Reimbursement of living organ donors

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

Singapore has amended its Human Organ Transplantation Act (HOTA) to allow for the reimbursement of living kidney donors for direct and indirect costs incurred as a result of the donation.

Neue Entwicklungen

Before the amendment, the HOTA prohibited payment of any kind to organ donors. Now, it will be legal to reimburse organ donors for direct expenses incurred as a result of the donation (e.g. transport and accommodation), as well as indirect losses (e.g. loss of earnings and time) and future expenses (e.g. anticipated costs of medical follow-up, costs of long-term care of the donor, and life insurance coverage) due to the donation. 

Three other related but less controversial changes were passed at the same time, namely: 

1. lifting the age limit on cadaveric donors (currently fixed at 60 years) so as to increase the number of cadaveric donors; 
2. allowing recipients to swop donors for a better match, and
3. increasing penalties for organ trading so as to protect donors and recipients from exploitation by unscrupulous middlemen.

In introducing the change in legislation, the government stressed that it was not setting a precedent but merely joining other countries like Australia, Britain and United States where such compensation is allowed. In fact, the word "compensation", which has been used during much of the debate here, has been replaced with the word "reimbursement" so as to clearly signal that no payment for organs is implied. 

While the organ recipients are expected to be the primary party paying the donors, some voluntary welfare organisations have expressed interest in giving ad hoc financial assistance to donors. Other suggestions being considered include third party reimbursement of post-operation medical care, topping up of the donor's Medisave account, and purchasing medical insurance on the donor's behalf.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral
current    previous

 

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Initiators of idea/main actors

• Regierung

• Parlament

• Leistungserbringer

• Patienten, Verbraucher

Stakeholder positions

The amendment to HOTA has not changed the fact that organ trading is still illegal in Singapore. However, the public debate leading up to the amendment was a much broader one concerning organ trading (see report 12(2008)). In particular, the Minister of Health during dialogue sessions that were held to discuss the issue had shared his own take on what principles might govern an acceptable organ trading situation; hinted that the quantum of any compensation would be "at least five figures, and possibly six"; and suggested that issues of equity could be addressed by having the rich subsidize the poor in obtaining their organs. 

It is fair to say, therefore, that what was passed reflects the recogniton that the majority of Singaporeans are not ready to accept organ trading of any form. Even then, the legislation allowing reimbursement of living kidney donors was itself considered controversial and passed by Parliament only after "heated" debate.  

Critics worry that the amendment may open the "back door" to organ trading. In the absence of a robust system to prevent such occurrence, the poor, especialy from the surrounding region, may be exploited by unscrupulous middlemen to sell their organs. It is an open secret that buying and selling of human organs does occur as a lucrative business for unscrupulous syndicates and for countries that allow foreign 'transplant tourists' to have transplant operations they cannot get at home. An estimated 10 per cent of transplanted kidneys worldwide are illegally obtained. 

A weakness pointed out during the parliamentary debate on the new legislation is that it lacks reimbursement caps and detailed formulae for assessing losses (the Minister of Health said he preferred not to "hardwire technical matters" into the Act) - hence it is not clear at which point reimbursement might become an inducement. Moreover, heavy reliance is being placed on hospital transplant ethic committees who are not endowed with the power of investigation, to verify that the donor was not being coerced, financially induced, or emotionally pressured. The Minister's response was that the committees will be given guidelines to work with, their members must undergo training in medical ethics, and their work would also be subject to close regular audits.  

There were also concerns that Singapore might be embarking on a slippery slope to becoming a center for "transplant tourism." During the Parliament debates on the HOTA amendments, the Minister of Health had insisted that to be fair, the law had to apply equally to both Singaporeans and foreigners. But he subsequently clarified to the public that in the implementation, the Ministry of Health will ensure that only Singaporeans will be reimbursed for donating a kidney, and that payments will be extended to foreigners only when there is "enough confidence in the scheme". In explaining this "staggered approach" to implementation, he was quoted as saying, "We don't want Singapore to be a rogue regime. Let's not rush into it". 

Singapore's National Medical Ethics Committee had endorsed the proposal to reimburse living kidney donors, "so long as the amount is not so great as to act as inducement". It had concurred with the government's view that comprehensive reimbursement of verifiable and reasonable expenses of kidney donation does not constitute a payment for that organ, and may be viewed as part of the legitimate costs of treating the recipient. Such payment to donors actually "rights a wrong", it said, conceding that donors could incur the risk of higher healthcare costs in the future as a result of the donation.

Leading up the legislative debate, the Health Ministry had announced that according to a survey it had conducted, more than eight in 10 people here support moves to change transplant laws to make more organs available, and punish organ traders more severely. Eight in 10 were in favour of even the "most controversial" proposal of reimbursing living organ donors - but only for their loss of income, as well as direct and future expenses related to the donation, and not for any profit. Three in four said the total should amount to at least $50,000.

Actors and positions

Regierung
Government lawmakers	sehr unterstützend		stark dagegen
Parlament
Opposition lawmakers	sehr unterstützend		stark dagegen
Leistungserbringer
Singapore Medical Association	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patients	sehr unterstützend		stark dagegen
current    previous

Influences in policy making and legislation

 

Legislative outcome

Enactment

Actors and influence

Regierung
Government lawmakers	sehr groß		kein
Parlament
Opposition lawmakers	sehr groß		kein
Leistungserbringer
Singapore Medical Association	sehr groß		kein
Patienten, Verbraucher
Patients	sehr groß		kein
current    previous

Positions and Influences at a glance

Adoption and implementation

 

Monitoring and evaluation

 

Expected outcome

It remains to be seen if the amendment, which is aimed at removing possible financial disincentives to living kidney donation, will result in any increase in altruistic organ donations, whether from living related and non-related donors.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch
current    previous

 

References

Sources of Information

Ministry of Health Press Release. Further Medisave Liberalisation. 29 March 2009.

Chia, Sue-Ann. "Kidney payment gets nod". The Straits Times. 25 March 2009.

 

Reform formerly reported in

Legalization of organ trade? Process Stages: Idee

Author/s and/or contributors to this survey

Lim, Meng Kin

National University of Singapore

Empfohlene Zitierweise für diesen Online-Artikel:

Lim, Meng Kin. "Reimbursement of living organ donors". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/sg/a13/3