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.]


Robert

I'm not sure if I fully understand the "repugnance" factor regarding kidney sales. If you can sell soft body tissues -- sperm, eggs, blood -- why the distinction for hard organs? Seems to me similar to the "culture of life" folks who see no problem with bombing innocent civilians but refuse to allow the destruction of embryos for stem cell research. Not only don't we have in this country universal health care but any broad-based agreement on what is medically ethical. Maybe an open organ-sale debate would be helpful.

Chris

@frankenduf:
Many Americans hate Iran because, to be honest, Iran hates us. Iran has some valid reasons to hate us (propping up the Shah, inconsistent policy, various attempts to destabilize the government, selling weapons to Iraq to prolong the Iran/Iraq war) but then again their hates lead to things like the Iranian Hostage crisis which caused us to hate them and back and forth. No one is really innocent in this whole thing.

@Panem et Circanses:
Several of the various methods of execution may end up 'ruining' the organs. I would think lethal injection would render most of the organs unsuitable for transplate, likewise with the gas chamber and electrocution. I think you'd have to either vivisect the condemned (you best method for organ collection really) or hang them. You could use a single shot to the back of the head like the Chinese do but a traditional firing squad wouldn't work out too well.

Read more...

Bob Aronson

I am a heart recipient. Don't be taken in by Dave Undis LifeSharers group. To date they have not saved one life. No LifeSharers member has given an organ to another member. Additionally, if LifeSharers is to have any effect they would have to sign up 85 percent of Americans. Right now they have 11 thousand members. Even if you double their current rate of growth it would take 250 years to get to a million.

I believe in trying something new but LifeSharers is not it.

Bob Aronson

Last August I received a new heart. I am one of the few, thousands just die waiting. People have been dying for years because there aren't enough organs and yet we hear all these arguments about new ideas that won't work. The old ideas aren't working either!

I'm tired of all the naysayers. All their opposition to new ideas accomplishes is to reinforce the status quo which is killing people. C'mon Americans, how do we know presumed consent or compensation won't work if we won't even give them a chance?

http://bobsnewheart.wordpress.com
http://www.facebook.com/group.php?gid=15612565382

Market Watcher

One way to improve kidney donations would be to appeal to those born with more than two. (One of my friends was born with three kidneys.) But an even bigger potential supply would be identical twins. Having 4 between them, they could easily give up one and still have 3 between them, one being the reserve backup in their later years.

(I haven't discussed this yet with my own "organ bank.")

Nicole

Another look into organ harvesting:

http://organharvestinvestigation.net/

Dave Undis

A market in human organs would save thousands of lives every year. Unfortunately, there is no reason to think Congress will legalize this in the foreseeable future.

Fortunately, there is an already-legal way to put a big dent in the organ shortage -- allocate donated organs first to people who have agreed to donate their own organs when they die. The United Network for Organ Sharing, which manages the national organ allocation system, has the power to make this simple policy change. No legislative approval is required.

Americans who want to donate their organs to other registered organ donors don't have to wait for UNOS to act. They can join LifeSharers, a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.

Read more...

Jayson

There has been a lot of discussion on this site about the possibility of exploitation if an organ market were permitted. By exploitation, I'm assuming posters refer to the possibility that indigent people will feel compelled by the financial incentives of the market to donate organs despite contrary personal preferences that would otherwise prevail. But nobody has mentioned a separate but related potential problem: that organs will go to the highest bidder. In a market system, it will be much easier for the rich to receive needed organ transplants than the poor. Even if prices are fixed in a regulated market, the rich will always be able to afford organs, while the poor lose out.

Panem et Circanses

If organs were harvested from executed criminals, the death penalty would serve a constructive purpose... and those executed might save more lives than they took. I know there are associated ethical issues, but why is letting innocent people die while useful organs of executed criminals go to waste the moral high ground?

Neal Martin

As a scholar of Harvard's Professor Roth (and of the unmentioned collaborator Utku Unver) I note that you are misrepresenting Professor Roth's work. Roth's work was on pairwise kidney exchange where no money changes hands. In Roth's work two potential donors would like to donate their kidney to their respective spouses but they are incompatible. However each donor is compatible with the other donor's wife allowing for mutually beneficial cooperation. The whole point of Roth/Unver's work was that it created an efficient mechanism for kidney-kidney bartering which is only useful in a legal framework which prohibits kidney-cash transactions.

typingmonkey

In typically ignorant American fashion, we indulge our intellectual and moral immaturity by insisting on living under the delusion that we lead clean, simple, puritan lives. We don't even want to think of anyone donating or selling an organ.
Until of course, the time arrives when we or our family members need one. At that moment, I have little doubt that every prudish critic will immediately start asking for an organ market, and will consider flying overseas to get to one. In other words, the rich can afford to live in denial, and then buy their way out when denial is no longer convenient. The poor had better reject denial now, for they will have no other options other than sober analysis and policy reform today.

John Heaney

It was only a matter of time until the comments opposing incentives focused on fairness. The magical, powerful word which has no concrete meaning.

Is it fair that over 7000 people die each year in a country of 300 million potential living organ donors. No.

