The Flesh Trade

We have a new “Freakonomics” column out in the current New York Times Magazine. (For a year, we wrote the column once a month), but we’ve just scaled back to once every two months.) This one is about organ transplants — specifically, how the huge success of transplantation in recent decades has created a surge in demand for donated organs, which are in very short supply, and how a variety of people (economists in particular) propose this problem be addressed. As usual, we’ve put up a page elsewhere on this website with various research documents and links. We also blogged about the subject here several weeks ago. Comments welcome.

Ken D.

I am not sure if we disagree on anything, pkimelma. Reverse mortgages may be relatively new, but sellable remainder interests are hundreds of years old. The type of arrangement you hang on the French may be less common in this country, but it is entirely possible and not unknown. It is also not necessarily unfair or unreasonable; the devil is in the details.


Hi Ken. I think we do agree then. My point was that organ trade is not enough like the French remainder model (it is more common in France than anywhere else if the Wall Street Journal is to be believed), else it would be a good precedent and example. LifeSharers is a good model, but without money involved, as far as I know. So, I do not see how LifeSharers can increase the pool at all. Even if you think that registering with LifeSharers will increase your chances, how many people think that way? That is, how many people worry about their organ needs in advance?


Most of the concerns listed in the posts here exist because there is no regulated market here in the US to compensate living kidney (and to a much lesser extent liver) donors.

The black market concerns would disappear immediately if there were a legal, safe and trustworthy domestic market for organ donation. The ideal regulated market would protect the health of the donor through extensive screening and post-operative checkups, would ensure that donors receive their full compensation, and would accept donations only from US citizens to avoid any criticism that the program is exploiting the world's poor.

Introducing market incentives appears to be the best solution to the ever worsening organ shortage. The number of recoverable organs from deceased donors will never satisfy the need for transplantable organs and can only be met by increasing the number of living donors. It's time to acknowledge the risk that these donors accept, compensate them accordingly and move swiftly to end the needless suffering and unnecessary deaths faced by those lingering on the transplant waiting list.



Let's also dispel the ridiculous objections positing 1) family members might pull the plug to get the cash for mom's organs 2) the compulsory donation of organs to satisfy outstanding debts 3) the extension of eminent (not imminent) domain to include a person's organs 4) the wealthy would be able to bid for organs thereby preventing the poor from obtaining transplants.

Now, one at a time:
1) doctors have absolutely no incentive - financial or otherwise - to hasten the death of any patient. Even if a family member were to receive payment for their relative's organs, there is no reason to believe that the patient's doctor would provide diminished care to satisfy the mercenary interests of the patient's relatives.
2) I just checked, and yep, we still have a Constitution that protects personal rights. There are no circumstances I can imagine that would provide any validity to this objection.
3)I just loved the conspiratorial extension of the Kelo decision to an individual's organs. It is neither imminent nor eminent.
4) the creation of a regulated market would preclude open market bidding for organs. We would not have kidneys for sale on E-Bay, but would provide incentives for donors to provide either a directed donation to a specific individual, or an anonymous donation to the next person on the transplant waiting list. Either way, all donors would receive the same compensation from the government or regulating agency and no individual patient would have the ability to secure an organ by paying more than any other person on the list.



Wow… so after reading all the responses, I have a few things to comment on:

1. “If someone, such as yourself, finds it morally wrong, then you don't have to participate in the market by either buying or selling organs. How about we let someone who has been waiting for months for a kidney (many people can live with 1) decide if it is moral. Why should'nt someone because they are poor or are in a ghetto be able to make such a decision? What are you implying?”

Moral decisions are not limited to a person selling their organs for money rather than donating through altruistic motives. Should an organ market open, there will indeed be a black market for organs STILL (this is a also a response to the person later on who says there will no longer be a black market). Why is this so? You can parallel this with current black markets. Why is there a black market for CD/DVDs/Clothing/etc when there are thousands of shopping malls, online stores, and flea markets? The black market will continue to exist because this in a way can cater to price discrimination and offer another market for unacceptable donors—who are these unacceptable donors? Not everyone with a kidney can donate. My father is dying every day before my eyes because I cannot donate a kidney to him. Why? Because I also have polycystic kidney disease and will be on a waiting list before I know it. To become a donor isn't simply a blood typing test and then a surgical procedure. It was a 2 month testing procedure for me before I was rejected as a donor because of my disease. Psychological tests, blood tests for STD's, genetic diseases, and any other immunodeficiency. There are urinalyses to test kidney function, protein levels, iron levels, etc. Then there's haplotype testing. You want BOTH to match… but 1 will do. So even if a person WANTS to donate, they can't necessarily donate. SO what happens to these people who need money and want to donate but can't? Black market. What happens then? People who opt to buy organs on the black market face numerous health risks, not knowing exactly what is going into their body and risking their lives in order to save them. Ironic, huh? It would become very dangerous. At the same time, to meet demand, there have also been rumors of organ harvesting in China where the black market is much more prominent. This would be a risk should a market open for organs in the US. So morally, there is more than just “donate for money or moral goodness”

