the likely effect of each incentive, the investigators examined whethereach policy would change the intentions of present donors and nondonors (asindicated on a current driver’s license or other official document). In every case,the percentage of nondonors responding positively was higher than donorsresponding negatively; thus, the net effect would appear to increase the supply oforgans.In contrast to most of the published work in this area, these two studies provideempiric evidence to the debate on incentives for organ donation.  Only a market testcan demonstrate conclusively the impact that financial incentives would have on thesupply of donated organs. However, such market tests are currently illegal, andstudies of the attitudes of the public and health care professionals toward incentivesmay provide useful insights in lieu of such tests.• Stakeholders do not view all incentives in the same way.  For both the transplantcommunity and the public, the acceptability of incentives varies by the kind ofTransplant communityfavors implementingdonor recognition, but notdirect cash incentivesThis Issue Brief is based on the following articles: J.D. Jasper, C.A.E. Nickerson, P.A. Ubel, D.A. Asch.  Altruism, incentives, and organdonation: attitudes of the transplant community.  Medical Care, April 2004, vol. 42, pp. 378-386;  J.D. Jasper, C.A.E. Nickerson, J.C.Hershey, D.A. Asch.  The public’s attitudes toward incentives for organ donation.  Transplantation Proceedings, 1999, vol. 31, pp.2181-2184.Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104-6218.Janet Weiner, MPH, Associate Director for Health Policy, EditorDavid A. Asch, MD, MBA, Executive DirectorIssue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic, and social andethical issues that influence how health care is organized, financed, managed, and delivered in the United States and internationally. The LDIis a cooperative venture among Penn schools including Dental Medicine, Medicine, Nursing and Wharton, and the Children’s Hospital ofPhiladelphia. For additional information on this or other Issue Briefs, contact Janet Weiner (e-mail: weinerja@mail.med.upenn.edu; 215-573-9374).Nonprofit OrganizationU.S. PostageP  A  I  DPermit No. 2563Philadelphia, PA 19104Issue Brief Published by theLeonard Davis Instituteof Health EconomicsUniversity of Pennsylvania3641 Locust WalkPhiladelphia, PA 19104-6218215.898.5611fax 215.898.0229ADDRESS CORRECTION REQUESTED© 2004 Leonard Davis InstitutePOLICY IMPLICATIONSContinuedVisit us on the web at www.upenn.edu/ldiincentive and the directness of each approach.  Studies of financial and non-financial incentives should always specify the nature and form of each incentive.• These findings indicate support for some change to the current policy of altruisticdonation, which has not met and is unlikely ever to meet the demand for organs.Further exploration of incentives that meet the tests of moral appropriateness andlikely effectiveness is warranted.• Congress is currently considering a bill that would defray some travel and housingexpenses for living donors to increase the supply of certain organs such as kidneysor livers.  As policymakers debate the wisdom of such financial incentives forliving donors, they should also consider revisions to federal law or regulation thatwould allow the piloting of innovative incentives for posthumous donation.

Professional and Public Attitudes Toward Incentives for Organ Donation

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Professional and Public Attitudes Toward Incentives for Organ Donation

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