Human Organs for Sale, Legally, in … Which Country?

Here is an oversimplification of a complex problem:

1. Thanks to the miracles of modern medicine, a sick or dying human being can receive a transplanted organ from another human being.

2. Some of those organs must inevitably come from cadavers: i.e., you can’t give your heart to someone else and still live.

But some transplanted organs can come from living people. Chief among them is the kidney: we are born with two but can live with one.

3. As the science has improved, there has been a huge increase in demand for transplantable organs. But the supply has not kept up with demand. The kidney waiting list gets longer every year, and every year more people die while still on the waiting list. The supply of kidneys from both cadavers and living donors is insufficient.

4. There are fewer cadaver organs than one might wish for because:

a) Traffic fatalities continue to fall.

b) Improved emergency-room care keeps alive people who in the past may have died.

c) Not that many people in the U.S. choose to be organ donors upon their death. (This could be significantly improved if the U.S. adopted a “presumed consent” rule, as some countries have.)

5. There are fewer organs from living donors than one might wish for because too few people are altruistic enough to undergo surgery and give an organ to someone they may or may not know and receive no compensation for said act.

6. Therefore, a movement is afoot to create a market for human organs in the U.S. whereby “donors” would be compensated for their time, trouble, and organ. There are many objections to this market:

a) Some say, for instance, that it would exploit poor people (although poor people are often the ones who need organs, which are currently not available).

b) Others say that such a market would be impossible to properly design and regulate (although this “kidney exchange” program, created by market-design expert Al Roth of Harvard, shows that one problem can have many clever answers). Also, compensation could come in various forms, ranging from cash to tuition to lifetime healthcare.

c) There seems to be a natural repugnance toward buying and selling human organs — illustrated nicely in this presentation by the economist Julio Elias, who has written with Gary Becker on a potential market for organs.

Considering all of these factors, it is hard to imagine that the U.S. will have an organ market any time soon. There is a fervent ongoing debate over our organ shortage, including an actual debate scheduled here.

While there has been some movement toward compensating donors in Israel and in Holland, there is just one country in the world that has apparently gotten rid of its organ shortage by creating a market. Before you read the name of that country in the following paragraph, take a guess. Now guess again, and again — maybe 20 more times.

Benjamin E. Hippen, a transplant nephrologist (and scholar) in North Carolina, recently published a paper called “Organ Sales and Moral Travails: Lessons From the Living Kidney Vendor Program in Iran.”

Yes, Iran.

“Although Iran clearly does not serve as a model for solving most of the world’s problems,” Hippen writes, “its method for solving its organ shortage is well worth examining.”

Here are a few facts from Hippen’s paper:

Insofar as the kidney procurement system in Iran can be characterized as a “market,” it is a highly standardized and regulated market with only modest room for negotiation. …

Vendors are paid in two ways. First, the Iranian government provides a fixed compensation to the vendor of approximately $1,200 plus limited health insurance coverage, which currently extends to one year after the exchange and covers only conditions deemed related to the surgery. Second, the vendor receives separate remuneration either from the recipient or, if the recipient is impoverished, from one of a series of designated charitable organizations; this amount is usually between $2,300 and $4,500. …

The most contentious disagreements in the literature regarding kidney vending in Iran have to do with the personal, physical, and financial consequences for vendors themselves. This issue is complicated by an absence of routine follow-up. …

Despite a flourishing kidney vendor program, biologically related donation has consistently constituted 12 to 13 percent of all donated kidneys, and that fraction has persisted in tandem with the rapid rate of growth in kidneys procured (without compensation to the donor’s estate or family) from deceased donors. …

I wrote to Hippen to ask what sort of reaction his paper has received. He said it has been received “cautiously.” One prominent transplant surgeon, he said,

… is reluctant to go out of his way to include Iran in the public discussion. While he has no quarrel with the paper that I’m aware of, he (legitimately) worries that it isn’t the whole story. I share the concern, which under the circumstances is not definitively answerable. The other concern, phrased in various ways, is that it is just unfortunate that all of this information is coming from Iran, for obvious reasons. Can’t do much about that.

People who are ideologically opposed to a market in organs, Hippen told me,

… don’t dispute the data, but deplore the example. I freely concede (and take pains to highlight) that a crucial moral failing of the Iranian system is that there is insufficient data on the long-term outcomes of organ vendors, and the data that exist suggest that vendors are disproportionately impoverished, which in turn may put them at long-term risk for kidney disease. The Iranian transplant professionals I corresponded with in the course of writing the paper share the concern.

When I asked Al Roth about Hippen’s paper — which he said he admired — he raised a separate point of concern.

Not only is the health and welfare of the vendors hard to quantify, Roth said, but it is also hard to get reliable data on “what percentage of patients with E.S.R.D. (end-stage renal disease) fail to get treatment, and how much this contributes to the absence of a transplant waiting list.”

These considerable caveats aside, here is what Hippen thinks the U.S. should make of the Iranian organ market:

The portion of the National Organ Transplant Act of 1984 which prohibits the sale of organs should be repealed. … Because so much is still unknown regarding how organ sales would work in the United States, individual transplant centers and organ procurement organizations should be permitted to experiment with how to implement a system of organ vending.

