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Incentivizing deceased organ donation: A Swedish priority-setting perspective.
Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.ORCID iD: 0000-0002-8159-1249
Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
2011 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 39, no 2, 156-163 p.Article in journal (Refereed) Published
Abstract [en]

AIMS: The established deceased organ donation models in many countries, relying chiefly on altruism, have failed to motivate a sufficient number of donors. As a consequence organs that could save lives are routinely missed leading to a growing gap between demand and supply. The aim of this paper is twofold; firstly to develop a proposal for compensated deceased organ donation that could potentially address the organ shortage; secondly to examine the compatibility of the proposal with the ethical values of the Swedish healthcare system.

METHODS: The proposal for compensating deceased donation is grounded in behavioural agency theory and combines extrinsic, intrinsic and signalling incentives in order to increase prosocial behaviour. Furthermore the compatibility of our proposal with the values of the Swedish healthcare system is evaluated in reference to the principles of human dignity, needs and solidarity, and cost effectiveness.

RESULTS: Extrinsic incentives in the form of a €5,000 compensation towards funeral expenses paid to the estate of the deceased or family is proposed. Intrinsic and signalling incentives are incorporated by allowing all or part of the compensation to be diverted as a donation to a reputable charity. The decision for organ donation must not be against the explicit will of the donor.

CONCLUSIONS: We find that our proposal for compensated deceased donation is compatible with the values of the Swedish healthcare system, and therefore merits serious consideration. It is however important to acknowledge issues relating to coercion, commodification and loss of public trust and the ethical challenges that they might pose.

Place, publisher, year, edition, pages
SAGE , 2011. Vol. 39, no 2, 156-163 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-65395DOI: 10.1177/1403494810391522ISI: 000288065000006PubMedID: 21239479OAI: oai:DiVA.org:liu-65395DiVA: diva2:395438
Available from: 2011-02-07 Created: 2011-02-07 Last updated: 2015-09-22Bibliographically approved
In thesis
1. The Art of Saying No: The Economics and Ethics of Healthcare Rationing
Open this publication in new window or tab >>The Art of Saying No: The Economics and Ethics of Healthcare Rationing
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

It follows from resource scarcity that some form of healthcare rationing is unavoidable. This implies that potentially beneficial medical treatments must be denied to patients to avoid unacceptable sacrifices in other areas of society. By focusing on four, core, conceptual themes – individual responsibility, paternalism, incentives, and inequality – this thesis explores the matter of finding justifiable grounds for saying no in the context of health care.

By combining the perspectives of welfare economics and population-level ethics, the author explicate and discusses conflicting moral values involved in healthcare rationing. Four papers form the foundation for this thesis. Paper I articulates the potential role of individual responsibility as a welfarepromoting, rationing tool by exploring when healthcare services exhibit characteristics that facilitate individual responsibility for private financing. Paper II explores the normative relevance of individuals’ time preferences in healthcare rationing and when paternalism can be justified in the context of individuals’ intertemporal health choices. Paper III examines the compatibility between incentive-based organ donation and the ethical platform for setting priorities in Sweden. Paper IV empirically  investigates the existence of horizontal inequalities in using waiting lists to ration care.

From the discussion it is suggested, inter alia, that: I) Prospective responsibility as opposed to retrospective responsibility is a more productive notion of responsibility when discussing actual policies. However, potential positive effects need to be weighed against the increased economic inequality that it is likely to invoke. II) Although cost-effectiveness analysis provides valuable input when making rationing decisions it should not be viewed as a decision rule, since it is based on utilitarian values that constantly need to be balanced against other nonutilitarian values. III) Potentially, increased health could negatively affect individuals’ well-being if it creates opportunities that they are unable to take advantage of. This needs to be taken into account before embarking on paternalistic policies to improve health – policies that often target the lower socioeconomic segment.

The author concludes that decisions on rationing cannot be computed through a simple formula. Moreover, given that rationing is bound to be associated with reasonable disagreements we are unlikely to ever fully  resolve these disagreements. However, by explicitly stating conflicting moral values we are more likely to narrow the disagreements and achieve a healthcare system that is both fairer and more efficient.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2011. 91 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1215
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-65397 (URN)978-91-7393-282-0 (ISBN)
Public defence
2011-02-04, Berzeliussalen, ingång 64, plan 9, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2011-02-07 Created: 2011-02-07 Last updated: 2015-09-22Bibliographically approved
2. Just Waiting: Ethical Challenges in Priority Setting Posed by Organ Scarcity in Kidney Transplantation
Open this publication in new window or tab >>Just Waiting: Ethical Challenges in Priority Setting Posed by Organ Scarcity in Kidney Transplantation
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Over the last few decades kidney transplantation has transformed from an experimental treatment to the treatment of choice for end-stage renal disease. Unfortunately, however, the established organ donation models in many countries, relying chiefly on altruism, fail to motivate a sufficient number of donors. As a consequence, many lives which could be saved are lost, and others which can be improved are left to deteriorate.

Dealing with the challenge of scarcity in kidney transplantation requires a dual approach. In the immediate term, we must ensure the fair distribution of kidney transplantation as a scarce medical resource. In the long term, we must find a policy level solution to mitigate the root issue of scarcity. The policy approach promoted in this thesis is the introduction of incentive based organ donation. Fair resource allocation, and incentive based donation are two themes which raise interesting normative questions, and ethical challenges. Each theme corresponds to two paperswhich form the basis for the thesis.

Papers I &II, evaluate fairness in the priority setting processes underpinning access to kidney transplantation; this is done both within Sweden's four transplant centers and the Toronto General Hospital in Canada. The criteria, values, and procedures used in clinical decision-making are analyzed to identify barriers to fairness and how such barriers can be removed.

Papers III and IV, propose incentive based living kidney donation and incentive based deceased donation, respectively, as policy solutions to the organ scarcity. The most frequently raised ethical objections against incentive based models are discussed in a bid to demonstrate the moral permissibility of incentive based organ donation.

The discussion about fairness, and incentive based models, highlights that the ethical challenges raised by kidney scarcity are inherently difficult. While we may not find infallible solutions we certainly can work towards better solutions. We can create clinical priority setting processes, that while not perfect, move us closer towards increased fairness by removing clear obstacles to just distribution. We can create organ donation policies while not free of ethical challenges; do not shy away from all risk, or from asking the difficult questions.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2011. 87 p.
Series
Linköping Studies in Arts and Science, ISSN 0282-9800 ; 544Linköping Dissertations on Health and Society, ISSN 1651-1646 ; 20
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-71197 (URN)978-91-7393-068-0 (ISBN)
Public defence
2011-09-29, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2011-10-11 Created: 2011-10-05 Last updated: 2012-10-18Bibliographically approved

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