Incentivizing Organ Donor Registrations with Organ Allocation Priority

How donor organs are allocated for transplant can affect their scarcity. In 2008, Israel's Parliament passed an Organ Transplantation Law granting priority on organ donor waiting lists to individuals who had previously registered as organ donors. Beginning in November 2010, public awareness campaigns advertised the priority policy to the public. Since April 2012, priority has been added to the routine medical criteria in organ allocation decisions. We evaluate the introduction of priority for registered organ donors using Israeli data on organ donor registration from 1992 to 2013. We find that registrations increased when information about the priority law was made widely available. We find an even larger increase in registration rates in the 2 months leading up to a program deadline, after which priority would only be granted with a 3‐year delay. We also find that the registration rate responds positively to public awareness campaigns, to the ease of registration (i.e. allowing for registering online and by phone) and to an election drive that included placing registration opportunities in central voting locations. Copyright © 2016 John Wiley & Sons, Ltd.     

Removing financial barriers to organ and bone marrow donation: The effect of leave and tax legislation in the U.S.

Many U.S. states have passed legislation providing leave to organ and bone marrow donors and/or tax benefits for live and deceased organ and bone marrow donations and to employers of donors. We exploit cross-state variation in the timing of such legislation to analyze its impact on organ donations by living and deceased persons, on measures of the quality of the transplants, and on the number of bone marrow donations. We find that these provisions do not have a significant impact on the quantity of organs donated. The leave laws, however, do have a positive impact on bone marrow donations, and the effect increases with the size of the population of beneficiaries and with the generosity of the legislative provisions. Our results suggest that this legislation works for moderately invasive procedures such as bone marrow donation, but these incentives may be too low for organ donation, which is riskier and more burdensome.     

Absence of significant dissent should be sufficient for deceased donor organ procurement in New Zealand

Objective: New Zealand's organ donation rates are among the lowest in the OECD. In a bid to increase organ availability, the New Zealand Human Tissue Act 2008 introduces new consent arrangements for deceased donor organ procurement. This article assesses these new arrangements and presents the case for further reform.
Approach: Our assessment and arguments are based on philosophical analysis informed by empirical data on the effectiveness of alternative consent systems. We: 1) Identify widely held ethical judgments about policies and practices relevant to organ donation (e.g. those relating to coronial post-mortems), 2) Assess the implications of these judgments for the Human Tissue Act and the assumptions that underpin it, and 3) Derive policy recommendations that are consistent with the judgments.
Conclusion: The Human Tissue Act 2008 retains a strong consent requirement for organ procurement: organs may not be transplanted unless either the deceased or the family consents. We argue that organ availability could and should be increased by shifting from a model that requires consent to one that requires the absence of significant dissent.
Implications: We recommend that New Zealand adopt either 1) an organ donation system similar to the existing system for ordering coronial post-mortems, or 2) a variant of the 'opt-out' system already in place in several other countries.     

The Challenges of Social Marketing of Organ Donation: News and Entertainment Coverage of Donation and Transplantation

While great strides have been made in persuading the public to become potential organ donors, actual behavior has not yet caught up with the nearly universally favorable attitudes the public expresses toward donation. This paper explores the issue by situating the social marketing of organ donation against a broader backdrop of entertainment and news media coverage of organ donation. Organ donation storylines are featured on broadcast television in medical and legal dramas, soap operas, and other television serials approximately four times per month (not including most cable networks), and feature storylines that promote myths and fears of the organ donation process. National news and other non-fictionalized coverage of organ donation are even more common, with stories appearing over twenty times a month on average. These stories tend to be one-dimensional and highly sensationalized in their coverage. The marketing of organ donation for entertainment essentially creates a counter-campaign to organ donation, with greater resources and reach than social marketers have access to. Understanding the broader environmental context of organ donation messages highlights the issues faced by social marketing campaigns in persuading the public to become potential donors.     

