MM Byrne, Houston HSR&D/Baylor College of Medicine; P Thompson, University of Houston

Objectives: In October 1999, over 66,000 patients in the United States were on waiting lists for one or more organ transplants. However, only approximately 10,000 organs were donated. Proposals have been made, including by the Council on Ethical and Judicial Affairs of the AMA, that financial incentives should be considered as a means for increasing cadaveric organ donations. This study uses a theoretical mathematical model to explore the effect of offering financial incentives for organ donation. Ethical issues are not discussed, and no advocacy is intended.

Methods: Our model represents the current practice that next of kin have decision-making authority concerning cadaveric donations. We further assume that next of kin have imperfect information regarding their family member's organ donation preference. When an individual registers to be a donor, the next of kin's subjective belief of the individual's preferences for donation are increased. Thus, the registration acts as a signal from the individual to the next of kin. The next of kin's decision to donate the individual's organs will be based on the subjective belief of the individual's preferences, and the next of kin's preferences. We examine what happens when financial incentives are offered either for registration or for actual donation of organs.

Results: When financial incentives are offered for registration, the threshold preference for donation that an individual must have to register decreases. Thus, more individuals will register. However, because a reward was offered and individuals with lower preferences for donation did in fact register, the next of kin's subjective belief for the individual's donation preference will be lower than it would be if there were no reward offered. That is, the financial incentive weakens the signal that registration provides. The next of kin is not certain if the individual signed up for the reward, or because his/her donation preference was high. Thus, fewer organs may in fact be donated when financial incentives for registration are used. In addition, offering financial incentives for registration will lead to time inconsistent choices for donation. That is, some individuals who register will prefer not donate after they've received the reward. If a financial incentive is given to the next of kin upon actual donation, the signaling problem remains.

Conclusions: Several policy steps are needed to rectify the situation where use of financial incentives may reduce organ donations. First, the Uniform Anatomical Gift Act, which requires that an individual's donation decision be followed, regardless of family preferences, must be enforced. Second, all individuals must be required to register an explicit preference for donation or non-donation. Finally, to avoid time inconsistent choices, financial incentives must be paid only to next of kin after a registered family member's organs are harvested.

Impact: Requiring explicit donation or non-donation choices will not necessarily raise organ donation rates. However, it will exclude perverse supply responses and ensure that there exists some level of financial incentives at which cadaveric organ supplies would rise significantly.Economic analyses of this type are an important, but often overlooked aspect, of policy decision analysis.