Finding replacement kidneys

More people will donate to help people they know than will donate to help strangers, but the donor might not be a match for the person he wants to save. The solution, says Virginia Postrel, is called a “donor chain.”

Virginia Postrel, who donated one of her kidneys to Sally Satel, has a long article up about kidney-donation policy. She’s thought about this more thoroughly than I have,

If you doubt that the current system is a catastrophic failure, Postrel provides the basic data:

In the United States, more than 80,000 people are on the official waiting list, all hoping that someone will die in just the right circumstances and bequeath them the “gift of life.” Last year, only 16,517 got transplants: 10,550 with the cadaver organs allocated through the list, and 5,967 from living donors. More than 4,000 on the list, or about 11 a day, died. And the list gets longer every year.

And she blasts my favorite dream: solving the problem by making consent to post-mortem harvesting “opt-out” rather than “opt-in.” Turns out the numbers don’t work:

The best estimate is that there are between 10,500 and 13,800 brain-dead potential organ donors each year. More than half already become donors, and not all their kidneys can be used. If every single person who died the right way became an organ donor, an optimistic estimate would be that 7,000 more kidneys a year would be available for transplant. Since the list is now increasing by 6,000 a year, that would be enough to end it—in 80 years.

The new (to me) idea in the essay is what Postel calls a “donor chain” but which might as well be called “organ brokerage.” There are people willing to donate a kidney to save a relative or friend who wouldn’t be willing to do it to save a stranger. (Kant would disapprove; Hume would approve. That’s why I wish contemporary ethicists started with Hume rather than Kant.) But sometimes the willing donor isn’t a “match” for the person he or she wants to save.

However, no one really cares who gets his particular kidney, as long as the person he cares about gets someone’s kidney. Pairwise trading would be simple: I give my kidney to your friend and you give yours to my cousin. When the numbers get larger, so does the complexity of the trade, but the principle is the same; I give a kidney to someone and someone else gives a kidney to the person I care about. The National Kidney Registry is designed to facilitate the process.

Postrel argues – convincingly to me – for a repeal of the law against cash payments to organ donors. Since transplant is actually cheaper than dialysis, and since dialysis is a federal entitlement, there’s no need to make the recipient pay, and therefore no issue about rich people crowding to the head of the line. But that’s the next step. The first step is to expand the utilization of the Kidney Registry; a little bit of money spent on publicity might go a long way.

Surely Postrel is right that the issue suffers from an unjustifiable lack of urgency. Ten peoplea a day are dying unnecessarily. For some reason, people who get outraged about the ethical problems surrounding paid donation don’t seem to regard those needless deaths as an ethical issue calling for urgent action.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: