Generosity won’t fix our shortage of organs for transplants
慷慨解决不了可移植器官的短缺
Each week, In Theory takes on a big idea in the news and explores it from a range of perspectives. This week we’re talking about government compensation for organ donors.
《华盛顿邮报》的“理论”栏目每周都会从新闻中选取一个大胆话题，从不同角度进行探索。本周我们的主题是政府对器官捐献者的补偿。
Sally Satel is a resident scholar at the American Enterprise Institute and a lecturer in psychiatry at Yale University School of Medicine. She is the editor of “When Altruism Isn’t Enough: The Case for Compensating Kidney Donors.”
Sally Satel 是美国企业研究所常驻学者和耶鲁大学医学院的精神病学讲师，也是《当利他主义不够时：补偿捐肾者的理由》一书的主编。
My interest in the national organ shortage began one steamy afternoon in August 2004. That day, my doctor told me my kidneys were failing. As a physician myself, I knew immediately that I would need to find a replacement organ or else face a shortened life tethered to a dialysis machine. My search was rocky at first, but finally I did get a kidney from a casual friend — now a very dear one.
我对国内器官匮乏的关注始于2004年八月一个闷热的下午。那天我的医生告诉我，我的肾快要不行了。作为一名内科医生，我立刻知道我需要找到替换的器官，否则我将命不长久，而且余生都要栓着透析机。
At the time of my search, there were about 60,000 people on the national waiting list maintained by the United Network for Organ Sharing. Today, a decade later, there are roughly 101,000. Meanwhile, donation rates from both living and deceased donors are effectively flat. The death toll is 12 people per day — individuals who could not survive the years-long wait for an organ.
根据我当时搜索的结果，美国器官共享网络的全国等待名单上大约有6万人。十年过去了，如今上面大约有10万1千人。与此同时，活体和死亡捐献率都走势平平。结果就是每天有12人由于多年得不到新器官而死亡。
Clearly, our current organ transplant policy is a qualified failure. And it is because our current system, by law, mandates altruism as the sole legitimate motive for organ donation. We need to give more healthy young and middle-age people a reason to become living donors.
显而易见，我们现今的器官移植政策是十足的失败。那是因为按照法律，利他主义是器官移植唯一的合法动机。我们需要给健康的年轻人和中年人足够的理由来让他们加入活体器官捐献者的行列。
Tragically, altruism is not enough. The yield from public awareness campaigns, the organ procurement teams that meet with families of the recently deceased and the reimbursement for donors’ expenses has leveled off. Moving to an opt-out system, under which we would harvest people’s organs at death unless they had earlier indicated they didn’t wish to donate them, can do only so much — relatively few people die in ways that leave their organs suitable for transplantation.
不幸的是，利他主义并不够。公众宣传活动，器官采集团队造访最近有亲人去世的家庭，为捐助者报销费用，这些措施的效果已趋于耗竭。即使在捐献者死去时默认可以采集器官（除非他们早先曾表明不愿意捐献），成效也不会太好——大多数人的死亡方式决定了他们的器官不适合移植。
So, to save lives, let’s test incentives. A model reimbursement plan would look like this: Donors would not receive a lump sum of cash; instead, a governmental entity or a designated charity would offer them in-kind rewards, such as a contribution to the donor’s retirement fund; an income tax credit or a tuition voucher; lifetime health insurance; a contribution to a charity of the donor’s choice; or loan forgiveness.
所以，为了救人，我们可以试试激励机制。一个理想的补偿计划应该是这样的：捐献者不会收到一笔现金，但政府部门或者指定的慈善机构会为他们提供非现金奖励，例如：向捐献者的退休基金供款，所得税抵免或者学费代金劵，终生健康保险，向捐献者指定的慈善机构捐款，或者债务豁免。
Meanwhile, the law can impose a waiting period of at least six months before people donate, ensuring that they don’t act impulsively and that they offer fully informed consent. Prospective compensated donors would be carefully screened for physical and emotional health, as all donors are now. These arrangements would filter out financially desperate individuals who might otherwise rush to donate for a large sum of instant cash and later regret it.
与此同时，法律可以规定捐献者在捐献前有至少六个月的冷静期，以确保他们不是冲动行事，而是经过周详考虑才决定同意。和现在所有捐献者一样，有偿捐献者也需要经过仔细筛选以保证身心健康。这些措施可以把那些急着等钱用的人过滤掉，他们会为了那笔钱而冲去捐献，但事后追悔莫及。
The donors’ kidneys would be distributed to people on the waiting list, according to the rules now in place. (People who wanted to donate a kidney to a specific person — say, a father to a son — would still be able to, alongside this system.) Finally, all rewarded donors would be guaranteed follow-up medical care for any complications, which is not ensured now.
