Fig 1 from Gill et al. © National Kidney Foundation

In a recent article in AJKD, Gill and colleagues discuss the possibility of implementing financial incentives to increase organ donation in Canada. They also discuss the Canadian organ donation system, and contrast it to the system in the United States and other parts of the world. In this interview, corresponding author Dr. John Gill (JG) discusses the controversial proposal with Dr. Vinay Nair (eAJKD), eAJKD Advisory Board member. This is the first part of the interview; the second will post later in the week.

eAJKD: What inspired you to tackle this important topic?

JG: The need for movement on organ donation in Canada was the deciding feature, but there are several reasons that inspired this particular paper. The first was the increasing literature discussing the use of incentives for organ donation in Canada. The other issue was that the comparison of the Canadian organ donation system to that in the U.S., when in fact there are clear differences.

eAJKD: You specifically mention reasons why incentives may be more feasible in Canada. Could you expand on that?

JG: People that thought that financial incentives for living donors in Canada might be more suitable than in the United States. If someone was going to receive financial compensation to be an organ donor in the model proposed by Arthur Matas and others, the catch net of a universal healthcare system may work better. The other aspect is to avoid coercion of vulnerable populations. Because of the standard of living in Canada, the discrepancy of people who might be potential donors in a paid system of organ donation would be less. For these reasons, Canada might be a place where incentivized living donation could be trialed.

eAJKD: I found it interesting that the title on your article was “Financial Incentives to Increase Canadian Organ Donation,” but you really talk about a lot more than just that. If you could implement just one of the recommendations in your paper to improve organ donation in Canada, what would it be and why?

JG: I think the biggest opportunities are on the deceased donation side. We believe that the appropriate healthcare investments to capture every potential deceased donor are not being made. One issue is that the Canadian healthcare system isn’t like that in the United States, where there’s a financial leger at the end of every healthcare interaction. As a result, the appropriate investments in securing an organ donor are not being made. I think it is necessary to make sure that we have appropriate resources and remuneration for the work that’s being done to capture organ donors. It may be that people don’t like putting organ donation into economic terms in Canada. The potential savings to the healthcare system and the investment that should be put into identifying organ donors never seems to come to pass. I think that’s probably the biggest difference from the United States that we need to get our heads around.

eAJKD: You make a compelling argument to that aspect in your paper. Have you come across any evidence that financial incentives can increase living or deceased organ donation?

JG: With deceased donation, the incentives described in the manuscript really aren’t payment for the organ. We are looking for a very small incentive that gets people to act. We know from surveys that people in general are on board with organ donation in Canada. But in terms of registration for organ donation, translating potential donors into actual donors is being lost there. There are two purposes of our proposal: one is to get people to indicate their willingness to be organ donors, and the second is the system then has the responsibility to provide that opportunity for people.

The Israeli model where you can earn “brownie points” by registering as an organ donor has been very interesting. It has resulted in increased organ donation, and I think that this is the first real evidence that incentiving people to register as potential organ donors may actually change behavior.

On the living donor side, most of what we talk about is removing disincentives. Even in Canada there still are significant financial barriers to organ donatiob. What’s unproven is whether removing disincentives to organ donation is really going to drive a whole swatch of living donors to come forward. I don’t think that is going to be the case, but we still think it’s the right thing to do. But if you ask me, I honestly believe of the two that we should go after the deceased donation side.

Stay tuned for Part 2 of this interview with Dr. Gill. To view the article full-text or PDF (freely available), please visit AJKD.org.