Kidneys for Sale?

There’s an interesting article about organ transplantation in today’s Wall Street Journal, by Laura Meckler. It’s primarily about a transplant surgeon named Arthur Matas who has been advocating for the legalization of kidney sales in the U.S. Despite much opposition in the transplant community, Matas has been making headway:

Appearing at a January meeting of the American Society of Transplant Surgeons, Drs. Matas and Delmonico each presented their thoughts on the issue. Afterwards, the audience was asked to take sides with a show of hands. The surprising result: A majority indicated they would support a trial to determine the viability of a U.S. organ market.

Dr. Delmonico, it should be noted, is Francis Delmonico, a friend of Matas, fellow transplant surgeon, and former president of the United Network for Organ Sharing.

Anyone who is at all interested in organ transplantation should read this article, if only to take the temperature of the issue. Among other things, you will learn that the legislation that banned organ sales in the U.S. was introduced in Congress by a representative from Tennessee named Al Gore.

I have to admit, the headline of the article was a little surprising: “Kidney Shortage Inspires a Radical Idea: Organ Sales.” While the idea may indeed be radical to many, this argument is hardly new. In a column about the economics of organ transplantation from more than a year ago, we wrote about a paper by Gary Becker and Julio Jorge Elias arguing that “monetary incentives would increase the supply of organs for transplant sufficiently to eliminate the very large queues in organ markets, and the suffering and deaths of many of those waiting, without increasing the total cost of transplant surgery by more than 12 percent.” (Here are more links about organ transplantation.)

Another problem with the Journal article: while it raises the common objection that poor people might be unduly pressured into selling a kidney, it ignores the logical flipside of the argument: what about all the poor people who need a kidney but can’t get one because there is no supply? In fact, you could argue that rich people have a larger advantage now than if a regulated market existed, since they have more options available — e.g., traveling to a foreign country to get a kidney — than disadvantaged people. So on average, a kidney market may well help the poor more than anyone.


Dave

If I were you I'd try to sort out some health care/insurance for the poor first, before worrying about their supply of spare kidneys...

...oh, and the old chestnut about "Aren't poor people also capable of critical thinking and don't they have the right to decide what they want to do with their own body?" reveals a complete ignorance of the kind of coercive forces that would be brought to bear on vulnerable people.

It is not patronising to recognise that many people in our society do not have the confidence to stand up for themselves and have never been given the opportunity to learn about scientific knowledge or how to assess complex medical information.

JS

While it makes economic sense it is still a very disturbing notion. On top of that, as you mention, free markets are not always fair markets.

zoe

Don't forget all the college kids who'll sell their kidneys to buy pot and booze (or textbooks).

kebko

JS, many would argue that placing someone else's organ in your body is a "disturbing notion". I hope we don't continue to let people needlessly suffer in order to protect your delicate sensibilities.

MM

It is a terrible idea. There may be some benefits but they are massively outweighted by the pitfalls. You will have an underground market of organs imported from poor countries. Women and children (and many men) live in slave-like conditions in many of these places and this would add to their misery. Forget poor people 'pressured to sell', you will have people robbed of their kidneys in poor countries.

kebko

Furthermore, is it fair to have to pay thousands of dollars to a surgeon, a hospital, months of unnecessary dialysis, etc.? What in God's name is fair about refusing to let the one transaction occur that would save lives in this picture?

D. Johnson

Is it more disturbing than having 4,400 die because they can't get a transplant? It may be disturbing to those of us who aren't facing death, but I bet it sounds like a great idea to someone who will die without a new kidney.

cheryl

You say that money incentives will increase the supply of organs? Forgive my ignorance, but where exactly is this supply coming from? Is the assumption that people who need money can start selling their body parts? As no one I love is waiting for a kidney, it might be easy for me to say this, but this does not sit well with me. I fear that the poor would be become pressured to treat themselves as organ farms and start hacking off pieces whenever they can't cover rent this month.

And, yes, I am sure there are poor people who need kidneys, but even if the organs were legally available on the open market, will the poor be able to afford them? Kidney transplants don't sound cheap so I am not sure the poor would benefit for their availability.

MM

@6 That is sort of a non-point WADR. Policy is not fashioned based on individual cases of distress. For example, if a member of my family is murdered, I may want the death penalty for the killer. But from a wider perspective, I may be opposed to the death penalty if I believe it is harmful to society in general.