根据现行规则，捐出来的肾将分配给那份等待名单上的人。（如果有人想把肾捐献给指定的人，例如，父亲捐给儿子，也同时可以做到。）最后，所有有偿捐献者都将得到术后并发症的跟踪治疗，这个规定是现在没有的。
The good news is that the general notion of incentivizing donations is gaining traction. A 2009 poll of the membership of the American Society of Transplant Surgeons revealed that 80 percent supported or were neutral toward the provision of tax credits for donors. In 2014, the American Society of Transplantation and the American Society of Transplant Surgeons published the results of a workshop in which the societies expressed approval of testing third-party, in-kind incentives. A few weeks ago, the American Medical Association passed a resolution in favor of testing the effect of incentives on living and deceased donation. (A reward for deceased donation could take the form of a funeral subsidy or a contribution to the estate of the deceased.)
好消息是，为捐献提供激励的观念正日益赢得关注。2009年一项针对美国器官移植外科医生协会的调查显示，80％的协会成员对向捐助者提供税收抵免持赞成或中立态度。2014年，美国器官移植协会（AST）和美国器官移植外科医生协会公布了他们一个研讨会的结果，在该研讨会上，两个协会对试行来自第三方的非现金奖励表示支持。几周前，全美医疗协会（AMA）通过决议，支持测试为活体和死后器官捐献提供激励的效果。（死后捐赠的奖励，可以葬礼补贴或并入死者遗产的方式实现。）
The objections I heard years ago seem to be wearing thin. Take the objection that rewarding donors “commodifies the body.” We already commodify the body, speaking strictly, every time there is a transplant: The doctors get paid to manipulate the body. So does the hospital and the agency that obtains and transports the organ. Why would we now object to enriching the donor — the sole individual in this entire scenario who gives the precious item in question and assumes all the risk?
多年前我所听到的反对声音，如今似乎越来越少了。例如，有人反对说奖励捐献者是“人体商品化”。其实，严格来说我们早就将人体商品化了，每一次移植手术，医生们都是拿着薪水在操纵着人体。那些获得和运输器官的医院和中介机构亦是如此。那我们现在为什么要反对给捐献者报酬呢？在整件事里面，捐献者才是唯一一个提供宝贵器官和承担所有风险的人。
At the heart of the “commodification” claim is really the concern that donors will not be treated with dignity. But dignity is affirmed when we respect the capacity of individuals to make decisions in their own best interest, protect their health and express gratitude for their sacrifice. Material gain, per se, is not inconsistent with this. The true indignity is to stand by smugly while thousands of people die each year for want of an organ.
诟病“人体商品化”，其核心实际是担心捐献者得不到有尊严的对待。但我们尊重他们有为自己做出最有利决定的能力，保证他们的健康，对他们的牺牲表示感激，这些就保证了尊严。物质上的获益，实质上与此并不矛盾。真正不光彩的，是眼见每年数以千计的人在等待器官中死去，却还站在一旁洋洋自得。
Some worry that that rewarded donation will attract only low-income people. This is possible, though only a trial project can provide the answer. But even if this turns out to be the case, why doubt the capacity of low-income people to make decisions in their own interest? From the standpoint of the recipient, it is low-income individuals who stand to benefit the most, as they are disproportionately represented among those waiting for a kidney.
有人担心奖励捐献只会吸引低收入人群。这是有可能的，但只有通过试验计划才可以得到答案。但即便事实就是如此，我们又为什么要去怀疑低收入人群基于自身利益作决定的能力呢？从器官接收者的角度看，受益最大的正是低收入人群，因为他们在等待新肾的名单上比例偏高。
Yet regardless of who ends up donating, any plan must ensure that donors’ decisions are thoroughly informed, their health is protected and they are amply rewarded. As the organ waiting list grows, the need to test incentives becomes stronger and stronger.
然而，无论谁来捐献，任何一个计划都必须确保捐献者在做决定前得到充分的信息，他们将得到健康保障和足够的奖励。由于器官等待名单日益增长，试行“激励计划”也变得越来越迫切。
We need to liberate patients from the tyranny of “the gift.” It’s glorious when you are the recipient, as I know better than most, but the penalty for being unlucky should not be premature death. Hollow moralizing from critics in the face of so much needless suffering must be replaced by sensitive and pragmatic policy.
我们需要将病患从“礼物”观念的思想束缚中解放出来。能得到器官捐赠当然非常美好，对此我比绝大多数的人都深有体会，但运气不好的病人也不应该就这样英年早逝。在如此众多不必要的痛苦折磨面前，批评者空洞的道德说教，必须被通情达理且切实可行的政策所取代。
翻译：龟海海
校对：小册子（＠昵称被抢的小册子）
编辑：辉格@whigzhou