Response to “Comment - Bold policy changes are needed to meet the need for organ transplantation in India”

To the Editor: We are pleased to see dialogue on the issue of deceased donor transplantation in India in response to our viewpoint publication that was critical of the lack of government investment and leadership in advancing deceased donor services. We emphasized, that unlike living donor transplantation which was advanced as a private enterprise in those with the ability to pay, the advancement of deceased donor transplantation will be dependent on ensuring that poor Indians who comprise the vast majority of potential deceased donors also have equitable access to transplantation. Dr Soin and colleagues point out that the cost of living donor liver transplantation may be lower than referenced in our viewpoint.1 Even so, at $24 000 USD the costs are still far beyond the reach of the vast majority of Indians. The authors are congratulated on the fact that 20% of their living donor liver transplants involved non-for-profit patients at a cost of $20 000 USD per transplant, that they work with charities to raise funds to help patients pay for their transplants, and that they train new transplant surgeons. Many in the Indian transplant community have made extraordianary contributions to advance transplantation. However, these efforts alone cannot overcome the system related issues the limit deceased donation which was the focus of our viewpoint. We reject their suggestion that Indians are unlikely to donate due to socio-cultural factors. We point to the high rate of cornea donations in India (38 per million population) as evidence of public willingness to donate.2 We understand that private hospitals recover deceased donor organs and that these organs are allocated through regional waiting lists. However, as shown by the stagnation in deceased donation since 2015, private hospitals alone will not be able to significantly increase donation because the vast majority of potential donors are motor vehicle accidents victims who present for care in government hospitals where there has been virtually no investment to establish deceased donor services.3 Facilitating organ transplantation for foreigners without transplant infrastructure in their own country may have helped the patients from neighboring countries, however, this should not detract from efforts to provide transplants for residents of India. Such transplants might be acceptable as part of the strategy to fund the advancement of deceased donor services. Our proposal to waive organ acquisition fees for organs used for transplant in poor patients is not unethical and is not different from any government subsidy to improve access to care in disadvantaged patients. Our viewpoint does not castigate the efforts of the Indian transplant community. We emphasize that there is much to be celebrated, but there is also an obvious and pressing need for systematic change to meet the tremendous need for transplantation in India. We look to the leaders in the Indian transplant community to urge government officials to take tangible steps to transform the current living donor system that narrowly benefits those with the ability to pay to a more inclusive system that benefits all Indians. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

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