Gender imbalance in living organ donation

Living organ donation has developed into an important therapeutic option in transplantation medicine. However, there are some medico-ethical problems that come along with the increasing reliance on this organ source. One of these concerns is based on the observation that many more women than men function as living organ donors. Whereas discrimination and differential access have been extensively discussed in the context of cadaveric transplantation and other areas of health care, the issue of gender imbalance in living organ donation has received less attention. This paper presents relevant data from the Eurotransplant and UNOS transplantation systems and discusses possible explanations for the documented gender discrepancies. The conclusion calls for are view of existing practice guidelines in order to secure effective protection of particularly vulnerable potential donors and an equitable donor-recipient-ratio in living organ donation. This revised version was published online in July 2006 with corrections to the Cover Date.     

Does Quality Improvement Work? Evaluation of the Organ Donation Breakthrough Collaborative

Objective. The Organ Donation Breakthrough Collaborative is a quality improvement initiative to encourage adoption of "best practices" for identifying potential donors and obtaining consent for deceased organ donation. We evaluate the impact of the first phase on organ donation rates.
Setting. We study donation rates in the 95 hospitals that participated in the first phase and a control group of 125 hospitals.
Design. We use a controlled pre/post design. The preperiod is the year before the start of the Collaborative (September 2002 to August 2003), the postperiod is the final 6 months of the first phase (March 2004 to August 2004).
Data. We use administrative data from the Organ Procurement and Transplantation Network to compute the conversion rate in each hospital group and time period. The conversion rate is the proportion of eligible donors who became actual donors.
Principal Findings. Preperiod conversion rates in Collaborative and control hospitals were similar: 52 and 51 percent, respectively. In the postperiod, the conversion rate increased to 60 percent among Collaborative hospitals and remained at 51 percent among control hospitals. The relative change was 8 percentage points (95 percent confidence interval: 2–13: p <.001).
Conclusions. Our findings suggest that the Breakthrough Collaborative led to an increase in donation rates at participating hospitals.     

Transplantation as an abstract good: practising deliberate ignorance in deceased organ donation in Denmark

This article investigates valuations of organ transfers that are currently seen as legitimising increasingly aggressive procurement methods in Denmark. Based on interviews with registered donors and the intensive care unit staff responsible for managing organ donor patients we identify three types of valuation: the needs of recipients, respect for donors' autonomy and support of donors' relatives in their grieving process. Sometimes these modes of valuation conflict with each other, and we show how our informants then respond with a form of deliberate ignorance. We suggest that deliberate ignorance has a more general salience in the organ transplant field by way of facilitating a perception of organ transplantation as an abstract moral good rather than a specific good for specific people. Furthermore, we suggest that multiple forms of ignorance sustain each other: a desire for ignorance with respect to the prioritisation of recipients sustains pressure for more organs; this pressure necessitates more aggressive measures in organ procurement and these measures increase the need for ignorance in relation to the actual procedures as well as the actual recipients. These attempts to avoid knowledge are in remarkable contrast to the otherwise widespread policy emphasis on education and information in this medical domain.     

Expanding the conceptual toolkit of organ gifting

In jurisdictions where the sale of body tissue and organs is illegal, organ transplantation is often spoken of as a gift of life. In the social sciences and bioethics this concept has been subject to critique over the course of the last two decades for failing to reflect the complexities of organ and tissue exchange. I suggest that a new ethical model of organ donation and transplantation is needed to capture the range of experiences in this domain. The proposed model is both analytical and empirically oriented, and draws on research findings linking a series of qualitative sociological studies undertaken in New Zealand between 2007 and 2013. The studies were based on document analysis, field notes and 127 semi‐structured in‐depth interviews with people from different cultural and constituent groups directly involved in organ transfer processes. The aim of the article is to contribute to sociological knowledge about organ exchange and to expand the conceptual toolkit of organ donation to include the unconditional gift, the gift relation, gift exchange, body project, and body work. The rationale for the proposed model is to provide an explanatory framework for organ donors and transplant recipients and to assist the development of ethical guidelines and health policy discourse.     

