World Kidney Forum
Financial Incentives to Increase Canadian Organ Donation:
Quick Fix or Fallacy?
John S. Gill, MD, MS,1 Scott Klarenbach, MD,2 Lianne Barnieh, PhD,3
Timothy Caulfield, LLM, FRSC,4 Greg Knoll, MD,5
Adeera Levin, MD,6 and Edward H. Cole, MD7
WKF Advisory Board
John T. Harrington, MD
Boston, Massachusetts
Rashad S. Barsoum, MD
Cairo, Egypt
Christopher R. Blagg, MD
Mercer Island, Washington
John Boletis, MD
Athens, Greece
Garabed Eknoyan, MD
Houston, Texas
Tazeen H. Jafar, MD, MPH
Singapore
Nestor Schor, MD, PhD
São Paulo, Brazil
D
uring the past decade, organ
donation has been stagnant
in Canada.1 Recently, proposed
standards for a regulated system
of financial incentives for organ
From the 1Department of Medicine,
University of British Columbia, Vancouver; 2University of Alberta, Edmonton;
3
University of Calgary, Calgary; 4Faculty
of Law, School of Population and Public
Health, University of Alberta, Edmonton;
5
University of Ottawa, Ottawa; 6University of British Columbia, Vancouver; and
7
University of Toronto, Toronto, Canada.
Received May 7, 2013. Accepted in
revised form August 5, 2013.
Address correspondence to John S. Gill,
MD, MS, University of British Columbia,
Division of Nephrology, St. Paul’s Hospital–
Providence Building, Ward 6a, 1081
Burrard Street, Vancouver, BC, Canada
V6K 1Y6. E-mail: jgill@providencehealth.
bc.ca
2013 by the National Kidney Foundation, Inc.
0272-6386/$36.00
http://dx.doi.org/10.1053/j.ajkd.2013.08.029
Am J Kidney Dis. 2013;-(-):---
Unlike the United States, the potential to increase organ donation in Canada may be
sufficient to meet the need for transplantation. However, there has been no national
coordinated effort to increase organ donation. Strategies that do not involve payment for
organs, such as investment in health care resources to support deceased donor organ
donation and introduction of a remuneration framework for the work of deceased organ
donation, should be prioritized for implementation. Financial incentives that may be
permitted under existing legislation and that pose little risk to existing donation sources
should be advanced, including the following: payment of funeral expenses for potential
donors who register their decision on organ donation during life (irrespective of the
decision to donate or actual organ donation) and removal of disincentives for directed
and paired exchange living donation, such as payment of wages, payment for pain and
suffering related to the donor surgery, and payment of directed living kidney donors for
participation in Canada’s paired exchange program. In contrast, it would be premature
to contemplate a regulated system of organ sales that would require a paradigm shift in
the current approach to organ donation and legislative change to implement.
Am J Kidney Dis. -(-):---. ª 2013 by the National Kidney Foundation, Inc.
donation were published.2 Many
of the prerequisites for such a
system are established in Canada, and a recent survey of Canadians indicated general support
for the use of incentives to increase organ donation.3 In order
to determine the priority that
should be placed on financial
incentives in Canada, an overview of organ donation and the
demand for transplantation is
presented, followed by a review
of legal and pragmatic considerations. Based on these considerations, strategies to improve
the system, including the use
of financial incentives, are proposed (Box 1).
The ethical arguments for and
against the use of financial incentives have been debated
extensively in the literature4-6 and
are not revisited here. Instead, the
focus on practical considerations
related to potential implementation of financial incentives for organ donation in the Canadian
context should provide a fresh
perspective on this polarizing
issue and may inform decision
making in Canada and other
countries considering this complex subject.
ORGANIZATION OF ORGAN
DONATION IN CANADA
Although the federal government in Canada is partially
responsible for funding health care,
oversight and administration of
health services, including organ
donation, are the responsibility of
provincial and territorial governments. Within provinces, deceased
donor services are managed by organ procurement organizations
(OPOs), while living donor services are managed by individual
hospitals. Although OPOs informally collaborate, there is no
national oversight of these organizations. The federal government is
responsible for safety, but there is
no federal oversight of system
performance or framework for
continuous quality improvement.
