Krawiec and co-author Alvin E. Roth explain the drawbacks of current WHO standards in their paper “WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs and Blood.” Roth is an affiliated scholar on the National Bureau of Economic Research and a professor of economics at Stanford University. He is the 2012 Nobel Prize winner in economics for his work on market design. Krawiec is the Charles O. Gregory Professor of Law at UVA; much of her work focuses on “taboo trades” — also the name of her podcast — such as blood and plasma, transplantable organs, and egg and sperm markets. . . .
How do current WHO policies on organ and blood donation contribute to this problem?
WHO policy mandates both national (or sometimes only regional) self-sufficiency and an absence of remuneration for both blood products and transplantable organs — what we refer to in the paper as “the twin principles.” These twin principles are unhelpful separately and unworkable together. Their effect on blood products is particularly stark — no country that fails to compensate donors is self-sufficient in plasma collection and few LMIC collect sufficient supplies of whole blood.
The self-sufficiency mandate presents a real hurdle to progress in transplantation, especially for smaller countries and LMIC. This is especially the case because some of the most exciting and promising developments for increasing the availability of transplants have been in kidney exchange, a mechanism that leverages in-kind exchange, rather than financial compensation, to encourage and facilitate donation among those with willing but incompatible partners. But kidney exchange works best when a large pool of patient-donor pairs can engage with one another. So, requiring that transplantation be contained within national boundaries unnecessarily limits access to transplants that could be achieved only by cross-border exchange.
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How could countries and the WHO balance the need for increased organ and blood donations with the ethical concerns surrounding paying for them?
First and foremost, WHO and the world health community should be realistic and transparent about what is possible and, in particular, about the tension between self-sufficiency and nonremuneration. No country that fails to pay donors is self-sufficient in plasma. In fact, nonpaying countries are becoming increasingly dependent on paying countries for their plasma supply, and this trend is likely to accelerate in the coming years as new medical uses for PDMPs are discovered.
Second, countries should engage in, and WHO should encourage, international cooperation, rather than national self-sufficiency. Current WHO policy denies to health care many of the benefits that trade has brought to so many other human endeavors. Substances of human origin are special, but they are not so special that we prohibit plasma or organ donation. We should be open to exploring and experimenting with ways to bring to health care some of the benefits that trade has brought to so many other areas, including the production and distribution of food and lifesaving vaccines and other medicines.
Third, we must rely on evidence-based policies, rather than on decades-old assumptions and understandings. Modern testing capabilities and stringent regulations have ensured that the plasma supply is safe, whether collected from paid or unpaid donors. Despite protestations to the contrary, wealthy countries around the world that prohibit remuneration for plasma must know this, given that they import large quantities from the United States, which pays donors.
While the case for remuneration to providers of whole blood for transfusion (which undergoes less processing than plasma that is used for PDMPs) is less straightforward, nonetheless WHO should (cautiously) shift its approach here as well. Much of the research prompting concerns with paid blood donation is dated or relies on surveys and uncontrolled studies. More recent research on incentivizing blood donation finds that incentives increase blood donations, are cost-effective and do not compromise blood safety. Indeed, wealthy countries, including the United States, already compensate whole blood donors through non-cash incentives, such as gift cards and paid work leave, and have for some time.
Finally, the provision of incentives for organ donation is the most complicated and most ethically fraught. Clearly, caution is warranted. Nonetheless, countries, with WHO support, should use pilot studies and trials to test the ethics, safety and efficacy of incentives in various settings. Indeed, many countries, including the United States, already provide such incentives.
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