West Nile Virus RNA in Tissues from Donor Associated with Transmission to Organ Transplant Recipients

We identified West Nile virus (WNV) RNA in skin, fat, muscle, tendon, and bone marrow from a deceased donor associated with WNV transmission through solid organ transplantation. WNV could not be cultured from the RNA-positive tissues. Further studies are needed to determine if WNV can be transmitted from postmortem tissues.     

Economic Consequences of Adult Living Kidney Donation: A Systematic Review

ObjectivesCurrent guidelines mandate organ donation to be financially neutral such that it neither rewards nor exploits donors. This systematic review was conducted to assess the magnitude and type of costs incurred by adult living kidney donors and to identify those at risk of financial hardship.MethodsWe searched English-language journal articles and working papers assessing direct and indirect costs incurred by donors on PubMed, MEDLINE, Scopus, the National Institute for Health Research Economic Evaluation Database, Research Papers in Economics, and EconLit in 2005 and thereafter. Estimates of total costs, types of costs, and characteristics of donors who incurred the financial burden were extracted.ResultsSixteen studies were identified involving 6158 donors. Average donor-borne costs ranged from US$900 to US$19 900 (2019 values) over the period from predonation evaluation to the end of the first postoperative year. Less than half of donors sought financial assistance and 80% had financial loss. Out-of-pocket payments for travel and health services were the most reported items where lost income accounted for the largest proportion (23.2%-83.7%) of total costs. New indirect cost items were identified to be insurance difficulty, exercise impairment, and caregiver income loss. Donors from lower-income households and those who traveled long distances reported the greatest financial hardship.ConclusionsMost kidney donors are undercompensated. Our findings highlight gaps in donor compensation for predonation evaluation, long-distance donations, and lifetime insurance protection. Additional studies outside of North America are needed to gain a global prospective on how to provide for financial neutrality for kidney donors.     

Assembling organ donation: situating organ donation in hospital practice

In this article I argue for the need to situate deceased organ donation in and as a hospital practice. This study puts the spotlight on the practical conditions that enable and emplace organ donation in the hospital setting. The analytical move serves the political purpose to inform and interrogate dominant policy framings intended to address the problem of organ shortage. I present an ethnographic investigation that draws upon a Science and Technology Studies (STS) approach to make visible the sociomaterial arrangements that bring together people, things and politics in the assembling of organ donation at a Catalan hospital. A progressive and indeterminate process which might fall through and become disassembled at any given time. This, as I explain, challenges current opt-out policy that unnecessarily reduces donation to an individual choice to be decided upon in life. Instead, and drawing on ethnographic materials, I propose a situated and relational understanding of organ donation: an embedded health care and procurement practice enacted as a collective accomplishment. I conclude that (more) responsible donation policies need to be informed by, and attuned to, the situated practicalities and enduring tensions that condition and constrain the assembling of organ donation at the hospital setting.     

Effect of nutritional state of brain-dead organ donor on transplantation

OBJECTIVE: We describe the effect of the metabolic and nutritional modifications caused by severe illness or injury in brain-dead organ donors on transplant organ function. Malnutrition is frequently found in brain-dead organ donors and nutrients may interfere with different organ functions. METHODS: Literature was obtained from MEDLINE using the key words organ donation, brain death, transplantation, nutrition, fish oil, amino acids. RESULTS: In the liver, infusion of large quantities of dextrose can restore glycogen reserves but may induce hyperglycemia and a hyperosmolar hepatic state. Feeding improves protein synthesis in hepatocytes, and fat (fish oil) administration in particular increases the hepatic energy and adenosine triphosphate content. Amino acids have a significant effect on regenerating hepatic tissue when given with fat and glucose. In the heart, free fatty acids administered during reperfusion improve cardiac functional recovery, and administration of propofol, a general anesthetic agent enriched with fatty acids, have protective effects on ischemia-and-reperfusion injury. Glutamine also can induce graft protection during ischemia-and-reperfusion injury. Renal function is improved by fish oil supplementation. In addition, effective renal plasma flow, glomerular filtration rate, and renal blood flow are increased, apparently by a reduction in thromboxane B2 production. Glycine or alanine can protect renal tubules from stress injury. CONCLUSION: Nutrition plays an important role in the modulation of organ function after transplantation.     

