**2. Financial incentives**

In Spain and Italy, it is considered that the increase in donation is the exponent of a better

In France according to the 1976 "Caillavet Law", a person is presumed to have consented to organ donation if he or she has never explicitly said otherwise to close relatives. But even for organs and tissue, where there is no such legal confusion, the "Caillavet Law" has not been applied uniformly in all French hospitals because there was no centralized administration in

France has modified its law on organ donation. All people are donors at death unless they record their refusal in an official registry. The new law provides for the procurement of

Spain is routinely cited as a successful example of presumed consent. But in Spain, the nextof-kin still has veto power. Most of the growth in donation rates there happened well after the

Some people do not trust the government or the health care system. Many of them are afraid that that signing a donor card may make physicians give up on them too soon, especially if

This legislation, if enacted, must take into account this relatively frequent fear of the people. Changing the law will not be sufficient. As the experience with presumed consent in Western Europe shows, education of the public and constant training of hospital personnel are essential to achieve the improvement of the structured medical organization for the increase of

Another possibility for increasing donors has been developed with the modification of it acceptance criteria. This means the alternative to consider the use of donors with different medico-surgical conditions that may diminish part of their chances of long-term success.

On the other hand, improvement in the detection, prevention and better therapeutic of the pathologies leading to terminal organ failure, provides alternatives by reducing the number

It is complex to establish whether the presumed consent can justify various social behaviors

The medical-social people behaviors are adapted to the degree of education on the subject, the quality and formation of the responsible medical organizations and the economies of each

In particular, the participation of a medical group trained in excellence in the psychosocial methodology of approaching families at the time of the grief of the loss of a loved one, is undoubtedly a factor of principal importance for a positive result regarding the family response [31].

Some critics claim that presumed consent is a "fiction" [32]. However, the conception of presumed consent as tacit and silent overcomes the notion of being a fiction. Sometimes it can be

institutional management rather than the result of the presumed consent law.

France to coordinate people's wishes.

organs, even against the wishes of the family.

54 Organ Donation and Transplantation - Current Status and Future Challenges

the hospital is likely to lose money on their care.

passage of presumed consent legislation.

of requiring organs for transplantation.

in countries with or without that type of legal measure.

organ procurement.

one of the countries.

Financial incentives are considered any material gain or value obtained by those who consent directly to the process of obtaining organs, whether to the donor, the succession of the donor or the family of the donor.

The arguments in favor of financial incentives for organ donation are based on the hope that such a system will increase the supply of organs safeguarding the basic ethical concern of saving lives.

A set of reimbursement of funeral expenses has also been suggested as a direct "milder" means of incentive for donation.

Finally, a form of "insurance for the donor" has been suggested, for which an individual agrees in advance of the donation, with a payment to their beneficiaries that will only take place after the donation.

The concept that financial incentives can offer a possible solution to the shortage of organ donors in progress has been considered and debated among experts in the field of transplantation, ethics, law and economics [34].

The essential conception of altruistic donation, unchanged in general in the last 50 years, has not been able to overcome the constant lack of organs, with a critical permanent increase in mortality on the waiting list. This constant reality has motivated the justification by different authors to invoke a fundamental change of the current altruistic criterion: financial incentives to facilitate organ donation.

It has been specifically pointed out in this regard that the current system generates financial gains for all concerned: doctors, coordinators, social workers, hospitals, pharmaceutical laboratories, etc. Consequently, it has been described as unjust and insensitive to the families of the donors and a source of basic distrust on the part of the public, that the donor and the family are the only ones that do not directly benefit from the donation process, which therefore, some type of compensation must be defined [35].

Finally, those who promote financial incentives for organ donation conclude that their motives are ethical because they are based on concern for patients and saving lives and not only on abstract theories and issues without concrete answers.

Pilot programs are proposed to evaluate the potential effects of financial incentives for organ donation instead of rejecting this proposal on the basis of theoretical disadvantages not yet tested [36]. This means that it is time to use incentives to reward people who are willing to save the life of a stranger through donation.

**3. Expanding donors**

mal organs have been included.

per year [42].

"suboptimal" organs.

One important factor in the number of transplantations, currently performed, is the growing acceptance of marginal grafts, which are defined as organs at increased risk for poor function

The Society, the Barriers to Organ Donation and Alternatives for a Change

http://dx.doi.org/10.5772/intechopen.73756

57

The persistent "organ shortage" remains with an increase of 8% organ transplants per year.