Canadian Blood Services recently
was tasked with the responsibility
to coordinate a limited number
1
Gill et al
Box 1. Six Strategies to Increase Organ Donation in Canada
Establish a national transparent and accountable organ donation system
Establish an appropriate remuneration framework to support and integrate organ
donation into the health care system
Increase opportunities to consent for organ donation
Provide incentives for individuals to register their wishes regarding donation
Consider compensation for pain and suffering related to live donation
Provide incentives to encourage participation in living donor paired exchange
of interprovincial initiatives to
improve system performance, including establishment of a national
living kidney donor paired exchange program.
POTENTIAL TO INCREASE
DONATIONS
There has been no significant
increase in deceased or living
kidney donation in Canada in the
last decade (2012 deceased and
living donor rate per million,
14.9 and 15.1, respectively),
and patients continue to wait
3-10 years for a deceased donor
kidney transplant.1 Using the
metric of deceased donor rate per
million, Canada ranks behind the
United States, France, and the
United Kingdom in deceased
donation.7
Unlike the United States, where
information on potential deceased
donors and conversion of potential donors to actual donors is
collected routinely and publically
available, there is limited information about the efficiency of the
deceased donor system in Canada.
In an analysis of administrative
data of all in-hospital deaths in
2005-2008 in Canada (with the
exception of Quebec), 1%-2% of
all in-hospital deaths involved potential organ donors (ie, ventilated
patients aged 18-60 years, with
head trauma or stroke as the cause
of death, without contraindications for organ donation).8 During
this time, only 1,067 of the estimated 5,310 potential deceased
donors actually donated organs
(conversion, 20%). Although this
estimate must be interpreted with
the understanding that hospital
2
discharge data are limited by the
accuracy and completeness of
medical diagnostic codes applied
to hospital separations, it nonetheless suggests significant potential
to increase the number of deceased
donors. Recent events in the province of British Columbia suggest
that these estimates may be realistic:
a change in the administration of
British Columbia’s OPO, together
with targeted investments in organ
donation services and development
of a donation after circulatory death
program, produced a dramatic 40%
increase in deceased organ donors
in that province during a short
2-year period.9
It is harder to determine the
potential to increase living organ
donation in Canada. When ranked
by the living donor rate per
million population, Canada places
in the top third of all countries
internationally.7 However, there is
considerable regional variation in
the use of living donation (range,
6.1-18.6 per million population in
2011),1 suggesting significant potential to increase living donation
in Canada.
DEMAND FOR ORGAN
TRANSPLANTATION
In 2011, there were 4,484
Canadians waiting for an organ
transplant in Canada, including
3,406 kidney transplant candidates.1 Notably, the waiting list in
Canada is increasing at a slower
pace than that in the United States.
For example, between 2002 and
2011, the waiting listing for all organs in the United States increased
by 47% compared to only 15% in
Canada, whereas the increase in the
kidney transplant waiting list was
78% in the United States compared
to 15% in Canada.1,10
The degree to which the waiting
list accurately reflects the need for
transplantation in Canada is difficult to assess. There were 23,188
patients treated with dialysis in
Canada in 2010, and 3,362 (15%)
were wait-listed.11 In comparison,
21% of the 405,267 patients
treated with dialysis in the United
States in 2010 were wait-listed.12
This suggests more conservative
selection of patients for waitlisting in Canada. Although all
eligible patients may not be represented on the Canadian waiting
list, it is evident that the gap between the supply of transplantable
organs and the demand for transplantation is smaller in Canada
than it is in the United States.
Furthermore, with fewer than
3,500 wait-listed kidney transplant
candidates and hundreds of unrecognized potential donors annually, it is conceivable that the need
for organ transplantation could be
met if potential donors were converted more efficiently to actual
donors.
PROBLEMS WITH THE
CANADIAN ORGAN DONATION
SYSTEM
The provincial organization of
deceased donor services is not
well suited for sharing of best
practices and there are few
mechanisms to share advances in
deceased donor identification,
consent, and management. This
contributes to wide provincial
variation in deceased donor performance and waiting times. For
example, in an analysis of regional variations in transplantation access among incident
dialysis patients in 1996-2000,
the median predicted waiting
time for a nondiabetic patient
younger than 40 years follows:
3.1 years in Alberta; 7.8 years in
British Columbia; and 8.0 years in
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Figure 1. Median waiting time (in days) among deceased donor kidney transplant recipients in different regions in 2009-2011.
