by Tejas Desai, MD
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This story begins as so many others in Nephrology often do. Mr. JC is a successful 43-year-old entrepreneur; a loving father and a devoted husband (1). He appeared to be living a wonderful life, but Mr. JC had end-stage renal disease, and had been receiving dialysis for three years. In those three years, he saw his business slow down, involvement in his family decrease, and his health deteriorate. After three years of dialysis, of his life not improving, and of no available donor kidney, he decided to place an ad in his local newspaper. He wanted to purchase a functioning kidney for $10,000. A psychiatrist would screen all potential donors, and those that were considered mentally competent would be eligible. To his delight, he received 200 replies to his initial advertisement, but one was from his physician. He was told that he made an illegal request and that he (the physician) would not transplant a kidney obtained in this manner. This angered Mr. JC, who felt that it was his right to purchase a kidney if someone was willing to sell his or hers to him. If the donor was of sound judgment, acting of his/her own free will, and the recipient was willing to pay a mutually agreeable price, neither the physician nor the government should interfere. Being a law-abiding citizen, Mr. JC agreed to place another ad in the newspaper apologizing for leading anyone into an unlawful contract. He resumed his dialysis while waiting for a donor kidney.
In recent years the AMA’s Council on Ethical and Judicial Affairs (AMA-CEJA) has begun considering the dilemma that patients like Mr. JC face (2). The AMA-CEJA is concerned that organ supply is not adequate to meet organ demands. At the turn of the century, 65,713 patients were on transplant waiting lists; a list that grows 16% each year (3). That amounts to one patient added to the list every sixteen minutes (4). Unfortunately, the number of available organs has remained relatively steady each year, and each year the gap between organ demand and organ supply widens.
With such disparity between supply of and demand for organs, the AMA-CEJA considered the idea of paying potential donors for their organs. It seemed that paying for organs was a good idea. As with other commodities, paying more for an item can increase the supply of that item. This principle has been proven true in the past, and seems sensible at a time of donor organ shortage. So why haven’t we enacted such a policy? Let’s carefully consider why organ commerce would fail.
The patient in our story would uniquely benefit if organ commerce was legal. Although he had end-stage renal disease, had been on dialysis for three years, and his overall quality of life was deteriorating, he was fortunate to have $10,000 to purchase a kidney. In fact, one can generalize that wealthy individuals are better able to afford various luxuries of life, such as exotic vacations, owning expensive automobiles, wearing designer clothing… and in the case of Mr. JC, a donor kidney. As a person who believes in capitalism, I am in favor of people having luxury. Going on vacation, driving a fancy car, and wearing expensive clothes are luxuries that most people want. Although debatable, most Americans don’t believe that receiving adequate health care, including organ transplants, is a luxury. If organ commerce was legalized, people like Mr. JC would find a donor kidney, but less fortunate individuals would not. The less fortunate simply could not afford the high price for a donor organ. This would mean that a large portion of the population would be excluded from receiving organ transplants. Many Americans would view this as an unfair exclusionary practice because adequate health care should be given to all people, whether they are financially fortunate or not. Simply put, a person’s financial status should not affect whether he/she can receive adequate health care, including donor organs. The “unlucky” ones would have great difficulty procuring an organ to save their life. Ultimately, this new health system would transform the nature of adequate health care – from a right to a luxury.
Now let’s revisit Mr. JC’s initial organ request. He stipulated that all potential donors would undergo psychiatric evaluation to assess their degree of competency and whether they were acting of their own free will. If the potential donor passed the psychiatric evaluation, he would feel comfortable entering into a contract with that person. The purpose of the psychiatric evaluation was to ensure that the potential donor would not be exploited in the organ – money transaction. Unfortunately, the same precautions that Mr. JC wanted to use would not be used in other countries providing organs for cash. Take, for example, the case of nations that execute a large number of prisoners (5). According to documents, the organs of those prisoners are harvested, without their prior consent, and sold to the highest bidder – usually a foreigner who is frustrated with the long wait for organs in his/her native country (5). Also consider that, in these same nations, documents suggest that hospitals frequently harvest organs from deceased patients without their prior consent or consent from their family (5). If organ commerce was legalized, the number of offers from foreigners wanting to pay for organs would increase. This would mean more business for the “foreign organ harvesting industry”, but would necessary precautions be taken to ensure foreigners are not exploited? In nations with poor human rights records, and/or those that harvest organs without the patient’s consent (prisoner or citizen), I believe that precautions, such as psychiatric evaluation, would not be implemented. These nations would view humans as organ receptacles rather than as people. Humans would be more valuable if they were gutted for their organs than if they were kept whole. Under a new system of organ commerce, the old saying that “the sum is greater than its parts” would no longer be true. The supply of organs may or may not increase, but the exploitation of humans would be more prevalent.
Quickly glancing at the idea of paying potential donors for their organs, one would think it to be a good idea. Offering a financial incentive to potential donors should solve the shortage at a time when the demand for organs is increasing faster than the supply (demand increases 16% each year, while supply remains steady). However, there are great inequalities and exploitations that are apparent and demonstrate real flaws in this idea. Still, the question remains as to how the medical community can increase the supply of donor organs.
1. Davis RM. Meeting the demand for donor organs in the US: It’s time for bold public policy, such as mandated choice or presumed consent. British Medical Journal. Vol 319, no 7222. 27 November 1999.
2. Razek T, Olthoff K, Reilly P. Issues in potential organ donor management. Surgical Clinics of North America. Vol 80, no 3. June 2000.
3. Levine DZ. Kidney Vending: “Yes!” or “No!”. American Journal of Kidney Diseases. Vol 35, no 5. May 2000.
4. Gibbons RD, Meltzer D, Duan N. Waiting for Organ Transplantation. Science. Vol 287, no 5451. 14 January 2000.
5. Fang, Poay. China’s bitter harvest. US News & World Report. 5 February 2001.
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