<em>This is the fourth article in a WEEKEND series by Aishwarya Vijay. Taking the time to read intense science magazines and research so that we don’t have to, Aishwarya will be giving our faithful readers regular updates and opinions on the field, so we aren’t all taken by surprise when, like, the sun melts.</em>
I have a bumper sticker stuck on a wall in my room that boldly proclaims “Recycle Yourself”. I got it for free at a medical conference, from an organ donation booth, and I keep it for two reasons. First, it’s kind of funny in a quirky/ironic/almost hip way, and second, because I am a big proponent of organ donation. Last year, I finally convinced my parents to put a “yes” on the forms when they renewed their drivers’ licenses. It was a proud moment, guys.
Though adding two people to the pool may not make much of a difference, every little bit counts when there continues to be a huge shortage of organs. The waiting lists are numerous, confusing and decentralized, causing controversy over who is most in need of the very few organs that are available. For deceased donors, the shortage is, in part, caused by the United States’ opt-in policy, which meaning that you are presumed to not be an organ donor until you specifically say you are. This stands in contrast to the opt-out system used in countries like Spain. People have objected to the opt-out system because outside of the World Cup, nobody pays attention to Spain. Ok, ok… in all seriousness, people don’t like opt-out because it could potentially exploit people’s ignorance and unfairly take their silence as consent.
The discovery and development of live kidney and bone marrow donations were meant to alleviate this shortage somewhat, especially since kidneys are among the most sought-after organs. The first successful live organ donation half a century ago seemed like a godsend for those in need of kidney or bone marrow. Additionally, the success rates for patients who receive a live kidney transplant tend to be higher than those who receive the kidneys of a cadaver — 94% as opposed to 88%. But finding donors for live transplants has proved problematic. Transplants involve four to five hours’ worth of surgery, days of recovery and huge amounts of risk. Even for a family member, this is a big sacrifice to make, and few are willing to do so. Those who are might not even have the right histocompatibility or blood type. Granted, there are online donor networks that help people find matches and perhaps not have to wait as long on the list. But simply relying on the goodwill of strangers might never be enough.
About a year back, a US Appeals court passed a ruling that would allow live donors to be monetarily compensated for donating bone marrow ($3000! – and here I was donating my blood to the Red Cross). The issue of selling kidneys for money in the United States has always been a controversial one. Supporters cite countries like Iran, where selling kidneys for money is legal and, probably as a consequence, no waitlist for a kidney transplant. Also, we do accept the principle of paying for sperm and egg donations — so what’s with the line between those and organs?
Could there be a place for commercial transactions in this market? The shortage that comes from not having this incentive seems too big to ignore. Offering more of an incentive could really help. Nobel Laureate economist Gary Becker and Julio Elias estimated that a payment of $15,000 for living donors would significantly alleviate the shortage of kidneys in the U.S. Payment could be made by the federal government to avoid any hint of inequality in kidney allocation. Moreover, this proposal would save the government money since, even with a significant payment, conducting a transplant is cheaper than covering the dialysis that is now paid for by Medicare’s End Stage Renal Disease program.
Opponents of this idea point to the fact that selling kidneys could lead to a potential blackmailing — or even the creation of a black market (this sounds like a TV show that probably already exists on like, Showtime, or something). In Iran, vendors often back out of the deal unless they receive more money than originally agreed upon. But how about a solution similar to that of a sperm bank? It is centrally regulated by a tissue collection lab in each state department and at the national level by a tissue bank. It is also a less personal transaction, in that the donor does not necessarily have the opportunity to meet with potential recipients.
Others cite recipients of kidneys who insist that it was extremely important to them that they received the organ from someone who chose to donate it out of goodwill, rather than for monetary reasons. But this argument misses the point that those saying this are the ones who received the organ. It would be fair to say that if they hadn’t reached the top of the list, they might be humming a different tune.
As with most bioethics issues, one must also tackle the question of exploitation. Offering monetary compensation could potentially change the entire demographic of the kidney donor network. Low-income groups could become disproportionately targeted or incentivized to give up their kidneys. Although this is a fair point, it is one that doesn’t really hold water if we look at broader medical standards. Much of high-risk human research is done on these same groups because the money on offer is more appealing to them than other demographics — and there is currently no special protections in that world. True, research is not usually a life and death matter, but, at this point, the mortality rate for a kidney transplant surgery is quite low and comparable to other major surgeries. This is certainly not something to brush off, but, given the right information, a competent individual should be able to decide whether the monetary reward is worth the risk.
Another downside in implementing this policy is the inevitable disparity it creates between separate recipients. It changes a relatively altruistic system into a capitalist one. If you are one of the 1%, then you’re in luck, but the rest of us 99-percenters might not be even able to afford a kidney if this changes. It would be sensible to consider changes in Medicaid and Medicare legislation to include coverage for organ payment as well as the actual operation costs. This isn’t impossible to imagine — with the court having already ruled to make bone marrow a commodity, are kidneys next on the list?