Incentives and Disincentives in Organ Donation: A Multicultural Study among Beijing, Chicago, Tehran and Hong Kong (Philosophy and Medicine, 133)

This book provides the first systematic study on three types of incentives for organ donation. It covers extensive research conducted in four culturally different societies: Hong Kong, mainland China, Iran and the United States, and shows on the basis of the research that a new model of incentives can be constructed to enhance organ donation in contemporary societies. The book focuses on three types of incentives: honorary incentives , commonly adopted in the United States and other Western countries by offering things such as a thank-you card and a memorial park for donors to encourage donations motivated by pure altruism; compensationalist incentives , adopted in the Islamic Republic of Iran to encourage donation by providing monetary compensation to unrelated living donors for appreciating their altruistic contribution of donation; and familist incentives , implemented in Israel and mainland China to provide priority to organ transplantation to donors and/or their family members. The book demonstrates that a new model of incentives must go beyond offering only one type of incentives and should rather include different types of incentives that are practically effective, politically legitimate and ethically justifiable for particular societies. This implies that suitable incentive measures may vary from society to society to optimize organ donation. This book provides a clear reference for both the scholars and practitioners in the field of organ transplantation, as well as for general readers interested in bioethics and health care policy. Acknowledgements Contents Contributors Part I: Introduction Chapter 1: Introduction: Toward a New Model of Incentives for Organ Donation 1.1 Introduction 1.2 Confronting the Organ Shortage Problem 1.3 Investigating the Three Types of Incentive 1.4 Rethinking the Three Types of Incentive 1.5 Toward a New Model of Incentives 1.6 Chapters in This Book References Part II: Beijing Papers Chapter 2: The Background to Organ Donation in Mainland China 2.1 Healthcare in Mainland China 2.2 The Development of Organ Transplantation in Mainland China 2.3 Important Legislation and Landmark Policies in Recent Years 2.4 The Organ Donation Operation System 2.4.1 Public Promotion 2.4.2 Registration 2.4.3 Witnessing Donation and Allocation 2.4.4 Memorial and Humanitarian Aid 2.5 Concluding Remarks References Chapter 3: Mixed Incentives, Different Voices: A Qualitative Study of Organ Donation Incentive Policies in Two Big Chinese Cities 3.1 Introduction 3.2 Honorary Incentives 3.3 Compensationalist Incentives 3.4 Familist Incentives 3.5 Conclusion References Chapter 4: Organ Donation Incentives in Mainland China: Ethical Commentaries and Reform Recommendations 4.1 Ethical Commentaries on the Incentives for Organ Donation in Mainland China 4.1.1 On the Honorary Incentives 4.1.2 On Compensationalist Incentives 4.1.2.1 On the Interviewees’ Conflicting Viewpoints on Compensation 4.1.2.2 On Financial Aid for a Donor’s Family Experiencing Financial Hardship 4.1.3 On the Familist Incentives 4.2 Further Comments on Future Organ Donation Policy Reform in China 4.2.1 On the Context of the Reform 4.2.2 Recommendations References Part III: Chicago Papers Chapter 5: The Concepts and Development of Organ Donation Policy in the United States 5.1 Introduction 5.2 Organ Donation Rates in the United States and Chicago 5.3 Policy and Legislation Regarding Transplantation 5.3.1 Justification and Goals 5.3.2 History of Regulation in the US 5.3.3 National Organ Transplant Act of 1984 5.4 Systems and Structures of Organ Transplantation 5.4.1 Organ Procurement and Transplantation Network (OPTN) 5.4.1.1 Criteria 5.4.1.2 Function 5.4.1.3 The Final Rule Guiding Principles 5.4.2 Payors’ Role in Regulation of Transplantation 5.5 OPOs in Organ Donation: The Case of Gift of Hope in Chicago 5.6 Conclusion References Chapter 6: Interviews in Chicago 6.1 Introduction 6.2 General Attitudes Toward Three Incentives 6.3 Honorary Incentives 6.3.1 How Honorary Incentives Work in Chicago 6.3.2 Bringing the Honor of Organ Donation to the Public’s Attention 6.3.3 Living Donation Enhances Awareness of the Honor of Donation 6.4 Compensationalist Incentives 6.5 Familist Incentives 6.6 Conclusion Reference Chapter 7: Ethical Considerations About Three Incentive Models Based on Research in Chicago 7.1 Introduction 7.2 Honorary Incentives 7.2.1 Gift Act: The Institutional Foundation of Honorary Incentives 7.2.2 The Donation Experience 7.2.3 Cultivation of a Donation Culture 7.2.4 Gift-Giving and the Psychological Impact of Organ Donation 7.2.5 Legal, Organizational, and Community Efforts to Overcome Existing Challenges 7.3 Supplementary Incentives: Implications for Policy Change 7.3.1 Why (or Why Not) Compensationalist Incentives? 7.3.2 Why (or Why Not) Familist Incentives? 