Using a standardized donor ratio to assess the performance of organ procurement organizations

OBJECTIVE: To develop a Standardized Donor Ratio (SDR) as an outcome measure for evaluating the effectiveness of organ procurement organizations (OPOs). DATA SOURCES/STUDY SETTING: All deaths by cause in the United States during 1993-1994 as reported in the Vital Mortality Statistics, Multiple Cause of Death files. The OPO-specific data were provided by the United Network for Organ Sharing (UNOS). STUDY DESIGN: Each OPO's expected number of donors was calculated by applying national donation rates to deaths with potential for donation in 24 age, sex, and race cells. The SDR was calculated by dividing the observed number of donors by the expected number. The chi2 tests of the hypothesis that the OPO's performance differed from the national norm of 1.0 were performed. The SDR was compared to the existing performance standard based on the unadjusted number of donors per million live population in the OPO's service area. An ordinary least squares (OLS) regression assessed predictors of the SDR. PRINCIPAL FINDINGS: The SDRs ranged from 0.41 to 1.99. Twenty-nine of 64 OPOs had SDRs significantly different than 1.0. The SDRs were positively associated with the percent of white living population and the number of organ types transplanted per transplant center served by the OPO. CONCLUSIONS: The SDRs can be used by Centers for Medicare and Medicaid Services (CMS), UNOS, and OPOs to target quality improvement initiatives, present more accurate comparisons of OPO performance, and develop public policy on the evaluation of the effectiveness of organ procurement efforts.     

Improving Organ Retrieval Rates: Various Proposals and Their Ethical Validity

The current global shortage of organs has prompted aseries of proposals for improving organ retrievalrates. They include preferred recipient status forregistered organ donors, payment for organs, presumedconsent and required response. This paper examinesthe tenability of these proposals and points out theirshortcomings. Taking the Canadian situation as anexample, it argues further that the shortage isexacerbated by unethical and essentially illegalretrieval protocols that flout the law of informedconsent. It is suggested that before any redrafting oflaws and regulations is undertaken, these protocolsshould be revised.     

Organ Donation: A Significant Marketing Challenge

Unlike most health care markets, the organ donation market is one where patients are the marketers, prospective donors are the customers, and no payment is allowed in the exchange process. The assumption that altruistic behavior by donors would satisfy the need for organs has proven woefully untrue. As a result, those needing organs have resorted to relying on unwilling or impoverished donors, to having to promote themselves on websites which have achieved success for only small numbers of patients, or to waiting for organs which they may never receive. This remains a still unsolved marketing challenge.     

Does Social Capital Explain Community-Level Differences in Organ Donor Designation?

Context

The growing shortage of organs has reached unprecedented levels. Despite national attempts to increase donation and federal laws mandating the equitable allocation of organs, their availability and waiting times vary significantly nationwide. Organ donor designation is a collective action problem in public health, in which the regional organ supply and average waiting times are determined by the willingness of individuals to be listed as organ donors. Social capital increases the probability of collective action by fostering norms of reciprocity and cooperation while increasing costs to defectors. We examine whether social capital and other community-level factors explain geographic variation in organ donor designation rates in Massachusetts.

Methods

We obtained a sample of 3,281,532 registered drivers in 2010 from the Massachusetts Department of Transportation Registry of Motor Vehicles (MassDOT RMV). We then geocoded the registry data, matched them to 4,466 census blocks, and linked them to the 2010 US Census, the American Community Survey (ACS), and other sources to obtain community-level sociodemographic, social capital (residential segregation, voter registration and participation, residential mobility, violent-death rate), and religious characteristics. We used spatial modeling, including lagged variables to account for the effect of adjacent block groups, and multivariate regression analysis to examine the relationship of social capital and community-level characteristics with organ donor designation rates.

