To pay or not to pay - that is the question

In all the coverage of the recent debate about egg and sperm donation, there has been much said about whether or not egg donors should be paid. Arguments have been put forward on various points and counter claims made. However, in all this what seems to have been missed is that there are in fact two totally separate arguments which have become merged into one, namely payment and compensation.

The two very different questions involved here are really: To what extent should money be used to encourage women to donate? And, what is an appropriate and fair level of compensation for donation?

If it is decided that payment is appropriate and allowable then the issue of compensation is redundant. On the other hand, if it is deemed inappropriate to pay donors then the matter of compensation becomes germane.

These are separate questions which need to be considered individually as they have different assumptions and principles behind them. To lump the two into one question about payment is to confuse the very important issues behind each. If the HFEA (Human Fertilisation and Embryology Authority) consultation on donating sperm and eggs is to reach a sensible conclusion it is important that these two differing positions are separated and debated on their own merits.

If we consider the first point: To what extent should money be used to encourage people to donate? Those advocating payment for donation are usually arguing from the basis that there is a shortage of egg donors in the UK and that offering a measure of payment will help to alleviate this.

However, this argument begs a number of further questions that are worth exploring, such as: Is there a genuine shortage of willing donors? How much is money a deciding factor in whether a woman is willing to donate? What is our preferred motive for women to donate their eggs? And what other ways are there to influence the number of donors coming forwards?

If we look at the first question: Is there a genuine shortage of willing donors? Currently there is an insufficient number of women coming forwards to donate their eggs. It is tempting to assume that offering payment will change this because we are so used to linking performance with pay in business. We are often led to believe that money is one of the most important motivators of human behaviour, and so it seems natural and logical to link the payment of donors with an increase in the numbers volunteering. This is especially tempting given some of the experiences of other countries such as US and Spain who both pay donors, although on very different levels.

It is possible however, that there are plenty of willing donors out there but the message that (a) they can donate their eggs and (b) that there is a significant demand for their eggs, has not managed to reach them. Therefore it could be a problem of technique and application rather than payment. This could suggest that there may not actually be a genuine shortage of donors, just a lack of awareness among the general public of what can be done.

If we now look at the second question: How much is money a deciding factor in whether a woman is willing to donate? When egg donors come forwards for donation they are usually questioned during a preliminary screening process about their motivation for wanting to donate. Anecdotally, most donors that do come forward say that money has little or nothing to do with their desire and in many cases they would in fact be put off by the idea of being paid. Introducing money could therefore actually deter some of the more altruistic donors.

Offering money in return for donation also opens up the potential problems of the appropriateness of any particular donation and the possibility of exploitation. Money is likely to be of greatest interest to those who have the least, whether that is through unemployment, low wages or being a student. The question then arises as to whether these are the best, or most appropriate, women to target for donation. A situation could easily arise where a young woman comes to view multiple donations as a means of earning money and thus become seduced into taking risks that she otherwise would not. Questionable marketing practices might also lead to levels of inducement that could be classified as exploitation.

The third question: What is our preferred motive for women to donate their eggs? Currently the preferred option is that all donations, whether of eggs, blood or organs should be altruistic. A low level of compensation is paid so that egg donors are not significantly out of pocket and it is presumed that this level does not interfere with the altruistic nature of the donation.

Whether or not we should move away from the altruistic model towards a payment model is an ethical dilemma which should be considered carefully because once done it will be almost impossible to reverse. There has been a strong culture of altruistic giving in the UK for a wide range of causes and, whilst there is a growing trend towards commercialism in many fields, it is likely that many people would regret a further swing in this direction.

The fourth question: What other ways are there to influence the number of donors coming forwards? The problem of low numbers of donors coming forwards may therefore not primarily be one of lack of willingness or motivation for which more money is needed, but one of lack of awareness. Experience suggests that amongst the general public there is considerable lack of appreciation that it is even possible to for a woman to donate her eggs, and knowledge about how to go about doing this. It is therefore quite possible that by focussing on raising awareness and by channelling greater resources in this direction then more donors will come forwards without the need to introduce payment or compromise donors' underlying altruism.

If, after weighing up these four questions, it is considered permissible to pay donors, then the question of amount becomes important. There are two simple options here, either the price is set by the free market or the price is set by a regulator. Where a regulator is involved then it is important to determine the factors that will be used to influence the level of payment, bearing in mind that this is not compensation, this is payment for donation with the specific aim of persuading donors to volunteer. Presumably therefore the level should be set at whatever it takes to achieve this end - that of attracting sufficient donors - anything less defeats the primary purpose. Of course, if payment is permitted then the process can no longer properly be called 'donation'.

If it is considered preferable not to pay donors, only then does the question of compensation come to the fore, which at that point, must be restricted to compensation only and not contain an element of payment or persuasion.