Justified compensation or organ selling?
Experts debate plans to increase donation rates
Wealthy dialysis patients faced with a worsening prognosis and a long wait for an available donor organ are able to secretly contact a "broker" — a mysterious figure who can arrange to buy a kidney from a living donor in another country, and for a price, take the patient abroad for a transplant operation.
Impoverished young men and women in countries such as India, Jordan, and Iraq line up outside hospitals seeking to sell a kidney for a meager cash payment (often less than $1,000), their best shot at a better life.
A doomsday prediction of the future? Not at all.
An article in the May 27 issue of The New York Times Magazine1 detailed the complex and wide-spread international market in human organ trafficking. While illegal in almost every country in the world, organ selling flourishes in countries such as India, Iran, and Turkey, and benefits wealthy patients in countries with low organ donation rates, particularly Israel and the United States.
"A single transaction often crosses three continents: A broker from Los Angeles matches, say, an Italian with kidney failure to a seller in Jordan, for surgery in Istanbul," wrote journalist Michael Finkel in the article "Complications."
Desperate patients pay brokers hundreds of thousands of dollars to find a matching organ, locate a hospital in another country, hire a transplant surgeon, and pay the seller and seller’s expenses. The sellers are often paid between $1,000 and $30,000, but there is no written contract — because the sale is illegal — and there is no recourse for the patients if there are medical complications or, for the sellers, if the payment is not made.
Though condemned by every international medical association and outlawed in almost every country, some ethicists and even some medical professionals are questioning the current absolute reliance on altruistic donation of human organs for transplant, particularly with regard to human kidneys.
Given the crippling complications of kidney dialysis and the high number of patients who die waiting for a transplant, Radcliffe-Richards and colleagues,2 writing in a 1998 issue of the Lancet, call for a re-examination of the practice of allowing people to sell their kidneys. "Since most potential kidney vendors will never become unpaid donors, either during life or posthumously, the prohibition of sales must be presumed to exclude kidneys that would otherwise be available," the authors write. "It is therefore essential to make sure that there is adequate justification for the resulting harm."
Even though those offering to sell their kidneys are very poor, and thus face financial coercion in making the decision, removing the option for their consideration is not necessarily a more ethical path, the authors argue.
"[Critics claim that] poverty has so restricted the range of options of the very poor that organ selling has become the best, and therefore in effect, that the range is too small," they explain. "If our ground for concern is that the range of choices is too small, we cannot improve matters by removing the best option that poverty has left, and making the range smaller still. The only way to improve matters is to lessen the poverty until organ selling no longer seems the best option; and if that could be achieved, prohibition would be irrelevant because nobody would want to sell."
The increasing number of people needing transplant organs coupled with the very small number of available organs is leading many health care professionals — even those opposed to organ selling — to call for changes to the current absolute prohibition on compensation to donors.
In the United States alone, 6,254 people died awaiting transplants last year — 2,583 of those were kidney patients, according to statistics kept by the Richmond, VA-based United Network for Organ Sharing (UNOS). Between 1990 and 1999, the organ transplant waiting lists grew five times as fast as organ donations.
But even though some changes should be considered, allowing organs to be bought and sold as commodities should never be an option, many experts say.
"Does anyone think the well-off and the rich will be selling organs?" asks Arthur Caplan, PhD, director of the Center for Bioethics at the University of Pennsylvania in Philadelphia. "The poor would, of course, be the primary sellers. One might hope that in the United States, you might be able to find more humane forms of making a living than selling your body parts."
More people are not becoming organ donors in this country because of the inequities in access to health care between the rich and poor, Caplan argues. Creating a "market" that would allow wealthier people to "purchase" lifesaving organs from poor people who cannot hope to afford similar treatments only worsens the current situation.
"Arguments about equity would be more persuasive if those zealously pursuing markets had even spent a few minutes trying to insure access to transplants for the poor," he says. "The poor know they stand a worse chance of getting a transplant and this demonstrable inequity chills their altruism. Throwing some money toward them for their body parts does not solve the inequity-in-access problem in any way."
