Monday, October 25, 2004
Cash-for-Organs: An Eye for an Eye, A Lexus® for Your Liver? 
by Lenka Reznicek [permalink] 
Or is it more like the desperate call in Richard III: "A horse! A horse! My kingdom for a horse!"? While organ transplantation technology continues to improve, and the medical procedures involved grow less costly, one limiting factor still constrains the organ transplantation system: there are simply not enough available organs to go around for all who need them. Prof. Gary Becker of the University of Chicago Economics Department describes the organ crunch:
It is essential to find ways to raise the supply of organs and ease the suffering and long wait that many sick persons now endure. That delay can cost lives: Almost 70 persons die each month while waiting for livers to become available. The waiting period varies enormously from state to state. Transplant candidates may receive a liver in less than two weeks in Kansas, while in Massachusetts they can languish for nearly two years.

Political jockeying among hospitals is the reason for this regional discrepancy in waiting times. Livers are allocated to patients in descending order of degree of sickness in the regions where they become available, even if patients in other regions are more likely to be helped, because smaller transplant centers fear that they would be shut out of a national allocation. Although a national system would reduce regional discrepancies in waiting times, it would not close the growing gap between an increasing aggregate demand for liver transplants and a flat total supply.
Prof. Becker has an intriguing working paper that calculates the costs of financial compensation to organ donors; it clearly demonstrates that paying donors would result in benefits to all concerned. It's available for viewing at his website, and I've provided the direct link to paper below.

The bottom line is that until we can develop new ways to produce replacements for failing hearts, lungs, kidneys and livers (as well as agree on the ethical considerations of controversial future methods such as therapeutic cloning) those seeking transplants are basically at the mercy of altruistic individuals willing to donate organs upon their death, or those rare souls who will give up an organ for a family member of stranger with a compatible tissue type.

Yet, there may be a simple way to help loosen those constraints - but unfortunately, many people think it's unethical or simply too ghoulish: offering financial compensation to living organ donors or the families of deceased donors. I've written before on the reasons I am personally opposed to human reproductive cloning, so it may surprise some readers that I feel a system of financially compensating organ donors is a good idea. Let me explain why I think so.

The idea of people selling their organs for money conjures up specters of inhuman exploitation, but when it comes right down to it, what exactly is it about the economics of trading human organs that bothers so many? I've come up with a few reasons, but there are undoubtedly more. All these arguments pose valid points, but there are existing examples in each of these cases which are generally accepted parts of the health care system:
  1. "It will lead to people being seen as means to ends rather than ends in themselves, as mere commodities to be bought or sold."A "cash for organs" arrangement could in some way lead to organs being seem as commodities, but aren't organs already seen as commodities by both transplant recipients and the medical system? Doctors, hospitals and insurance companies all receive above-board payment for transplants, but only the donors themselves are expected to shoulder their burden without compansation. Are organs not, in a true sense of the word, "medical supplies" that can only be obtained (or "manufactured") from human beings? It would seem to me there would be less - not more - commodification of organs if there were a systematic, consistent, fair and 'above the table' means of paying donors as well.

    Since the demand for organs is unlikely to drop, if the supply of organs rises their relative dollar (but not life-saving) value should fall. As this article mentions, an unregulated sub rosa network of party-to-party or brokered organ sales may arise or already exist if the critical organ shortage continues unabated - and all black market systems thrive on exploitation.

  2. "People should only offer organs of their own free uncompensated will..." There are many instances where living persons are financially compensated for tissues or body materials, such as sperm and egg donations, surrogate gestation, or even blood. While the cash-for-blood system tends to attract the indigent (and often unhealthy) I would argue the fault lies more in the nature of the businesses running blood-purchasing operations than the basic fact that compensation is offered. In the cases of sperm and egg donations, egg donors are compensated more than sperm donors because the donation procedure is far more time-consuming and invasive than sperm donation. Remember that like blood, semen is a replenishable resource - but while women have thousands of latent ova they could never use during their childbearing years, like kidneys or corneas, eggs are non-replaceable body parts.

    Certainly, ethics would prohibit donation of an organ if its removal would cause serious harm or death to the donor, regardless of compensation. No reasonable person would approve of a living individual donating their heart, for instance, no matter how much money their surviving family was offered in return. Considering that something like blood is a renewable resource, and requires minimal sacrifice on the part of the donor to provide, would it not seem at least fair to compensate people willing to undergo surgery, the pain and inconvenience of recovery - as well as the prospect of life without one or more vital organs - something in return besides that "warm feeling" of altruism?

  3. "The standard of medical care one receives shouldn't depend on economic status..." Ahem...there's no good way to say this, but for better or worse, unless we instituted a government-administered socialist-type medical system, standards of medical care will always in some way be connected to a patient's ability to pay. Even with robust insurance networks for the poor, or charity-based health care, expensive heroic measures like organ transplantation are a rarity for lower-income people (see "Barriers to Cadaveric Renal Transplantation Among Blacks, Women, and the Poor," by G. Caleb Alexander, MD and Ashwini R. Seghal, MD) - and unfortunately, socialist-type managed health care systems tend to "minimize the maximum" level of care, rather than the reverse - making expensive complex procedures like transplantation less available within the system overall.

    Developing a legitimate "money-for-organs" system should in no way increase the capitalistic nature of our current medical system, since currently a patient's likelihood of receiving a needed transplant depends not only on pure luck and ability to generate publicity, but their ability to pay for the surgery and followup care. As mentioned above, leaving underhanded organ 'sales' to the black market will inevitably lead to more, not less, inequity in allocating available organs, and likely a lower standard of care.

  4. "No person has the right to sell their body or its component organs for anyone else's use..." See #2, above.
Which raises the question: how would we select and pay donors for their contributions? Should we use a public or private system? Through private party-to-party contracts, or some type of auction system? A government clearinghouse concept? By creating local, state, or other organizational registries?

Speaking of registries, one of the main problems with the existing organ donation system is the difficulty of matching compatible donors and recipients because of the relatively small amount of extant tissue-typing information. It's likely that enacting a donor compensation system would prompt more individuals to be tissue-typed as potential donors, expanding tissue databases and increasing the likelihood that compatible organs could be secured in time to save patients' lives.

Perhaps we could avoid some of the unpleasantries of a "cash-for-organs" system by using alternative forms of compensation. What if we compensated donors with a fixed dollar amount of state and/or federal income tax amnesty (but not amnesty by years or percentage of income, since this would undercompensate poor and unemployed individuals), a fixed dollar amount of student loan forgiveness, or a fixed dollar amount to be paid to a retirement annuity of the donor's choice.

Of course, the fixed dollar amounts would need to depend on the organ(s) donated, whether the donation was made from a living donor or post mortem, and some type of formula would need to be used to calculate the risk of the donation as well as subsequent complications and health risks. We also run into the difficulty of how to compensate post mortem donors - do we provide compensation in advance with a contract to donate organs upon death (and risk paying compensation to an individual who may die with their organs in unusable condition), or do we arrange some type of survivor benefit to the heirs of deceased donors? What do you think?

UPDATE: with a pay-for-organs system, we could avoid nonsense like this.