7.4 Conclusion References Part IV: Tehran Papers Chapter 8: The Kidney Transplantation Program in Iran 8.1 Introduction 8.2 Healthcare System in Iran 8.3 End-Stage Kidney Disease (ESKD) in Iran 8.3.1 Hemodialysis 8.4 How Did Kidney Transplantation Start in Iran? 8.5 Brain-Dead Donation (BDD) Program 8.6 Financial Aspects of the Iranian Model 8.7 Conclusion References Chapter 9: Interview Findings in Relation to Organ Donation in Iran 9.1 Introduction 9.2 Objective and Methods 9.2.1 Objectives 9.2.2 Methods 9.3 Main Findings 9.3.1 Attitudes Toward Brain-Dead Donation (BDD) 9.3.2 Attitudes Toward Living Kidney Donation 9.3.3 Attitude Toward Compensationalist Incentives for Unrelated Kidney Donation (Iranian Model) 9.3.4 Attitudes Toward Incentives for BDD 9.3.4.1 Honorary Appreciation 9.3.4.2 Compensationalist Incentives 9.3.4.3 Incentive Options for Deceased Donors’ Families 9.4 Reasons for Refusal to Consent to Donation 9.4.1 Aspects of Brain Death on Which the Public Needs to Be Educated 9.5 Conclusion References Chapter 10: A Comment on the Barriers to and Incentives for Organ Donation in Iran 10.1 Introduction 10.2 Barrier 1: Public Knowledge About Brain Death 10.3 Barrier 2: Controversy Over Financial Compensatory Incentives 10.3.1 Live Kidney Donors Deserve Financial Incentives (Iranian Model) 10.3.2 Compensatory Incentives Mitigate Hidden Pressure on Female Family Members to Be Donors 10.3.3 Cost of Donation for Live Donor Vs. Deceased Donor 10.3.3.1 Direct Medical Costs 10.3.3.2 Direct Non-medical Costs 10.3.3.3 Indirect Future Non-medical Costs 10.3.3.4 Indirect Psychological Costs 10.4 Compensationalist Incentives in BDDs 10.4.1 Crowding Out 10.4.2 Undue Inducement 10.4.3 Commodification of Human Organs 10.5 Barrier 3: Informed Consent to Donation 10.5.1 Autonomy 10.5.2 Being Informed 10.5.3 Voluntariness 10.6 Iran’s Successful Policies in Addressing Barriers to Public Knowledge of BDD 10.7 Government Contribution to Funeral Service Expenses as the Optimal Respectful Incentive 10.8 Conclusion References Part V: Hong Kong Papers Chapter 11: Organ Donation: The Hong Kong Context 11.1 Introduction 11.2 Human Organ Transplant System in Hong Kong 11.2.1 Human Organ Transplant Ordinance: Prohibition of Commercialization 11.2.2 Mentally Incapacitated Recipients of Donated Organs 11.2.3 Eligible Age for Living Donors 11.2.4 Exemptions for “Regulated Products” 11.2.5 Paired Donation 11.3 Organ Shortage and Unsuccessful Promotion 11.3.1 Family Value, Equity, and Organ Shortage 11.3.2 How Serious Is the Shortage? 11.3.3 Limited Success of Governmental Promotion 11.3.4 Adopting an Opt-out System vs. Crucial Organizational Changes 11.4 Seeking New Measures to Encourage Donation 11.4.1 Some Proposed New Measures 11.4.2 Lowering the Eligible Age of Living Donors 11.4.3 The Role of Media Coverage 11.5 Conclusion References Chapter 12: Incentives for Organ Donation in Hong Kong: In-Depth Interviews 12.1 Introduction 12.2 Interviewees’ General Attitudes Toward and Experience (First- or Second-Hand) of Cadaveric Organ Donation 12.3 Honorary Incentives 12.4 Compensationalist Incentives 12.5 Familist Incentives 12.6 Conclusion Reference Chapter 13: Incentives for Organ Donation in Hong Kong: A Survey 13.1 Introduction 13.2 The General Attitude Toward Organ Donation 13.3 Honorary Incentives 13.4 Compensationalist Incentives 13.5 Familist Incentives 13.6 Discussion 13.6.1 Compensationalist Incentives and Familist Incentives as a Token of Respect for Donors in Hong Kong 13.6.2 Should Hong Kong Change to an Opt-out System 13.6.3 Comparison of the Three Incentives Appendix: Tables in This Survey Report References Chapter 14: Organ Donation, Comprehensively Good Incentives, and the Family: A Comment on Hong Kong’s Interview Findings and Survey Results 14.1 Introduction 14.2 Offering a Columbarium Niche to a Deceased Organ Donor 14.2.1 A Mixed Incentive Measure 14.2.2 An Ethically Justifiable Measure 14.3 Adopting Familist Incentives in Hong Kong 14.3.1 Removing Altruism from Donations? 14.3.2 Inappropriately Favoring Large Families? 14.3.3 Compelling Donation against a Deceased Family Member’s Own Wishes? 14.4 Maintaining the Familist Decision Model 14.4.1 The Family’s Power to Make a Deceased Donation 14.4.2 The Family’s Power to Veto Deceased Donation 14.5 Concluding Remarks References Part VI: Implications for Hong Kong and Other Societies: Toward a New Model Chapter 15: Organ Donation Incentives: A Multicultural Comparison 15.1 Introduction 15.2 Incentives 15.2.1 Honorary Incentives 15.2.2 Compensationalist Forms of Incentives 15.2.3 Family Priority on Organ Waiting Lists 15.3 Beyond Incentives 15.4 Future Directions References Chapter 16: Organ Donation Incentives: Implications for Hong Kong and Beyond 16.1 Introduction 16.2 Legal Implications for Hong Kong 16.2.1 Organ Donation Incentive and Consent to Donation 16.2.1.1 Do the Organ Donation Incentives Amount to an Offer of Inducement for Giving Consent? 16.2.1.2 Who Will Be Motivated by Organ Donation Incentives? 16.2.2 Legality of the Three Incentive Models 16.2.3 Design of Organ Donation Incentive Rules 16.2.3.1 Honorary Incentive Rule 16.2.3.2 Rule on Reimbursement for Reasonable Costs 16.2.3.3 Allocation Priority Rule 16.3 Further Ethical Thoughts and Recommendations 16.3.1 An Opt-out System Is Not a Panacea for Organ Donation 16.3.2 A Paradigm Shift in Incentive Structure Is Necessary 16.4 Concluding Remarks: Building an Integrated Model of Incentives for Organ Donation References Index