Deceased donor kidneys are not routinely shared between provinces. Instead, kidneys are shared within 7 geographic regions in which
organ donation services are managed by provincially administered organ procurement organizations (eg, a single organ procurement
organization provides organ donation services for all of Atlantic Canada, including Nova Scotia [NS], New Brunswick [NB], Prince
Edward Island [PEI], and Newfoundland [NF]. Abbreviations: AB, Alberta; BC, British Columbia; MB, Manitoba; ON, Ontario; PQ,
Quebec; SK, Saskatchewan; YK, Yukon. Data source: Kim.1
Ontario.13 Figure 1 shows the
wide variation in median waiting
times of kidney transplant recipients in different regions in
2009-2011. Similarly, in some
provinces, donation after circulatory death donors account
for $20% of deceased donors,
whereas in other provinces, such
protocols have yet to be implemented.14 The provincial oversight of OPOs also limits the
collection of standardized national
data to inform system improvement. Information on potential
deceased donors and converting
potential organ donors to actual
donors is collected provincially,
but not coordinated nationally,
and is not available within a
transparent reporting process to
allow interprovincial comparisons. Detailed collection of this
information has proved useful in
increasing organ donation in other
countries.15 The only mechanism
to obtain national information on
system performance is through
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the Canadian Organ Replacement
Register, which is a voluntary
data system.
The available national information suggests that identification
and referral of potential deceased
organ donors rather than failure to
consent potential donors is a major issue limiting deceased donation in Canada. Specifically, data
obtained directly from each of the
provincial OPOs indicate that only
35% of medically eligible donors
in Canada are referred for organ
donation, but that 90% of referred
donors consent to donation and
are converted to actual donors.16
These data are consistent with
survey responses showing that
.73% of Canadians support
deceased organ donation and
intended to donate their organs.17
In contrast, examination of
living donation in Canada suggests
significant advantages over other
countries such as the United
States, including the provision
of life-long publically funded
universal health care. Programs
to reimburse expenses related to
living donation and provide some
compensation for lost wages have
been established in most provinces.
However, the greater than 3-fold
regional variation in the use of
living donation among provinces
suggests significant opportunities
to increase living donation.1 Of
note, provinces with higher rates of
deceased donation appear to have
lower rates of living donation,1
suggesting that health system–
related factors rather than regional
differences in public acceptance
of organ donation underlie this
dramatic regional variation.
FINANCIAL INCENTIVES
Canadian Legislation
In order to discuss the feasibility of strategies incorporating
financial incentives to increase
organ donation, it is necessary to
review Canadian legislation and
public opinion regarding this issue.
3
Gill et al
Each Canadian province has its
own legislation that effectively
bans the sale of organs and tissues.
However, it is evident that some
practices (ie, reimbursement of
donation-related expenses) have
been implemented, although a
secondary objective of such programs is to increase the number of
organs available for transplantation. Canadian legislation
intends to prevent individuals from
profiting from the sale of organs
and tissues. In contrast, payments
to living donors for costs related to
donation (eg, travel, child care, and
elder care costs and time away
from work) are distinguished
because they are considered reimbursements rather than benefits.
There is lack of clarity on what is
and what is not permissible under
Canadian law and incentives that
are designed as either reimbursements or perhaps compensation for sacrifices related to organ
donation might be permitted.
Public Opinion
There is limited contemporary
information regarding Canadian
public attitudes toward the use of
incentives in Canada. In a recent
survey of more than 2,000 Canadians, Barnieh et al3 reported general acceptance of financial
incentives for both deceased
(w70%) and living (w40%) donors. However, differentiating the
most strongly supported types of
incentives is important. For
deceased donors, the most strongly
supported incentive was reimbursing funeral expenses, whereas
direct payment was supported by
only ,30%. For living donors, the
most strongly supported incentive
was reimbursing expenses and lost
wages, whereas direct cash payments were supported by only 45%
of respondents. Overall, these results suggest general support for
financial incentives, but limitations
on the type of incentive that would
be accepted.
4
Pragmatic Considerations
It is unknown whether financial
incentives will increase the number of organs available for transplantation in Canada. According
to the crowding out motivation
theory, payment for organs could
compromise intrinsic motivation
and decrease existing organ donations for which no payment
currently is provided.18 The proposed standards for a regulated
system of financial incentives excludes payment for directed donations to guard against the risk of
corruption, increasing the likelihood that adoption of financial
incentives could crowd out existing unpaid donations.2 The extent
of crowding out also is unknown.
For example, it is unknown
whether the introduction of financial incentives for one type of
donation (ie, living donation) also
would compromise existing unpaid deceased donations.