This proposal strikes me as rational and wise, though it may never be tried out here. The repugnance factor in this country, as Roth and Elias have pointed out, may simply be too large to overcome.

But if data, like justice, is truly blind, then it is probably worthwhile to look toward a country that many Americans hate in order to save the lives of the people they love.

(If you’ve made it to the end of this long post, you may be interested to know that I’ll be discussing this topic sometime shortly after 6 a.m. E.D.T. on Wednesday, April 30, on the new public-radio show The Takeaway.)

[Addendum: Here’s the Takeaway radio segment.]


Keil Boone

Ok well i feel that it is a good idea and Iran might look like they have a good plan, but the probability is that the program doesn't go at all like that. Saying that, i am glad to hear that Iran is taking steps this to help their people out. I feel the US should really focus on their health care program. I don't feel the presumed consent is the way to go about donation; this is usually what turns people away from being an organ donor. I agree with Michael above when he says that if a market is introduced to the US it should be financially and personally rewarding but at the same time it shouldn't get in the way of the moral aspects. The poor people would defiantly be in risk of abandoning morals and even risking health to make the money by donating organs. The marked would be highly monitored but I feel in the future we will be seeing this type of thing and I agree with it.

RZ

I think the "presumed consent" plan would work best.

Another reason why some people choose not to donate kidneys (or other organs) is the fear that they themselves would need that organ that they gave up later on.

Imo

Iran was easily my first guess. I don't know why this kind of thing would surprise people. It is a remarkably progressive country in a number of other ways. For instance, instead of throwing people with drug problems into jail, it offers them a drug rehab program.

David Damore

Heard of The Takeaway the other day.
Look forward to the podcast with your discussion.

mgroves

I was close...I guessed "Iraq"

Chris/Nashville

I like the idea of the buyer/receiver being able to compensate the seller/vendor with health care credits of some kind. The post barely touched on that, but it really peeked my interest. I think that the American public would be less disgusted by the sale of body organs, if the money paid would be in the form of health insurance or medical expense account. It could go into a savings account (can't be allowed to be a risky fund, but shouldn't be in a stodgy bank account) that is managed by an authorized financial institution & then money could be withdrawn solely for medical purposes. So $10K paid for a kidney could cover an individual or family for years. I would not buy insurance with this, but allow it to supplement insurance - or even hedge for someone who wanted to gamble & not buy insurance.

Mike

I guessed Iraq too! This is a great article by the way...

frankenduf

why do "many Americans hate" Iran?- or is that just made up?

Nathaniel

One of the problems in the US is that there is no standardized, "free", basic healthcare. So not only is there essentially no benefit (other than a warm fuzzy feeling) to being an unrelated living donor, you're also accepting a lifetime of personal health risk and higher insurance premiums for your trouble.

If you want random kidney donors to step forward (I'd certainly be willing to donate), you have to at least guarantee that any kidney-related health issues are covered for the rest of the donor's life, and that if a donor ever needs a new kidney they automatically go to the top of the transplant list.

Of course if you simply let the market do whatever it wants, you'll wind up with college-age kids selling kidneys for cash in hand, and then burdening the health care system with much higher costs later in life. It will be a great deal for the recipient and the private insurance company, since they get to externalize all the real expenses to the general public and pocket the profit up front.

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jared

I guessed right only because there was a very interesting documentary on (I think HBO... maybe) about the Iranian organ market. It's worth watching for sure.

Lloyd

"Presumed consent" is a figment of some socialist's imagination. To presume consent to any such act, in the absence of actual consent by a donor, is contrary to the laws of all - or nearly all - of the states in the U.S. Why? Because in every state, the corpse is the property of the estate, hence of the deceased, to be disposed of - guess how? - in accordance with the deceased's wishes whether expressed in a testimentary statement, in a pre-mortum letter of instruction to the executor of the estate, or in a death-bed oral instruction - allowed in some jurisdictions. In none of those states, therefore, is any sort of "presumed consent" lawful. In principal, legislating "presumed consent" by the federal government is unconstitutional as no authority for that power exists in the Constitution and, further, it is an area regulated by state laws. Such a law by a state government would fly in the face of the previous argument and would, arguably, constitute an uncompensated "taking", which is not allowed to the states or the Federal government by the Fifth Amendment.

Quite convenient for those who stand to gain financially from it: funeral homes and others to be compensated by the state (or Federal) treasury for their work, as well as the bureaucrats who will gain power and increase their work force to meet the "administrative burden" of the consequences of "presumed consent". Quite an imposition on the families of those who died without consenting to being a post-mortem organ donor, though. But, after all, what matters the rights of people compared to the convenience of the government and its parasites, eh?

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Spock

hmmm... so apparently, there's a giant conspiracy between politicians, funeral homes, and the mafia to legalize presumed consent. Huh.

Anyway... Although I think a regulated kidney market is a good idea, I have to admit that it may have the same results as when it was legal to purchase blood. The monetary incentive caused drug addicts and the sick to lie on the application. There was a serious problem with blood banks receiving large amounts of unusable blood.