2. The abuse of markets. “information asymmetry also can fail open markets. There are plenty who will prey on the less informed, as I am sure you well know.” No doctor will take an organ out of a person without making them well informed of the risks and regulations. The only way you would see this happening is in underground operations—black market?
3. “I think many, including myself, would find that a sold organ has moved donation from a noble cause to a commercial one. I would likely destroy my organ donation form if this were to happen.” A proposed solution that has been floating around the organ donation community has been to offer a government incentive for organ donation of a person who died. (Some sort of monetary compensation to the family/payment for funeral/tax breaks). Donating an organ is a noble gesture nowadays and is great and all. Making it a commercial gesture is not as noble sounding but at the same time, offering some sort of compensation does not make a deed evil. Saying you would destroy your organs rather than help a person in need is a little extremist sounding/martyr like. It's a little unnecessary to destroy your organs in order to make some sort of noble gesture. In both cases, a person in need is still getting help. The goal here is not to make saints, it's to save lives. Simply, get organs for those who need organs---BUT in a safe, efficient, manner.
4. “Why Not?, they recommended that instead of having to sign the back of our dirver's licenses in order to donate organs, it simply be changed to a requirement that we have to sign it if we DON'T want to become organ donors” yes, Why Not?is a great read—I took Nalebuff's class at Yale. It's a great idea, and Spain actually functions on an “Opt Out” system and it does seem quite successful. Keyword, SEEM. There is a lot behind the opt out system and it does seem like a great idea but It will NEVER pass in through the US Government for obvious political reasons. The question is, WHY is the Opt In system failing? –If you analyze the way it works, simply saying yes on your driver's license does not make you an organ donor. You need to talk to your family and make sure they know your wishes and if they don't agree with your wishes, you will need to make it known in a legal will. Even if you say “Yes” on your license, your family can say “No” when you're on your death bed and you will not be an organ donor. Simple as THAT. Thus, donors need to make their wishes known to their friends/family, not merely think it themselves and put it on a license.
5. “Think about the increase in health care cost”—Think about the decrease in health care cost. The most expensive people that happen to be draining Medicare these days are the people with chronic illnesses—heart failure, kidney failure, etc. Dialysis is incredibly costly—about $800/session and a kidney patient will require a session every other day for the rest of their lives. A solution to this organ shortage will greatly decrease health care costs. If you ask any doctor, a kidney transplant vs. dialysis, the doctor will say kidney transplant for cost reasons and quality of life reasons. And a side note, Medicare/Social Security are predicted to run out in 2031/2021. Consider THAT dilemma.
6. “I think education and awareness are much more important than opening up the market.” I completely agree: If people realized what donation accomplished and the advances nowadays—kidney donors can be in and out of the hospital in 2 weeks for the operation and be back to themselves. The operation is much less invasive and much more efficient nowadays. Technology is amazing.
7. “of course over time , the organ market will fall – i'm guessing due to development to cheaper artificial substitutes and picky recipients – perhaps in the future an ailing british millionaire would prefer an artificial kidney instead of an actual one from a cas-strapped cowherd in africa…....” They will fall should the technology get to the level that it's predicting nowadays (read the nytimes article about Anthony Atala and his developments at WFU in growing organs from patients own cells). Should the market fall, oh well, the point of the market is to help fix this inequality in supply and demand right now in organ donation, not to turn a profit.
8. My thoughts on a solution? 1. Create a national waiting list and a national donor list because many people who want to be donors are not able to voice their choice—a drivers license simply is not enough. With a national donor list online, any hospital who receives a patient/potential donor can see whether they are on that list and determine whether the person has chosen to be a donor—this will save a lot of the organs that are thrown away (because when a person dies, their organs are only harvestable for a short amount of time before they become unusable and the time to transfer the organ to a recipient is already high and to add additional time in trying to contact someone to determine whether the person is/is not an organ donor costs us many donors). Then, I believe offering a tax break/health insurance incentive to families of donors AFTER a person is determined an acceptable donor would serve fair compensation (think of this as medical returns for lowering medical costs that would be incurred should the recipient require other medical attention from lack of an organ). OR the family could receive free funeral service for the deceased loved one, etc. This would not be a cash benefit but rather a semi-physical benefit of lesser liquidity which would discourage (but not necessarily remove all cases of) people from selling organs for money. 2. Put more government funds towards stem cell research and organ research to promote development of artificial organs because the technology is there and that is the best solution possible for cost as well as meeting needs (from the ability to tailor organs to individuals). 3. Educate people on organ donation. Thousands of people die annually. Everyone can donate, but there are too many myths out there that people buy into and with a lack of education, fear persists and there is a lack of donors. Awareness changes things… Education is one of the key fundamentals in progress everywhere. That is one fact that can't be refuted.