RWG

If you're interested in organ markets and organ procurement, check out this book:
The U.S. Organ Procurement System: A Prescription for Reform (Evaluative Studies.) by David L. Kaserman

Toni

We live on an over populated planet as it is, and it's every man for himself survival anywhere in the world. Who is to say what any one human life is worth? Humans are not an endangered species. Allow organ transplantation, open it up to the free market (such as it is) and let competition determine the value of life.

Leslie

I think that donors should be reimbursed; they are the only ones in the current process who are expected to be altruistic (do the surgeons do their jobs gratis?), and in the case of living donors, the participant with the most to lose.

Why not test the idea with deceased donors, thereby eliminating the argument about poor people being coerced into donating and risking their lives? This could be done in just one of the regions over a five year period and then evaluated.

htb

I think the analysis is more complicated than that. For example, the analysis assumes that basically all kidney recipients receive Medicare. This is pretty much true (as a first approximation), but giving ESRD (end-stage renal disease) a special place in the Medicare program has always struck me as ethically suspect: You've got kidney failure, so everything's covered, but your neighbor, who is dying from heart failure, is on her own, plus she has to pay higher taxes to cover your expenses.

Therefore the real question is: Should the government use taxpayer money to buy kidneys?

In the short term, it could save the taxpayer money by reducing dialysis expenses (which could, of course, be reduced by treating ESRD like any other disease instead of enshrining it in a special place in the Medicare code).

In the long-term, who knows? For example, who knows how many of these sellers will be disabled by this, thus decreasing our net health value here?

I'd add a few more restrictions:

* The person selling the kidney needs to be middle-aged or older. This increases our ability to exclude people with kidney-destroying diseases, eliminates women who are likely to get pregnant in the future, and may reduce the likelihood that the seller's remaining kidney will give out (by reducing the post-sale lifespan from 60 years to a mere 40 years). It also eliminates the possibility of "I was young and foolish" regrets.

* I would categorically exclude any seller who has even slightly above-average risk for kidney failure. A history of healthy blood pressure and low risk of diabetes are non-negotiable criteria.

* The person selling the kidney can't be receiving government assistance, such as food stamps. This reduces the likelihood that the seller will be a person with limited education and limited access to healthcare -- and, relevantly, whose mistakes will be fixed by the government.

* The compensation should include sale-related healthcare for the seller.

* The compensation should be paid out in small sums over time, so that the seller isn't dazzled by the prospect of thousands of dollars in one fell swoop. I'm thinking that a non-assignable $500 a month for five years is better than a single check for $20,000 now. Besides -- for the purpose of the study -- people will stay in touch to get a $500 check each month, when they might not bother for mere scientific value.

* The transplant needs to be as nearly perfect a match as humanly possible. This will involve slightly different priority criteria, but these "extra" kidneys should go to the person who will be least likely to reject them.

Overall, this proposal still gives me the willies. I see way too much opportunity for seller exploitation, and way too little awareness on the part of potential sellers that this decision could actually kill them.

I'm also not sure that there's a willing market of sellers in the U.S. Would YOU sell a kidney to a stranger for $20K? $40K? I wouldn't, even if they would accept me.

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kebko

I find it disturbing how much egalitarian, anti-market, anti-wealth biases play into this debate. Supposed "ethicists" essentially are arguing that they support a system that kills thousands of people a year, because at least those people are dying regardless of their wealth. Practically all of these people would live if a market for kidneys existed, but we can't allow that because we can imagine a case where a few who still died might be disproportionately poor. It's a stark statement on the human costs people are willing to impose in order to support their egalitarian world-view.

htb: I wonder, do thousands of people dying give you the willies?

Silvansu

Support a market for stem cell grown kidneys. Problem solved.

John

I guess I really haven't thought about all of the implications of a "market for kidney sales." What I do know is that my father needs a kidney. He is on two waiting lists in Wisconsin, one of which could take up to five years to provide a donor at which time his health may prevent the transplant. The time for a transplant is now!