The theoretical concerns of
crowding out do not preclude
consideration of financial incentives, but have direct implications for the design of strategies
involving incentives. For example, although there is little
empiric evidence that the value of
the financial incentive is related to
the risk of crowding out, it is
intuitive that this risk might be
greater with the use of large cash
payments. Further, the frequently
proposed strategy to provide a
financial incentive to all donors to
protect against the risk of crowding out19 would limit the value
of the incentive that could be
provided from an economic
perspective.
Undertaking a change in Canadian legislation that currently
precludes the provision of any
valuable consideration in exchange for an organ would be a
heroic undertaking. This practical
barrier limits the design of any
strategy to implement or even pilot
test the use of financial incentives
in Canada. Strategies that might be
finessed under existing legislation
may fail simply because the
incentive was not of sufficient
value to motivate individuals to
donate organs.
These considerations limit
enthusiasm for strategies such as a
regulated system of organ sales as
proposed by Matas et al2 and make
it difficult to design incentivebased strategies that would be
permissible under existing legislation, would not compromise existing unpaid donations, and still
would increase the number of
transplantable organs.
POTENTIAL SOLUTIONS
Canadians strongly support organ donation and there appears to
be significant potential to increase
deceased organ donation.16 Therefore, the primary emphasis should
be implementation of strategies to
increase the efficiency of the
existing deceased organ donation
system (see Box 1).
Establish a National Organ
Donation System
Canada’s provincially administered organ donation system does
not
promote
interprovincial
collaboration or transparency of
processes. Although some provinces have made concerted efforts to improve performance, the
lack of national oversight is an
obvious factor that precludes a
coordinated sustained effort to
improve the system. The establishment of the Canadian Blood
Service to develop interprovincial initiatives, such as the
living kidney donor paired exchange program, has been a
welcome development, but the
mandate of this organization does
not include oversight of the provincially administered donation
systems. A national system with
mandatory reporting would provide the necessary transparency
and accountability to identify and
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test the impact of strategies to
improve system performance.
Establish an Appropriate
Remuneration Framework to
Support Donation
In the publically funded Canadian health care system, the economic benefits of organ donation
are underemphasized, resulting in
a lack of investment in deceased
organ donation services. Hospitals
receive little or no direct compensation for identifying deceased
donors. The lack of a payment for
organ acquisition means that there
are few dedicated resources for
donor management and potential
donors must be managed with
available health resources. This
leads to the misperception that
scarce hospital resources are being
diverted away from critically ill
patients in urgent need of care to
support organ donation. Even in
provinces in which some limited
payment for donor services is
provided, payments are applied to
global hospital budgets and are
not dedicated to enhancement of
donor services. Lack of reimbursement for donor management
services also precludes the development of specialized donor
management expertise. As a
result, physicians often are placed
in the difficult position of having
to approach, consent, and provide
donor management services for
critically ill patients whose lives
they were previously trying to
save. It perhaps is not surprising
that potential deceased donors are
not identified or consented when
the Canadian system continues to
piggy-back donation services onto
an existing health infrastructure
that is already operating at
maximal capacity.
Potential deceased donors
should be recognized as a potential health resource, and dedicated
financial investments should be
made to maximize attainment of
this resource. Hospitals should be
fully reimbursed for health care
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expenditures related to all aspects
of organ donation, including the
organization and implementation
of programs related to the identification, consent, and facilitation
of organ donation. Funds also
should be provided to establish
and maintain dedicated resources
to enable the work of organ
donation and avoid competition
for resources required for the care
of other critically ill patients.
Appropriate remuneration of
health professionals for organ
donation services would minimize
the need for the treating physicians to also take on the care of
potential donors. Concerns that
implementation of such a remuneration framework would lead to
potential coercion of donor families should be allayed because
many of these strategies have long
been implemented successfully in
the United States.
Increase Opportunities for
Donation Consent
Consent for organ donation
should be incorporated into the
routine health management of
Canadians. For example, primary
care physicians could be remunerated for counseling and
obtaining consent for organ
donation during routine clinical
encounters. Available information
suggests that few family physicians counsel patients regarding
organ donation, despite the majority agreeing it was within the
scope of their practice.20 There is
evidence that when primary care
physicians engage patients in
end-of-life care planning, more
patients complete advance care
directives.21,22 Payment of primary care physicians for counseling and recording of an
individual’s wishes regarding organ donation would help ensure
that consent for donation was
informed and would reduce the
likelihood that consent would be
revoked by family members in the
event of neurologic brain death.