This reality has conditioned a modification of the classic acceptance criteria for an organ donor. Currently, donors regarded as "expanded criteria donors" with potentially subopti-

Simultaneously, the number of cadaveric organ donors has remained relatively static, with only a 4% increase per year. Most of this incrementally small increase has been through the use of "expanded" donors, reflected by the fact that the uses of donors older than 50 years old increased by 24% per year while those younger than 50 years increased by only 1.5%

As it was mentioned, to increase the potential donor supply, the implementation of presumed consent and financial incentives for donation have been proposed, nevertheless public attitude toward presumed consent would probably not be acceptable. On the other hand, there has been resistance to financial incentives to the donor family because of the perceived danger of this escalating to the selling of organs as currently taking place in Southeast Asia and India [42]. Efforts to expand the donor pool are therefore limited to expand the criteria for the use of

Mainly, suboptimal donors are considered when donors are less than 5 years old or older than 65, donors with moderate decrease in renal function, donors with antibodies positive against hepatitis C, donors with type 2 diabetes or with moderate arterial hypertension and particu-

*Older donors*: the general refusal to use kidneys from older donors is due to the normal struc-

However, these changes may not occur in all donors. For this reason, it has been considered that the older donor should be evaluated individually for its renal function at the time of death. Renal biopsy can be used in donors older than 50 years or with a history of significant hypertension. An organ that presents a glomerular sclerosis less than 20% and with mild

It is important in these cases to implement the system called Old to Old, it does means, old

It is very important in these kidneys the evaluation of the cold ischemia time (CIT). Kidneys with CIT of more than 48 h have a graft survival of 38% compared to kidneys with CIT less

Nefrotoxic injury with medication or rejection may also limit the long-term final result of

than 48 h, which had a very acceptable graft survival of 76% at 1 year.

larly the use of donors with cardio-circulatory death [42].

Essential characteristics of these suboptimal donors:

interstitial fibrosis is acceptable to be implanted.

donors kidneys for old donor receptors.

these organs [43].

tural changes in the aging kidney.

or failure that may subject the recipient to greater risks of morbidity or mortality [41].

The annual growth of patients on the waiting list is 22% and its mortality is 18%.

Those who support the establishment of economic incentives consider that our current transplant system is inadequate for the task of increasing the volume of organs necessary to save lives. Altruism is not enough, incentive pilot trials are needed [37].

On the other hand, opposed to financial incentives base their objections on the argument that the altruistic system has not been correctly promoted.

It is pointed out that there would be a decrease in respect for life and the sanctity of the human body, and a loss of the personal relationship that currently exists in the donation process [38].

Great concern has also been expressed regarding a potential phenomenon of rich versus poor. Ironically, this type of incentive would be mainly aimed at racial communities of significant poverty [39].

Economic necessity should not be linked in a coercive way to consent to obtain organs. This money would be better spent more on education for medical communities regarding the need for organ donation through the current system to make the society understand the fundamental benefit for its future of donation and organ transplantation.

Beyond that the proposed incentives can be negative for potential donors, it has been argued that the financial gain of the family of the donor has not resolved at all the economic problem motivating the acceptance of economic incentive to donation.

On the other hand, the relative failure of the medical community to participate in the donation process will not be improved by the incentives directed to the potential donor [40].

In the discussion of the problem of acceptance of economic incentives for organ donation, it is convenient to mention the Iranian program of transplants. In this country, a system for payment of organ donation coordinated by the government has been implemented with significant results. Actually, a candidate for transplantation in Iran can get a kidney from a cadaver, living relative, or a living stranger.

However, in contrast to most countries, 76% of kidneys come from strangers; only 12% of kidneys are from deceased donors.

This significant difference makes it necessary to consider the obvious poverty-donation relationship, which notwithstanding any image of responsibility on the part of the state, does not excuse an unavoidable presumption of social injustice, ethically not compatible with the basic principles of ethics in organ transplants.

Those who oppose the financial incentives for organ donation predict the possible loss of control of this process by the government bureaucracy and the "organ traffickers" with a tremendous increase in the cost of administrative requirements [39].

Until it is available through universally accepted surveys as accurate and representative, the feasibility and effect of financial incentives for organ donation remain questionable.