He is blood type O-, my sister and I are A+ which means we can't donate to him. We are both on a paired donation list which would arrange a double transplant (i.e., I give my kidney to an individual who's significant other donates to my father.) Sounds great but still a relative long shot. It's scary to think that there's a high likelihood that I, too, may need a transplant in twenty five years. If the marketplace is sound, it would make great sense to give up my 46 year old kidney (which probably has at least another 25 years left in it) to someone my father's age, so that 25 years from now I might benefit from the same.

So, yes, there are many dynamics at play in this debate. When it comes down to it, I'd just like a way to ensure that my otherwise healthy father can stick around long enough to see the weddings of his grandchildren.

My mom and I both blog about related topics at:
http:\\pegsponderings.wordpress.com
http:\\randomthoughts.johnmichl.com

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D. Johnson

@8: I would argue that policy is, in fact, fashioned based on individual cases of distress in many cases. Your point about the death penalty is an illustration of that: a relatively small number of people have family members murdered, yet the death penalty is legal.

Individual and collective beliefs may not always be aligned, but there are plenty of instances in which legislation is a response to the impact of something on a relatively small number of people.

My original point is that the notion of selling organs for money may be disturbing, but so is the notion that 4,400 people will die this year because they can't get something that lots of people would sell to them if it wasn't illegal.

Jeff

Being able to sell organs is a terrible idea, but not out of keeping with many American health care policies! One can argue that ideally all Americans would have medicare and so would all equally benefit from wider availability of kidneys, but that is simply not true. Even if the US did have full public health care (like many more civilized countries), the rich citizens would not be the ones selling their organs. My understanding is that giving away a kidney is still a very serious procedure and can lead to complications. This practice would essentially constitute rich Americans taking advantage and further deteriorating the already poor health of poorer Americans.

Ali John

This article sums up nearly every positive thing and addresses the negatives about organ markets. It should convince you to come to the side FOR ORGAN MARKETS. http://ecommons.library.cornell.edu/bitstream/1813/219/1/vh_fa2004.pdf (page 34)

htb

> htb: I wonder, do thousands of people dying give you the willies?

Frankly -- and speaking as a thirty-something woman with incurable leukemia: No. Dying is a normal part of life. Some hundred and fifty thousand people do it each day. Failing to reduce that number by (at best) a single-digit quantity does not particularly disturb me.

Encouraging a healthy person to take a non-trivial risk of death or disability just so you have a chance at postponing your own death is immoral -- especially if you're setting things up so that they're so dazzled by the money that they don't pay attention to the substantial risks. This isn't like donating blood (sale of which is also banned): this is a major, irreversible surgery with lifelong implications for the donor.

What could you possibly say to the family of a deceased seller? "Sorry to hear your dad bled to death right after the surgery, but I'm really glad to be off dialysis, and even after paying for the funeral expenses, you've got a few extra thousand dollars, so we're even, right?"

What about a seller who ends up disabled from the operation? "Sorry to hear that you ended up in constant pain due to complications from the surgery, and you've lost your job and your house. I'm doing really well and have a great new job lined up. Isn't life funny that way?"

How about if the seller's remaining kidney gets damaged? "Sure was nice of you to sell me the good one. Maybe you can buy one off of someone else."

I repeat: this is NOT a minor surgery. These situations WILL come up.

The ethical issues are very similar to self-defense issues. Are you familiar with the announcement that instructors make at the beginning of self-defense classes? "If you're not emotionally okay with the idea that you might kill your attacker while defending yourself, then you shouldn't be here."

I might be willing to kill an attacker, but I am not willing to kill a healthy, innocent person to postpone my death. Perhaps you are, but I am not willing to rate my life more important than someone else's.

Would I make some changes to our system? Sure. I'd make kidney donation at the time of death be normative. (We're really only short of kidneys.)

I'd provide massive support to diabetic patients and high blood pressure patients so that we didn't need so many kidney transplants in the first place.

I'd cheerfully pay substantial taxes to get a 'free' major health screening every five or ten years for all adults so that we could discover these treatable problems earlier.

And I'd make every person who wants to have a kidney-selling market read the reports about the Iranian kidney sellers. Six out of seven kidney sellers think that they made a huge mistake. Three out of four think would strongly discourage another person from selling a kidney. (Start with http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11586226 )

I really don't think we should ignore their actual experience in favor of "Gosh, it sure would be nice if the federal government would buy my way out of the hole I dug when I decided that taking my blood pressure pills was unpleasant."

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