Is it fair that black and hispanic dialysis patients wait the longest on the transplant waiting list. No.

Is it fair for paternalistic spectators to deny willing living donors the right to make their own decision regarding the donation of their organ for just compensation when we allow them to make the identical decision if no compensation is involved? No.

Is it fair that living organ donors currently have to bear the costs of missed work, vacation time, travel and their own follow up care? No.

The assumption of these sanctimonious obstructionists is that any transaction tainted by commerce will lead to exploitation. Without hearing details. Without consideration of the costs in human misery, suffering and death. Without any personal consequence to their imposition of their utopian fantasies.

Ethically sound incentive programs are entirely possible. The incentives can take the form of health insurance, long term care, tax incentives or credits, educational or housing assistance, or a variety of other suggestions that don't provide direct monetary compensation from rich patients to the perpetually victimized benighted poor.

We can even put minimum income requirements on living organ donors, though I don't want to be the one to explain to those who fall under the income floor why they are unable to make decisions for themselves.

We are a nation of innovators. This is a problem that can be solved in creative ways that ultimately result in reduced health care expenditures, significantly reduced suffering, transformed lives and regenerated families.

Just free us from the legal shackles that prohibit the testing of incentive programs that have the potential to restore the lives and families of tens of thousands of desperate patients.

Read more...

medical student

To Nathanial: I believe that UNOS moves living donors up on the list if they should ever need a transplant later. I know the transplant program at my school definitely does this.

Dave Undis

To John Heaney:

The UNOS transplant waiting list grows by about 5,000 people every year. Americans bury or cremate 20,000 transplantable organs every year. So getting more organs from dead people can reduce the size of the transplant waiting list. It would also reduce the need for so many live donors.

Organs are also needed from dead people because live donors can't supply hearts.

Patricia

If the US instituted a "presumed consent" rule, then the discussion of organ sales would be unecessary. Instead, non-profit organ donation organizations are forced to use resources that could go to other deserving groups to convince people to donate their organs when they die. If people are too squeamish to donate organs after death, what real chance is there for an organ market? We should be lobbying the government to include a presumed consent rule, not worry about an organ market that could have disastrous consequences for the poor. It is a much simpler solution!

Dan M.

I agree that presumed consent may violate the takings clause, so perhaps charities or the state may fill the gap? In cooperation with governments, charities can offer one-time compensation when someone chooses to become an organ donor. Or an upfront tax deduction? People may be more inclined to "donate," or de facto sell if the incentives were placed in the short-term. It would be a creative way to circumvent the National Organ Transplant Act.

Mac

The problem I have with the notion of a "regulated organ market" is that sooner or later the "regulated" part of the market will become target of market ideologists who will cite presumed inefficiencies or warn against possible market failures: One kidney isn't like the other, every kidney has an individual demand, therefore price regulations are flawed!! FLAWED!

So why couldn't we start to tackle the problem in a smaller scale? Allow health insurances to contract people for their organs after their death. Compensation could be in money or enhanced service if the potential donor decides to buy insurance to the company. Insurances with a large organ pool would be highly attractive for new customers and donors would benefit from their "altruistic" attitude in the here and now without scares.

Sara

@Dave -- I've never really understood the Lifesharers organization. If you end up needing a donated organ, it seems unlikely you'd be eligible to donate anything (except maybe your corneas) upon your death because of the disease/injury that caused you to need one in the first place. Therefore, the people who go to the trouble of signing up for Lifesharers then seem likely to be either: people needing organs who won't ever actually be able to donate anyway (and might not have signed up if they didn't need one), AND healthy people concerned/interested enough to sign up, but were probably already listed as organ donors via their drivers license, since that takes less effort than going to sign up for LifeSharers. Maybe I'm missing something?

michael donnelly

For the folks who object to presumed consent: do you understand that it means opt-out rather than opt-in, and that those with religious or other objects can still decline to participate?

I can understand any number of logistic concerns with a plan like this, but it clearly isn't inherently unfair to people who don't want to give up their or their family members' organs.

John Heaney

Although I commend Dave Undis and his Lifesharers organization (of which I am a member), my primary concern is that Lifesharers and the assortment of organizations devoted to paired donations do not - and never can - solve the underlying problem:

Even if we recovered the organs from EVERY person in the US who died under circumstances that allowed their organs to be harvested, we would not reduce the size of the transplant waiting list, we would only slow its growth.

This is the key problem that is currently being ignored by UNOS and the National Kidney Foundation.

The organ shortage problem can ONLY be solved by securing organ donations from living donors.

We all know this. Even UNOS and the NKF acknowledge this. But all efforts to increase organ donations are still focused solely on gaining marginal increases in deceased donors. This is insanity.

The Dutch performed extensive surveys that indicated that 15% of their population would consider donating a kidney if there were some type of incentives, e.g. health care coverage, to do so.

We only need to attract .025% of the US population to eliminate entirely the kidney transplant waiting list. Forbidding even the testing of the only solution that can save over 7000 lives per year is cruel and unethical.

An assortment of plans and discussions on the topic of market incentives to promote organ donation can be reviewed at www.organomics.org

Read more...