I note that the last two posts have focused on government run and maybe subsidised "markets". This is quite different from an "open" market, since it does not find the price based on willingness of the buyers to pay and sellers to sell at.
A regulated system which then also provides some "compensation" is a different story. It still raises questions about whether someone needing an organ can buy their way to the top of the list (black markets do exactly this of course).
I agree that a system which pays compensation to the donor's survivers will work just fine, since it is not a commercial transaction. In some sense the adoption system sort of works this way. The people adopting pay agency fees (to keep the system working) and the women giving up their child usually are at hospitals where their bills are paid for by medicare. In some states, when women/girls indicate they intend to give their baby up while pregnant also get prenatal care. So, this kind of heavily regulated system which detaches the buyer/seller works when dealing with "moral" issues.
Do not get me wrong. I am not trying to be a prude, but simply looking at how society deals with death, organs, etc. I am well aware of the suffering of those people and their families who are desperately waiting for an organ (I worked in a hospital for a while). I certainly agree that we need to do something. Opt-in will work since most families will not go against their loved one's wishes. The problem today is getting those loved ones to make a decision to say yes when they just lost someone, since there were no wishes stated anywhere. They are grieving and thinking about body parts is not what most survivers want to discuss minutes after losing someone.
I also agree that education is a big step. Public service announcements would go a long way here.
Finally, as to donations from live people, I think you need to be careful if you assume all doctors are concerned with such patients. In a truly open market, there will always be licensed doctors who work with "brokers" for a cut. They will not violate the law, but they will not be as worried about the donor as you imply. This is seen in India and other countries today. I would love to be wrong about this, but if you think poor people are not taken advantage of by the less scrupulous, you need to open your eyes. I am not implying that poor people are stupid, but desperate people with less information (most will not have strong medical and science backgrounds and most will not be that well informed about health implications of giving up half of an organ pair) will not always be in the best position to make a fully informed decision. This is why the poor are more prone to being ripped off and overcharged in other areas.



I think a big reason it is illegal is that the insurance companies don't want to pay. It would probably cost at least $50,000 USD for an organ and $100,000 USD for the operation. If there are 3,500 people each year dying each year it is much cheaper to bribe the politicians, I mean um donate, than pay for the operations.


Everyone is trying to increase the supply of organs. This method or that isn't particularly interesting. What no one seems to question is why is the demand so high? Kidney donations went up 45%, but demand for kidneys went up 119% in 10 years. It seems to me that organ transplant is the medical equivalent of tickle-me-Elmo, everyone wants one BECAUSE its scarce. You think this doesn't matter because you think of the organ waiting list like its a queue, with the teller yelling out "next!," but it doesn't work like that. If someone who really could live a lot longer with their own organ but gets listed and an organ pops up that is a very good tissue match, that relatively healthy person will get bumped ahead of others. So potentially, it is not the lack of supply, but the increase in demand itself that is killing people. The other reality is that some people on the list will never get an organ because they aren't necessarily medically stable enough to survive the operation. Before trying unorthodox methods to increase supply, one must really ask if this would mean lives would be saved. This can not be done without examining who comprises the increase in demand.



There are several reasons explaining the increase in the number of people waiting for kidney transplants:
1) the increase in hypertension and diabetes among the overweight population
2) the introduction of new immunosuppressants that allow transplants in more cases
3) improvements in dialysis technologies that allow patients with renal failure to live longer

As the recipient of a kidney transplant myself, I can assure you that those waiting for a transplant aren't in it for the novelty and attention. We face a lingering death if the spply problem is not resolved.

The average wait for a kidney right now is 5 years. In 2010, the average wait is projected to be 10 years. Since the average mortality for those on dialysis is only five years, the current crisis will become exponentially worse in just a few years.


Nothing could be more ironic than a relatively well-off American dying for lack of a kidney transplant. Nature, thanks to it's love of redundancy, has created a kidney glut, not a shortage - there are nearly twice as many kidneys as anybody really needs.

I think the repugnance has been overstated, it's more a product of fear. The largest benefit anyone could obtain from giving an organ (with or without payment) would be a general guarantee that any donor (paid or no) instantly takes precedence over anyone else for an organ if they need one later; plus an insurance policy that yields more than enough money to pay someone else for an organ later.