Similarly, consent for organ donation should be sought at the time of
any hospital admission and should
be integrated with routine end-oflife care planning. Providing opportunities for Canadians to
discuss and register their decisions
regarding organ donation during
routine health care interactions
would increase the level of comfort
with this subject in the lay public.
“Normalizing” consent for organ
donation could improve acceptance and uptake of organ donation
within the Canadian population
and is a strategy that has been used
successfully in other areas (eg,
promotion of HIV [human immunodeficiency virus] testing).23
Provide Incentives for Registration
of Donation Wishes
Identification of potential organ
donors admitted to Canadian hospitals appears to be the major
issue limiting deceased donation
in Canada. Implementation of
opt-out strategies (ie, presumed
consent legislation), in which an
individual is considered to be an
organ donor unless they have
prespecified otherwise, is one
strategy to increase identification
of potential organ donors. However, opt-out strategies contravene
the expectation of autonomy held
by most individuals, donor families, and health professionals and
are unlikely to be supported in
Canada.24 Further, it is evident
from the Spanish experience that
adoption of presumed consent
legislation had little impact on
deceased organ donation until
improvements to organ donation
services were implemented.25
In contrast, strategies that
involve providing an incentive to
register for deceased organ donation offer an opportunity to increase identification of potential
donors while respecting the principal of autonomy. Strategies in
which a reward is provided only
in the event of potential organ
donation (eg, neurologic brain
5
Gill et al
death) are the most economically
feasible. These strategies may be
viewed as noncoercive because
the decision to donate is provided
by the individual during life and
therefore is separated in time
from the act of donation, the
likelihood of potential donation
is remote, and the individual
will not personally benefit. Providing the incentive irrespective
of the decision to donate and
whether donation actually takes
place further reduces the risk of
coercion.
The recently publicized Israeli
model that provides registered organ donors with priority access to
deceased donor transplantation is
one example of this approach26 that
has been associated with a preliminary increase in donation.27
The model was designed specifically to counteract the negative
public perception of organ donation that was created in part by
those who refused organ donation on religious grounds, but
were willing to accept life-saving
deceased donor transplants. Although providing special access to
deceased donor transplants to
registered donors might be justified
in Israel, prioritization for transplantation based on nonmedical
considerations
potentially
is
discriminatory and likely would not
be accepted in Canada. The provision of other types of incentives,
such as a modest contribution toward funeral expenses or a charitable donation in the name of the
deceased donor, would be favored
because the penalty for nonregistration would be limited to
nonreceipt of a reward rather than
possible exclusion from life-saving
transplantation. Although large incentives including payment of
money to the families of deceased
donors may increase the likelihood
of donor registration, this approach
could be coercive and may trigger
feelings of guilt in the family,
paradoxically causing the family to
override the consent for donation.28
6
Providing an incentive for
donor registration also should
prompt improvements to the organ
donation system. Individuals who
registered their intention regarding
organ donation would have to be
assured that they would be identified in the event of potential organ donation, that their wishes to
donate would be upheld, and that
the reward would be provided.
Placing this responsibility on the
health care system would require
development of mechanisms to
ensure that all potential deceased
donors admitted to Canadian hospitals are identified.
Ideally, implementation of a
strategy to reward donor registration also would include development of knowledge translation
activities to ensure that all Canadians receive appropriate information to facilitate an informed
decision. Similarly, mechanisms
to enable individuals to easily
register their intention to donate
would be needed. This was precisely the experience in the Israel,
where the introduction of a reward
for donor registration was accompanied by a number of other initiatives to enhance public
awareness and enable registration
for organ donation.26 An upfront
capital investment would be
required to implement this strategy with the understanding that an
increase in organ donation may
not be recognized until many
years after implementation.
The legality of payment of a
posthumous reward such as funeral
expenses directly from the government to the funeral home would
have to be established in Canada.
Payment of funeral expenses might
be allowed if this incentive was
positioned as a gift for contributing
to Canadian society rather than a
valuable benefit in exchange for
organ
donation.
Importantly,
providing the reward to potential
donors based solely on registration
of a decision regarding organ
donation during life, independent of
whether the decision was to donate
or not donate and independent of
actual organ donation, is an essential feature that distinguishes this
strategy from other strategies
involving payment for organs.
The potential for this strategy to
crowd out altruistic deceased donations would appear to be low,
especially if the incentive (ie,
funeral expenses) was presented
successfully to the public as a gift
rather than a payment. In addition,
providing the ability to register for
deceased organ donation without
receiving the incentive, as well as
allowing families the option to
decline payment of funeral expenses in the event of donation,
also may help mitigate this risk.