Compensation without buying and selling
However, there have been recent moves by several states to develop models of compensation that remove the economic "disincentives" to become an organ donor. In 1994, Pennsylvania passed a law creating a fund to support organ donation, says Howard Nathan, president of the Gift of Life Donor Pro-gram, the organ and tissue procurement organization serving Pennsylvania, New Jersey, and Delaware. Part of the law allowed people to donate a dollar when they renewed their driver’s license or when you register an automobile.
"Ten percent of the money was to be used for a pilot program to provide reimbursement to families for expenses of organ donors related to the funeral or burial or expenses not already reimbursed by the donor program," he explains. "The expenses were reimbursed directly to the funeral home or other organization, not directly to the family, because that would be illegal under federal law."
However, the Pennsylvania Department of Health stopped the pilot program because of concerns about its legality. Though the department has proposed alternatives, no other program is currently in place, he says.
"I think that is a shame because a pilot program would test the theory that, for some families — particularly those who are trying to bury someone — that [organ donation] is acknowledged by the state as an important gift from one person to another. Certainly, we feel altruism has worked pretty well, but in some cases, it may help families to feel that there is additional value in giving the gift to someone else."
Incentives to donate
Other states have proposed similar initiatives, for example giving tax credits to families of donors or establishing government-paid life insurance policies for people who agree to be organ donors, he adds. Pennsylvania also is considering a law that would provide tax credits to employers of people who agree to be living kidney or liver donors. The tax credits would be designed to offset the cost of paying the workers’ salaries while they take time off to have the operation and recover. "At this point in time, because legislation that exists really doesn’t permit it, many of these types of ideas have hit a brick wall," he says.
Nathan, whose organ procurement area has led the nation in donations since 1995, disagrees with the contention that legalizing organ sales would solve the transplant shortage. "I have met with thousands of families and, for the most part, they are motivated because this is what their loved one wanted," he says. "The transplant system, the way that it is, is not only ethical, but safe. The concern is, once you start mixing in financial incentives, that people would not disclose potentially important information about their medical history in order to donate. Right now, that doesn’t happen."
He also points to the rise in the number of living donors in the United States as evidence that people can be persuaded to donate without financial incentives. "If you look at the UNOS statistics, the biggest increase we had last year was in the number of living donors," he says. "We had 5,600 people nationwide who donated either a kidney or a part of their liver. That was a 16% increase over just the previous year."
Improved medical techniques — including a laparascopic procedure to perform kidney removal — has contributed to more people being willing to donate an organ while they are still alive, he says. "Fifteen or 20 years ago, it was only a relative — brother, sister, mother, father — now husbands and wives donate, friends donate, and there has been an occasional anonymous donation, where there is no blood relation. But, these are also the types of situations where you want to make sure that they are doing it for the right reasons."
In his experience, removing logistical obstacles will do much to increase available organs for transplant. For instance, part of the 1994 Pennsylvania law created a computer registry of people with signed donor cards; this eliminated a lot of confusion about whether a person wanted to donate or not.
And, the state instituted the concept of "routine referral." Hospitals report all deaths, regardless of age or cause of death to the regional organ procurement organization. The officials at the procurement organization then are responsible for determining whether the patient could be an organ donor and approaching the family with a request. "Since then, we had a 63% increase in donations," he says. Routine referral is now a mandated practice in all U.S. hospitals accepting Medicare patients.
But, even if everyone who is eligible to be an organ donor after their death agreed to do so, only 14,000 people a year would be eligible to be a donor, he acknowledges. "Right now, there are 80,000 people on the waiting list, so one of the things we are going to have to do is look at other options, this includes living donors," Nathan says. "But, we need to make sure that it is in an ethical and altruistic manner."
References
1. Finkel M. Complications. The New York Times Magazine. May 27, 2001; pp. 26-40.
2. Radcliffe-Richards J, Daar AS, Guttman RD, et al. The case for allowing kidney sales. Lancet 1998; 352:1,950-1,952.
Sources
• Arthur Caplan, Center for Bioethics, University of Pennsylvania, 3401 Market St., Suite 320, Philadelphia, PA 19104-3308.
• Howard M. Nathan, President, Gift of Life Donor Program, Delaware Valley Transplant Program, 2000 Hamilton St., Suite 201, Philadelphia, PA 19130-3813.
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