It's habit more than real irrationality that keeps the kidney glut going, while patients die. Money overcomes irrationality quickly, and even habit - but not reasonable fears. So very strong legally binding insurance (not bland assurance) has to be given of the organ provider.



The first step toward market-based organs would be for living donors to demand full insurance coverage and preference on the waiting list in case of failure of their remaining kidney.

After that, the toe is in the door.


Several good points where brought up in the article, each of them with there pros and cons. In todays free market society, everything is for sale, including organs. Though not legal the sale of black market organs has become a huge market overseas. That market will only continue to grow as the waiting lists get longer and longer. The program LifeSharers offers an intersting, and legal alternative to the black market. You agree to donate your organs when you die, and in return you increase your chances of getting an organ if you ever need one to live. Possible, America runs on incentives, a what better than one that could save your life.

Gord Wait

I also think it is a dangerous thing (ie ripe for abuse) to have a cash value market for organs, and it could be unnecessary.

Aren't there a number of countries with an "opt out" donation system rather than the "opt in" system found in Canada and the US? It was my understanding that this would greatly increase the supply, bringing the effective market value to zero.

Most people don't care either way, but don't get around to opting in, just like they don't bother putting together a will.


Not having read the article, but when you mention unmet demand with limited supply, could this be from essentially a fixed price in the market? Simple supply and demand curves show that fixing a price below where the curves meet, a shortage will appear. Since, the price one can sell one's organs is zero, we have a shortage. Could'nt this problem be solved by allowing an open market for organs?


>> Could'nt this problem be solved by allowing an open market for organs?

Besides the moral issues, you then create a market which is open to abuse. Imagine the doctors asking you if you want to disconnect Aunt Sally now, since the value of her organs has gone up this month. Imagine the kind of market as in India where Doctors go into ghettos and offer money for organs (from living people)...


If someone, such as yourself, finds it morally wrong, then you don't have to participate in the market by either buying or selling organs. How about we let someone who has been waiting for months for a kidney (many people can live with 1) decide if it is moral. Why should'nt someone because they are poor or are in a ghetto be able to make such a decision? What are you implying?


The opposition to payment for organs usually is expressed as fuzzy moral arguments which, in my mind, reflect a misunderstanding of markets and misplaced morals. Of course a market for organs is a good thing, in the same way that a market for food - another life necessity - is a good thing.

However, there is a legitimate argument to the contrary. It's possible that if a low price is set for organs, the supply could be reduced. I'm thinking of an analogy to the Haifa day care center result. (Discussed in the D&L's book, in which a fine for late pickup resulted in MORE late pickups.) The argument is that an economic incentive can displace a moral incentive.

I don't believe that this would occur in the organ market - but it might. I think that this is what some of the organ market opponents really mean when they give their muddled ethical arguments.


Markets are subject to abuse when people have unequal baragining power. This is another form of information asymmetry. The poor people who sell their organs are likely not well protected in terms of information (consequences of selling an organ for example) and do not have much bargaining power, as these are not "open" markets. A truly open market at least would make pricing clearer. But, as is seen in much real estate lending abuse (and other lending abuse), information asymmetry also can fail open markets. There are plenty who will prey on the less informed, as I am sure you well know. I suppose, like adoption, this would settle after some number of years due to regulations being created after enough abuses are made public.

The other side of this coin is that making a market for this is likely to severly reduce organ supplies. I think many, including myself, would find that a sold organ has moved donation from a noble cause to a commercial one. I would likely destroy my organ donation form if this were to happen. I would like to believe that offering my organs upon my death is not just another transaction, like selling a car. Perhaps others would feel different, but I think this is not like selling food at all. It is not even like the French house sales-on-death thing (where someone pays an old person money now, betting they will die soon).



In the book, Why Not?, they recommended that instead of having to sign the back of our dirver's licenses in order to donate organs, it simply be changed to a requirement that we have to sign it if we DON'T want to become organ donors. This would massively increase organ supply without denying anyone's rights.


I see. That sounds like fancy talk for, Indians are too stupid to make such decisions for themselves. God forbid they try to improve their conditions by making money. Plus, the reduced supply thing makes absolutely no sense to me. Simple supply & demand tells you without price fixing, the supply line will rise to meet demand intersecting with a market price. Sure, some dumb Indians may get screwed in the beginning, but as others come in to make offers, they will have to offer an advantage over the rip off organ people you believe will be covering the country. As far as nobility, I think it is safe to say that more people can be motivated by money than nobility, or we wouldnt have the shortage in the first place. Now, if you took any state organ program, and added an incentive where your estate or surviving spouse will get $5000 if you donate your organs, I am sure you will see membership rise. In the end, you will see more people receiving the organs they desparately need. Isn't that the morally correct thing to do?