by Dr Qiang Fang, Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou.
In China, about 1.5 million Chinese patients are placed on organ transplant waiting lists each year, yet less than 1% of them have managed to receive an organ.
The gap between the need for and the supply of organs is large—and growing. The Regulation on Human Organ Transplantation strictly stipulates that living organ donation is limited to relatives. The number of organs from executed prisoners is decreasing. In March 2010, the Red Cross Society of China (RCSC) and the Ministry of Health of China jointly launched a pilot programme of deceased organ donation in 10 provinces and cities. This programme marks a turning point in the transplant history of China. By March 2012, there were 207 deceased donors in total. However, with the country's population of 1.3 billion, the deceased donor rate remains significantly lower than in Spain and other Western countries.
In China, the shortage of deceased organ donors is due to a belief that the body should be left intact, a lack of incentive policy to increase the donation rate, and the weakness of programmes promoting voluntary organ donation. Traditional cultural beliefs about the proper disposition of a corpse constitute the major obstacle to deceased organ donation in China. The Confucian tenet of filial piety requires that a body be returned to the ancestors in an intact state and declares that every part of the body that is given by the parents deserves respect. People have also believed for thousands of years that keeping the dead body intact is a way of respecting the dead. These beliefs produce resistance to organ donation. Although nowadays cremation is carried out in many parts of China, most people still insist that the dead body be kept intact before being taken to cremation.
In order to provide incentive for deceased organ donation, five pilot provinces and cities (Zhejiang, Tianjin, Jiangxi, Jinan and Liaoning) have launched a financial compensation policy. We will take Zhejiang Province as an example. Zhejiang Red Cross established the Human Organ Donation Compensation Foundation in March 2012. From March 2010 to March 2012, there were 20 donors. From April 2012 to the end of July, there were 23 donors. During these 4 months, Zhejiang organ donation witnessed rapid growth. Zhejiang Province, with 43 donors, is now rated number 2 of the pilot provinces and cities.
Organ donation can proceed only if one of the following conditions is met: the deceased has expressed a willingness to be an organ donor in either a living will or another written form, and his or her closest relative provides written consent for organ donation, or the potential donor has not expressed opposition to donation before his or her death, and his or her closest relative provides written consent for organ donation.
A characteristic of organ donation in China is that the Red Cross acts as the third party non-profit organisation in implementing the donation policy with the authority of law. In Zhejiang, the Red Cross is responsible for raising and managing funds for financial compensation, thus ensuring that money is used in a fair and legal way. Transplant hospitals are not allowed to be involved in management of the funds. Government appropriation, transplant hospital contributions and charitable donation are the usual sources of funds.
Financial compensation can be considered to include two main forms, the ‘thank you’ form and the ‘help’ form. ‘Thank you’ compensation includes three aspects. First, Zhejiang Red Cross Society will pay for basic funeral expenses, which cover body transportation, cremation and ash urn storage. Then the Society will offer the donors’ families USD 1600 for the cost of purchasing a grave plot. In addition, the donors’ families will be provided with USD 3200 allowance. This kind of compensation is gratitude on behalf of the Society for consenting to donation. If the families of deceased donors face hardship, Zhejiang Red Cross will offer them extra compensation, which can be no more than USD 4800. The family is eligible to apply for extra compensation only if one of the following conditions is met: the family has been designated a low-income family by the local Bureau of Civil Affairs and receives dole from the government every month, or the income of the family is at the level of local per capita income before the donor's death and the deceased donor was the family's main earner. The committee of Human Organ Donation of Zhejiang Red Cross will assess applicants’ eligibility. Then the committee will discuss how much money should be offered to a donor's family. The amount of compensation offered to a family is not according to the number of procured organs, but according to the degree of the family's suffering. However, there is no formal criterion to estimate the degree of suffering. Generally, the committee will make enquiries into the family's financial situation, assessing such factors as how many dependants the family supports, and whether the donor's spouse has the ability to support the family. Then the final decision will be made by the committee. This kind of compensation is social welfare support for needy families.
Those who consent to donation out of altruism deserve social appreciation and respect. Chinese social ethics not only upholds the moral value of benevolence, humaneness and mutual aid, but also advocates rewarding a good deed. In 1993, China established the China Foundation for Justice and Courage aiming to carry forward traditional Chinese virtues, foster healthy social trends, commend justice-upholding volunteers, and provide legal protection and financial assistance for those who take up the cudgels for a just cause. In July 2012, a Good Samaritan regulation was placed on the legislative agenda to protect those who lend a hand. A good deed itself might not have any economic value. However, the reward could be offered in spiritual and material form. A survey of 463 people of different educational level showed that 87.96% supported financial compensation. Financial compensation could express society's gratitude for altruistic spirit and ease the financial pressure of voluntary donors’ families in needy circumstances.
In January 2012, a student from Hubei Province died from carbon monoxide poisoning in Shenzhen city. The grieving parents donated their daughter's organs and body. Meanwhile, they were unable to pay USD 11 200 for medical expenses, which is a heavy burden for a blue-collar family. As Shenzhen has not yet implemented the financial compensation policy, the organisation's charitable donation provided the family with the means to meet these expenses. China is a developing country with a gross national product of USD 5432 per capita in 2011. There are 128 million citizens, accounting for 10% of the country's total population, living below the poverty line (per capita income for living expenses of urban households less than USD 368 a year). The majority of them live in the country. In addition, medical expenses are a heavy burden for rural residents because of the lack of a good medical insurance system. If a donor's family is faced with financial problems, financial compensation will give timely assistance to that family.
Although China needs a financial compensation programme for deceased organ donation, undesirable consequences have emerged. Of the 207 deceased donors, the proportion of poor donors is much higher than that of other donors. The vice minister of the Red Cross, Zhao Baige, said in an interview that 90% of 207 deceased donors’ families faced financial difficulties. This indicates that some of these families consented to donation because they were in need of financial assistance. With the developing economy, the continued increase in deceased organ donation rate dependent on this policy is doubtful in the long run. In addition, some donors’ families in needy circumstances have suffered great stress, as they were thought to have sold organs of their deceased loved ones.
Financial compensation for deceased organ donation is not unique to China. In 2000, the US state of Pennsylvania implemented a programme of offering USD 300 to the families of organ donors to defray funeral expenses. In 2010, Israel launched a new policy to offer compensation to the families of deceased organ donors. The Israeli Ministry of Health stipulates that families who agree to donate the organs of deceased loved ones will receive USD 13 400. However, China differs from other countries with similar programmes by offering extra compensation for needy families of deceased donors.
In July 2012, the State Council of China issued a guideline for promoting the development of the RCSC. According to the guideline, the government will help the RCSC found provincial organ donation foundations that can sponsor donations and transplants. Financial compensation programmes will be implemented in other pilot provinces and cities. To promote the healthy development of deceased organ donation, programmes promoting voluntary organ donation should be operated extensively to encourage altruism and raise the proportion of donors other than poor ones.
Source: Journal of Medical Ethics