The effect of this strategy on
living donation also should be
considered. Implementation could
lead to the perception that living
donation is somehow less important, and a parallel effort to promote living donation may be
needed. Although providing a
reward for deceased donor registration is unproved, we believe
this strategy is consistent with
Canadian values and has the potential to both increase public
awareness and indirectly improve
the identification of potential donors in the Canadian system.
Consider Compensation for Living
Donor Pain and Suffering
Elimination of disincentives for
living donation, including full
reimbursement for lost wages, is
noncontroversial. However, the
acceptability of extending compensation to include payment for
pain and suffering related to the
donor surgery is uncertain. Although what is and is not allowed
under existing law still requires
further examination, extending compensation in a manner that seeks
to more fully reimburse the donor
may be permissible. Specifically,
a system that is aimed at providing funds that would seek
to put the donor in a financial
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position that he or she would
have been in “but for” the donation seems both fair and a true
removal of disincentives.
Although removing all disincentives to living donation is a
laudable goal and should be pursued, whether this will increase
living donation in Canada is unclear. Removing disincentives is
likely to enable donation among
those already predisposed to
donate (ie, because of some
emotional connection to the
recipient), but it is less likely to
motivate donation from a new
pool of donors who otherwise
would not consider live donation.
The available information suggests that strategies to remove
disincentives to living donation
(ie, reimbursement of donationrelated expenses) may be inadequate to increase living donations.
In a survey of 181 living kidney
donors in British Columbia, Canada, who had received reimbursements for out-of-pocket
expenses incurred while donating
a kidney, as well as payment for
lost wages (up to $350/wk for
8 weeks), 100% of respondents
thought the program should
continue, but only 36% indicated
that they might not have donated
without the presence of the program.29 In another recent study,
legislation to provide modest
financial support (including paid
and unpaid leave or tax credits)
for living donors in the United
States had no overall impact on
the rate of living kidney donation
(though there was a measurable
increase in unrelated donations).30
Provide Incentives for Living
Donor Paired Exchange
Removing disincentives to
participate in Canada’s living
donor paired exchange program to
encourage participation of biologically compatible living donors
and their recipients in this program is an intriguing possibility
that should be considered. In this
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proposed strategy, medically suitable and approved biologically
compatible living donors and their
recipients would be offered additional compensation to participate
in the living donor paired exchange program. Increasing the
number of participants in paired
exchange programs increases the
number of transplants that can be
facilitated by this mechanism.31
The payment would be provided
to compensate participants for the
inconvenience of participation in
the paired exchange program (ie,
for donor travel or delaying donor
surgery to accommodate the
completion of multiple living
donor transplants on the same
surgical day). Providing a financial reward for participation might
even be considered in this limited
scenario because restricting eligibility to individuals who had made
an a priori decision to donate an
organ and had been approved for
directed donation would limit the
risk of donor coercion.
SUMMARY
There is significant capacity to
increase organ donation in Canada
and potentially to fulfill the need
for transplantation in this country.
Canada has not made a coordinated systematic attempt to increase the efficiency of its
deceased donor system and therefore abandoning the present system in which no payment for
organs is provided in favor of an
unproven payment-based system
would be premature. Instead,
feasible strategies to increase the
identification and conversion of
potential deceased donors to
actual donors, facilitate interprovincial cooperation, encourage
decision making regarding organ donation, and remove disincentives to live donation are
proposed. These include strategies involving the use of financial incentives that carry a low
risk of coercion and are unlikely
to threaten existing sources of
donation. Although these recommendations are opinion based and
unique to Canada, they may be
useful in informing efforts to increase organ donation in other
jurisdictions.
ACKNOWLEDGEMENTS
This work was motivated by a special
forum on Incentives for Organ Donation
held at the 2012 Canadian Society of
Transplantation Annual Scientific Meeting
in Quebec City. The authors acknowledge
Arthur Matas, Louis Tomatis, Tom BlydtHansen, Aviva Goldberg, and Linda
Wright, who participated in the special
forum.
Support: None.
Financial Disclosure: The authors
declare that they have no relevant financial
interests.
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Incentives for organ donation: proposed
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306-312.
3. Barnieh L, Klarenbach S, Gill JS,
Caulfield T, Manns B. Attitudes toward
strategies to increase organ donation:
views of the general public and health
professionals. Clin J Am Soc Nephrol.
2012;7(12):1956-1963.
4. Matas AJ, Hippen B, Satel S. In
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