By Christopher De Luca and Katarina Zorcic
Organ advocacy initiatives have made strides in informing Canadians about the increased need for organ donors. As highlighted by Amy Kwon in a prior article, 90% of Canadians express their support for the issue of our current organ shortage crisis. However, the focus now must shift to considering new strategies or policies that would incentivize Canadians to become organ donors. While Canadians may be aware of the unfortunate realities faced by individuals on transplant waitlists, only a few actively take action to change their status and sign up to be organ donors.
Having to “change status” is one of the main critiques of Canada’s current opt-in system of organ donation. This system is the opposite of opt-out, which automatically identifies citizens as organ donors. Thus, citizens must make an effort to change their status to not forfeit their organs1. While both systems have more nuanced pros and cons, the limiting factor in Canada is that becoming an organ donor becomes a chore; something requiring an individual to go out of their way and change status. And considering that there is no direct and immediate compensation to becoming a donor, there is no motivation. The benefit of becoming a donor is not tangible.
To overcome this, many incentive initiatives – both financial and non-financial – exist around the world2. For example, Ontario’s Program for Reimbursing Expenses of Living Organ Donors is a financial incentive that provides reimbursement (~$5500) to living organ donors for eligible out-of-pocket expenses and lost income during the transplant process3. But placing a price on a living donor’s organs can present a host of legal and ethical disputes. Furthermore, such financial policies do not address the large portion of citizens who are deceased organ donors and the accompanying complications that would arise (e.g., should I be paid for my organs even though they are only of use after I die?).
Instead, non-financial incentives are becoming more common around the world. An interesting example can be seen in Israel where organ allocation priority is given to individuals who have become donors. That is, future donors will be assessed with higher priority if they are ever in need of an organ. Israel implemented such a non-financial incentive in 2008, and according to Levy et al. (2018), 70,000 Israelis signed up for organ donor cards within the first 10 weeks of public awareness4. This priority system also has policies in place to prevent exploitation. For example, in the scenario that a non-donor is in urgent need of an organ, they cannot become a donor and automatically have priority. Singapore has also adopted a similar priority system.
Levy also brings up the principle of reciprocity in her analysis, highlighting the fact that people generally partake in an action if they expect something in return. Somewhat different from becoming an organ donor for the sake of someone else, an individual donates an organ and places hope that they will be on the receiving end of a donation if needed in the future. In biology, this is the concept of reciprocal altruism where “the cost of helping is offset by the likelihood of the return benefit” as stated by Samir Okasha5.
Li and colleagues build on this topic by saying that proponents of a priority incentive highlight that current systems in the US and Canada do not garner enough donors because their motive is solely altruistic, not reciprocally altruistic6. This study also developed a simulation that quantified college students’ rate of choosing to donate. They found that the highest donation rates arose when a priority rule was in place. However, they noted that similar increases could be seen with solely an opt-out policy. This finding raises questions on whether opt-out and priority systems are better in tandem or alone in increasing donor numbers.
I do believe that considering other non-financial incentives would be beneficial in mitigating the shortage of organs available for those on waitlists. There are obviously more nuanced dimensions that should be considered and compared to the current system in place. For instance, how much priority do I receive as a registered donor? Will I be considered before those more acutely at risk than me? Can I give my priority to a member of my family who is unable to be a donor? Nonetheless, if the goal is to increase registered donors, then I believe there are aspects of Israel and Singapore’s policies that Canada could adopt.
1. Glannon, W. Free riding and organ donation. Journal of Medical Ethics 35, 590–591 (2009).
2. Caulfield, T., Nelson, E., Goldfeldt, B. & Klarenbach, S. Incentives and organ donation: what’s (really) legal in Canada? Can J Kidney Health Dis 1, 7 (2014).
3. Living Kidney Donation | LHSC. https://www.lhsc.on.ca/multi-organ-transplant-program/living-kidney-donation.
4. Levy, M. State incentives to promote organ donation: honoring the principles of reciprocity and solidarity inherent in the gift relationship. Journal of Law and the Biosciences 5, 398–435 (2018).
5. Okasha, S. Biological Altruism. in The Stanford Encyclopedia of Philosophy (ed. Zalta, E. N.) (Metaphysics Research Lab, Stanford University, 2020).6. Li, D., Hawley, Z. & Schnier, K. Increasing organ donation via changes in the default choice or allocation rule. J Health Econ32, 10.1016/j.jhealeco.2013.09.007 (2013).