Results
Of the 7324 e-mail invitations, 2856 were undeliverable; 1448 of the 4468 e-mail recipients (response rate of 19.8%) completed the survey. Excluding 168 respondents who indicated that they did not practice any clinical nephrology, we analyzed a total of 1280 responses. Table 1 shows the demographic and practice characteristics of the respondents. The majority of respondents were 50 years of age or younger, male, had more than 10 years of clinical experience, with more than 50% clinical activity, were affiliated with an academic medical center and worked in an urban/suburban setting. Half of the respondents identified themselves as transplant nephrologists. Thirty-seven percent stated that kidney transplantation is performed at the hospital in which they practice, and 51% noted that at least 50 kidney transplants had been performed at their hospital during the previous year. Ninety-five percent of the respondents identified 74 countries within nine geographic regions as their country of practice. The largest proportion of respondents (33%) was from the Canada/US region. Ninety percent indicated that they would donate a kidney to a first degree relative in the event of need and 82% noted that they have consented for deceased organ donation. Associations between respondent characteristics and responses are outlined in Table 2 , Table 3 , and Table 4 and the results of the multivariate analyses are detailed below.
Health Insurance for Donors
Thirty-seven percent of the respondents agreed with the provision of free life-long health insurance to donors (Figure 1; Table 2). Nephrologists from India/Pakistan (OR: 6.40; 95% CI: 1.81–22.65; P < 0.01), Africa (OR: 3.54; 95% CI: 1.36–9.21; P < 0.01) and Eastern Europe (OR: 3.46; 95% CI: 1.19–10.01, P < 0.05) were more likely to agree with health insurance for donors.
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Figure 1.
Attitudes toward compensation and rewards for organ donation and perceptions about the effects of financial rewards. Top panel: percentage of nephrologists who agree with statements about providing compensation and rewards to living donors or to families of deceased donors. Lower panel: percentage of nephrologists who agree with the statements about the effects of financial rewards on living organ donation. The first three bars indicate positive perceptions, the lower two bars indicate negative perceptions about financial rewards.
Compensation for Donation
Forty-nine percent of the participants agreed with some form of compensation, and 26% agreed with direct financial compensation for living donors (Figure 1; Table 2). Respondents from Latin America (OR: 0.18; 95% CI: 0.10–0.33; P < 0.01), Eastern Europe (OR: 0.40; 95% CI: 0.19–0.86; P < 0.05) and Western Europe (OR: 0.37; 95% CI: 0.23–0.61; P < 0.01) were less likely to agree with any form of compensation for living donation. Respondents from the Middle East (OR: 2.38; 95% CI: 1.41–4.04; P < 0.01) were more likely, while those from Latin America (OR: 0.43; 95% CI: 0.25–0.73; P < 0.01) and Western Europe (OR: 0.24; 95% CI: 0.13–0.46; P < 0.01) and nephrologists practicing in rural locations (OR: 0.50; 95% CI: 0.29–0.86; P < 0.05) were less likely to favor direct financial compensation for living donation.
Financial Rewards to Living Donors
Thirty-one percent of the respondents believed that living-unrelated donors should receive financial rewards, while 23% favored rewards to related donors (Figure 1; Table 3). Respondents from the Middle East (OR: 4.23; 95% CI: 1.95–9.20; P < 0.01) and India/Pakistan (OR: 2.26; 95% CI: 1.13–4.53; P < 0.05) were more likely, while nephrologists from Latin America (OR: 0.35; 95% CI: 0.18–0.70; P < 0.01) and Western Europe (OR: 0.26; 95% CI: 0.14–0.49; P < 0.01) and nephrologists older than 50 years of age (OR: 0.71; 95% CI: 0.53–0.94; P < 0.05) and those practicing in a rural setting (OR: 0.46; 95% CI: 0.28–0.76; P < 0.01) were less likely to agree with financial rewards to living-unrelated donors. Physicians from Latin America (OR: 0.23; 95% CI: 0.11–0.50; P < 0.01) and Western Europe (OR: 0.23; 95% CI: 0.14–0.53; P < 0.01) were less likely to agree with financial rewards for living-related donors.
Financial Rewards for Families of Deceased Donors
Twenty-seven percent were in favor of financial rewards for families of deceased donors (Figure 1; Table 3). Respondents from India/Pakistan (OR: 2.43; 95% CI: 1.20–4.92; P < 0.05) and the Middle East (OR: 2.24; 95% CI: 1.04–4.83; P < 0.05) were more likely, while nephrologists from Australia (OR: 0.36; 95% CI: 0.14–0.97; P < 0.05) and Western Europe (OR: 0.27; 95% CI: 0.14–0.55; P < 0.01), those older than 50 years of age (OR: 0.71; 95% CI: 0.53–0.96; P < 0.05), female nephrologists (OR: 0.71; 95% CI: 0.51–0.98; P < 0.05) and those practicing in a rural setting (OR: 0.44; 95% CI: 0.26–0.75; P < 0.01) were less likely to agree with providing financial rewards to families of deceased donors. In a post hoc analysis of the association between the predominant religion of the respondents' country and the responses, respondents from predominantly Catholic countries were less likely to agree with rewards to families of deceased donors (OR: 0.52; 95% CI: 0.28–0.96; P < 0.05).
Perceptions About the Effects of Financial Rewards for Living Organ Donation
Sixty-six percent believed that financial rewards for living organ donation will lead to an increase in living kidney donation, 45% felt that it will lead to a decrease in the likelihood of rampant commercialization and a similar proportion (44%) believed that it will lead to decreasing disparities in transplantation (Figure 1). Thirty-seven percent of the nephrologists believed that financial rewards will have a negative impact on deceased-donor organ transplantation programs and the majority (73%) were concerned that rewards will lead to exploitation of the poor. Forty-seven percent (504) agreed with both statements that 'financial rewards for living organ donation will lead to an increase in living kidney donation' and 'financial rewards for living organ donation will lead to exploitation of the poor'.
Association Between Perceptions About the Effects of Rewards and Attitudes About Donor Compensation and Rewards
Respondents who perceived that rewards will lead to an increase in living donation, decreased commercialization in transplantation and decreased disparities in transplantation were more likely to have favorable views about providing compensation, health insurance and rewards to the living donor and to families of deceased donors (Figures 2 and 3). Perceptions that providing rewards will have a negative impact on deceased donation or that it will lead to exploitation of the poor were associated with unfavorable attitudes toward financial compensation and rewards to the living donors or to families of deceased donors.
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Figure 2.
Association between perceptions of the effect of rewards and attitudes toward compensation and health insurance for living donors. OR of attitudes favoring financial compensation, some form of compensation and donor health insurance as related to perceptions about the effects of providing rewards to the donors. The top three rows indicate positive perceptions and the lower two rows indicate negative perceptions about the effect of rewards (data shown as OR, 95% CI; *P < 0.05; **P ≤ 0.01).
Opinions About Legislation Banning Organ Sales
From 1050 respondents to the question about legislation banning organ sales, 819 (78%) agreed with such legislation (Table 4). Age >50 was associated with a higher likelihood (OR: 1.61; 95% CI: 1.17–2.22; P < 0.01), while practice in the Middle East was associated with a lower likelihood (OR: 0.38; 95% CI: 0.17–0.87; P < 0.05) of agreement with such legislation.