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Organ Quality as a Complicating Factor in Proposed Systems of Inducements for Organ Donation

I INTRODUCTION All potentially transplantable organs are not created equally. Even among organs currently used for transplantation, there exists a wide spectrum of quality. Donor risk factors can account for as much as a twenty-percent absolute difference in post-transplant survival. (1) Thus, in some cases, actual receipt of a transplant matters less than the quality of organ received. Organ quality might complicate inducements for organ donation in several ways. First, organ quality can diminish the impact of inducements on net increase in organs transplanted, and furthermore, can increase the cost of inducements. Second, whether directed toward organ-procurement organizations or potential living or deceased donors, inducements risk increasing the supply of organs at the expense of quality. Finally, the heterogeneous quality of organs can complicate market systems. These issues are most relevant to deceased-donor organs, and can be less problematic in the setting of living donation. Furthermore, there are a number of potential regulatory mechanisms that could mitigate concerns related to organ quality. II WHAT IS ORGAN QUALITY? For the potential recipient of a solid organ transplant, whether from the deceased or living, two types of donor-specific risks exist: (1) risk of disease transmission, such as infection or malignancy, and (2) risk of graft failure. Of the two, the latter risk is both more common and more harmful. Among potential donors, the prevalence of transmissible diseases is approximately ten percent, (2) and, since donor-screening methods are fairly effective, disease transmission occurs in just under one percent of transplantation cases, causing nine deaths in 2007.2'3 By contrast, risk factors for graft failure are present in more than two-thirds of actual donors, and are even more common in the overall population of potential donors. (4) These risk factors include donor age, type and cause of death, and medical comorbidities, all of which not only affect pre-transplant organ function, but also make the organ more susceptible to ischemic injury during procurement and storage. (5) Among deceased-donor organs currently used for transplantation, donor-specific risk factors account for an absolute difference of twenty percent in risk of graft failure for the recipient. (6) For example, an average-risk recipient of a liver transplant will have a twenty- percent risk of graft failure with a high-quality organ, and a forty-percent risk of graft failure with a low-quality organ. (7) Because re-transplantation is often not possible, in many cases graft failure means death for the recipient. Thus, even conservative estimates implicate donor risk factors for graft failure as causing more than 1000 deaths each year. (8) For these reasons, studies show that, when faced with an offer of a below-average-quality organ, some patients are actually better off declining that offer in order to wait for a better one. (9) III HOW DOES ORGAN QUALITY AFFECT ORGAN UTILIZATION? In 2011, only 3.5% of Americans who died while hospitalized became organ donors. (10) Poor organ quality prevented many prospective donations--organs from most deceased people are not usable. (11) For example, two of the most important risk factors for graft failure are donor age and type of death. Donor age over seventy years increases the risk of graft failure by 20-60% depending upon the type of organ and other factors, whereas donation after circulatory death (DCD) increases the risk by 50-70% compared to donation after brain death (DBD). (12) Thus, although individuals with one or both of these characteristics account for 95% of deaths, they contribute less than 5% of donor organs. (13) This is not because the individuals or their families decline donation. Rather, transplant centers are not willing to use their organs, and in most cases their families are not even approached for consent. …