Does a kidney market have the same potential for problems?

SM

It was buried somewhere in recent news that the transplant waiting list in the US is a big sham. The study found that many patients on the list were ineligible due to various health reasons but were still kept on the list to inflate numbers. Could this whole list be a big mess that should be cleaned up first?
Traveling to foreign countries to buy kidneys is also getting harder. Just today Philippines banned the sale to foreigners. I hope other countries follow this example.

Kevin

By the way, Marginal Revolution scooped you by two weeks :)

http://www.marginalrevolution.com/marginalrevolution/2008/04/financial-compe.html

Lloyd

We appear to already have prevented the formation of any market of any character, at least here in the U.S., for organs. If it is genuinely our purpose to help those who need organs - while concerns about creating a bloodthirsty self-seeking market are important - we need to keep in mind that without some incentive to donate organs supply will always be outstripped by demand and someone will die without a donated organ.

At the risk of being thought a cynic as well as a believer in vast and hidden conspiracies, doing something good is usually a less-compelling motive for doing things for the benefit of strangers, compared with being paid to do so. That apparent "fact of human nature" played a large part in creating markets in the first place; is that not so?

Kevin

I'm undecided about the markets idea, but I am a big fan of the "opt out" system, as well as implementing some sort of "paired exchange" system.

links and more explanation here:
http://blog.kevinmarkham.com/2007/11/kidneys-for-sale.html

Michael

Fair points all, but Levitt specifically points out in his book that providing a monetary incentive (healthcare, cash, etc.) can actually act to replace a moral incentive (help someone in need) or a social incentive (get rid of questions like "why haven't you provided consent on the driver's license?"). Freakonomics cites the example in the decline of blood donors when a monetary incentive is offered or when parents willingly took a 3 dollar penalty for picking their kids up late.

I am actually a supporter of the organ market, especially on the donor end. However, the way in which we go about it must create financial or personal incentives without destroying the moral incentives associated with it. Health care is likely one such way, but only because it minimizes the costs actually associated with the kidney donation. If the care is restricted to post-donation epinephral troubles, it is not creating a new financial incentive to donate, only adding benefits to that decision that prevent the costs (to short and long term health) from being prohibitively high. Think of it like paying someone's transportation if they are going to volunteer to babysit your kids. It encourages them to do something that they are already interested in doing out of goodwill. Donating a kidney out of goodness is easier if you know it won't harm you. Providing full health care outside of the organ area looks suspiciously like a bribe to a good Samaritan, who might be turned off by such a market mechanism.

The waiting list idea appears a bit more thought out; allowing someone to move to the top if they have a need for an organ regardless of whether it was the one that they donated would work better because it combines a personal incentive (not really financial) without damaging the moral incentive that is at its heart what encourages donations from the living.

I just think we have to be careful about creating a bloodthirsty, self-seeking market for something that people usually do out of the goodness of their heart. Instead, limit the costs associated with actually doing something good.

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Gordon

As a live kidney donor (last yr, to an unrelated HS classmate) I was delighted to see this breakthrough thinking on freer markets in organs. I gave mine (affectionately known by its recipient now as "Valdez") gladly and gratis, but have always wondered why so many needfuls are allowed, by govt decision/policy, to croak, every day, while waiting.

I'm not surprised that Iran is ripping off its citizens at $1200/kidney. The grey market worldwide is $30K ! Maybe we could buy some parts for our soldiers maimed by Iran-supplied devices.

Undis' link (above) http://www.lifesharers.org/ was fantastic, btw. I'm signing up for my remaining organs.

If you have read down to this post and are considering donating: DO IT ! I couldn't find a single donor online who regretted the whole experience. Standards for donors are broadening as tech gets better -- don't rule yourself out. I'm fat, 50s.

People give because of gratitude for all they've been given. That you?
http://www.csec.org/this_week_5121.htm

An academic look at this altruism is at
http://tinyurl.com/6b98qk

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Student

Why do people always seem to favor ideas that limit choice over those that don't? I find "implied consent" morally repugnant. Some people have religious or other reasons for the desire to keep their body whole after death. The fact that people prefer that over a decision that is actually made by the donor (and with which the state should have zero business meddling) is bizaare.

Wes

The general focus on 'repugnance' in this ongoing debate should be properly shredded as the straw man that it truly is. The issue of fairness is of far greater concern. Any allocation scheme that suggests that organs will be equitably distributed across diverse income groups is nonsense. An organ market amounts to nothing more than a system of extracting organs from those who need money (the poor) and making those organs available to those who can afford them (the non-poor). Charity arrangements will not overcome the disparities that will - with certainty - arise.

There are many many things that people are willing to pay to do, to see, to experience, or to have that are morally reprehensible. We should not accept a depraved economic utilitarian moral calculus as a meaningful mechanism for making moral decisions. This entire argument rests on the presupposition that the donors 'perfectly' understand the consequences of their actions and are capable of forecasting that decisions utility implications into the permanent future. Everyone should know such calculations are absolutely impossible.

We do not allow the sale of many things and for good moral reason.

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