Findings

Block groups with higher levels of social capital, racial homogeneity, income, workforce participation, owner-occupied housing, native-born residents, and white residents had higher rates of organ donor designation (p < 0.001). These factors remained significant in the multivariate model, which explained more than half the geographic variance in organ donor designation (R² = 0.52).

Conclusions

The findings suggest that community-level factors, including social capital, predict more than half the variation in donor designation. Future interventions should target the community as the unit of intervention and should tailor messaging for areas with low social capital.     

Suicide and Organ Donors: Spillover Effects of Mental Health Insurance Mandates

This paper considers the effect of mental health insurance mandates on the supply of cadaveric donors. We find that enacting a mental health mandate decreases the count of organ donors from suicides and results are driven by female donors. Using a number of empirical specifications, we calculate that the mental health parity laws are responsible for an approximately 0.52% decrease in cadaveric donors. Additional regression results show that the mandates are not related to other types of organ donations, ruling out the possibility that the mandates are related to an overall trend in the supply of organ donations. The findings suggest that future policies aimed at reducing suicide in a large and significant way can potentially increase the inefficiency that currently exists in the organ donor market. Copyright © 2014 John Wiley & Sons, Ltd.     

The phenomenology of death, embodiment and organ transplantation

Abstract Organ transplantation is an innovative 21^st century medical therapy that offers the potential to enhance and save life. In order to do so it depends on a supply of organs, usually from cadaveric donors who have suffered brain stem death. Regardless of whether and how the deceased recorded their wishes about donation, health professionals will approach the bereaved relatives, before organs are removed. In this article, the results from 19 semi‐structured interviews with Scottish donor families will be presented. These accounts will focus exclusively on the families’ beliefs about death, the dead body and bonds with the deceased, and whether these affected the donation decision or the organs donated. What the families said about brain stem death (BSD); how and when they understood that death had occurred; and whether the families thought that death caused a ‘disembodiment’ (that the self was no longer embodied) will be explored. Finally, attention will turn to the bereaved's previous relationship with the embodied person. I conclude that the phenomenology of embodiment, death and organ transplantation offers new answers to the question of ‘Who am I’? That is, in order to understand what identity is, one might look for what it is that is lost at death; the body, the self and relationships with others.     

Giving,receiving … and forgetting? On the social conditions of receiving an anonymous face transplant

In 2004, the French National Consultative Ethics Committee expressed strong misgivings about the proposal to include the face among body parts that can be removed from deceased donors for organ transplantation. Yet, the first face transplant was performed a few months later. How do medical teams and patients deal with the singular nature of the face? I argue that what the face represents – from the medium of the donor’s personal identity to an interchangeable organ – is not fixed. It emerges through the practices and can evolve through the interactions between medical professionals and patients. In the postoperative time, I show that patients receive potentially contradictory recommendations about how to integrate the organ: to consider it theirs and forget the donor, but also to thank the donor for the donation and never forget the origin of the graft. Based on the plurality of relationships developed by the patients with their donor, I revisit Maussian interpretative analyses of organ reception. The effects of giving a face vary both in terms of reciprocity and identity: the feeling of debt is variably felt and can be interpreted negatively or positively, and the experience is more or less transformative.     

An expedient and ethical alternative to xenotransplantation

The current voluntary posthumous organ donation policy fails to provide sufficient organs to meet the demand. In these circumstances xenografts have been regarded as an expedient solution. The public perception seems to be that the only impediments to this technology are technical and biological. There are, however, important ethical issues raised by xenotransplantation that need to be considered as a matter of urgency. When the ethical issues raised by using non-human animals to provide replacement organs for human beings are considered in a wider context and the possible alternatives to xenotransplantation are taken into account, a new dimension is added to the debate. In this broader context it is argued that a less ethically problematic solution is to adopt a presumed consent or opt-out organ procurement policy to regulate posthumous organ harvesting from humans. If there are still too few organs available, then the whole question of transplantation must be reassessed.This revised version was published online in October 2005 with corrections to the Cover Date.