Monday Memo — Vouchers for Kidneys?

According to D. Joy Riley, MD, MA (Ethics), “Here’s a riddle: What is worth tens, if not hundreds, of thousands of dollars; cannot be bought or sold, but can be given away; can now be converted from flesh-and-blood into paper; and can become worthless in the blink of an eye?”

In a very thought-provoking blog for the Christian Medical Association, Dr. Riley writes:

D. Joy Riley, MD, MA (Ethics)

The answer to the riddle can be found in a recent health news article by Carolyn Crist published in Reuters called “Kidney transplant vouchers could address timing issues.” Crist references an article forthcoming in the journal Transplantation, which describes three cases of organ transplantation chains, revolving around a 4-year-old boy and a 10-year-old girl.

An explanation of an altruistic organ donation chain is in order. It typically begins with a willing but non-compatible donor. That person can give a “non-directed” donation, meaning the kidney goes to someone whose donor is not compatible with him/her. The second donor (willing, but incompatible with the first recipient) gives a kidney to yet another person with an incompatible donor. The chain reaches as far as the line of willing but non-compatible donors extends. (For further explanation,check out this graphic.

The donation chains described in the paper in Transplantation had their starting points at donors who were “chronologically incompatible”—that is, the donors would be too old to give their kidneys when the young persons would likely need them. The young boy’s grandfather, aged 64, wanted to provide a kidney for his grandson, but the boy doesn’t need a transplant—yet. So the grandfather initiated a donation chain by making a “non-directed” donation of his kidney. The grandfather was thereby able to provide a voucher for his grandson, a voucher that the National Kidney Registry Medical Board stipulated “…had no monetary value, could only be used for his grandson, couldn’t be transferred to another patient, and couldn’t guarantee that a kidney would be available.”

The other two “cases” were relatives of the 10-year-old girl. She previously had a kidney transplant, and her father, aged 52 years, wanted to provide her a voucher for another transplant in the future. Therefore, he donated his kidney to someone else, and thus began another chain of donations. Similarly, her 60-year-old aunt donated a kidney to provide the niece with a second voucher.

According to Crist,

“When adopting use of vouchers, transplant centers must consider the effects of redemptions and guard against the potential for gaming the system, the study authors say. For example, if recipients don’t need the transplant or die first from other causes, the voucher can’t be sold or traded.”

It is not only patients and their families who may be tempted to “game the system.”  Anyone with access and power has the potential. 

It should be noted that theNational Kidney Registryfacilitates living donor transplants; this is not about cadaver kidneys. Concerned, loving family members are giving up kidneys in the hope that sometime in the future, somewhere, a kidney may be available for their loved ones, should the need arise. They are trusting in a piece of paper with no guarantees. What if no living donor is ready to donate when the voucher-bearer needs to redeem the voucher? On the other hand, if a living-donor kidney becomes available, and there are several good matches for that kidney, who receives it? Does it go to the voucher holder first? What if there is more than one voucher holder? Does the earliest-date voucher win the prize? Or does the person with the most vouchers win?

Who started all of this, and where is it going? Where is the path of wisdom? We need a national conversation about organ transplantation—with all the cards laid plainly on the table.

I’d be interested in your thoughts.