The organ shortage

The way to fix it is to allow financial rewards for donors.

Zoe Pollock, posting on Andrew Sullivan’s blog, links to a paper that notes the shortage of organs for transplant: 114,000 recipients on waiting lists, 14,000 donors per year.

The two most promising alternatives are xenotransplantation, the replacement of a human organ with an animal one, or engineering human organs from scratch.

Actually, no. As Sally Satel keeps pointing out, the most promising alternative is allowing financial rewards for organ donors. That’s especially relevant to kidneys, where the donor can go on to live a perfectly normal life and where the savings to the government from not needing to do dialysis are in the tens of thousands of dollars per patient per year. That would allow for hefty payments while leaving the program still a net cost-saver.

The bioethical dogma that forbids payment for donation is just another version of “Right-to-Life” absolutism: it caters to the scruples of those sitting comfortably in their offices, with no skin in the game, at real cost to the lives of actual people. (Just imagine if each opponent of payment had to explain, in person, to five potential recipients and their families that he, personally, made the decision to let the patient die, in order to prevent “commodification” and preserve the moral freedom of donors to make altruistic choices.)

Time to get past it.

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:

36 thoughts on “The organ shortage”

  1. Sorry to be predictable but … I don’t agree. Having any operation is a risk, and no one knows when they might need their second kidney. The only people who would do this *as a result* of a change in policy would be poor people. Therefore, I am opposed. Some things shouldn’t be for sale, period. If a sick person is so great, someone in their family should be willing to make the sacrifice, or trade their kidney for a match. And if not, well?

    The system we have works just fine. What we should be doing is preventing people from getting sick.

    1. Poor people take on lots of risks that they would not take on if they were less poor. This is a crappy thing about the world. I wish the world were not so, I try to make the world less like that, but I cannot, we cannot, make it so. But sure, you get to decide what risks the poor can and cannot take on and take away their ability to make decisions for themselves.

      The system we have clearly does not work fine. If it did, we would not have a shortage of organs.

      1. I understand your point, but on the other hand, any time we let people make a contract, as a society we have also agreed to enforce it. So it’s not this lovely libertarian paradise you’d like to live in, where people make their decisions “freely” and the rest of us stay out of the way.

      2. I agree with JAW, and find that you don’t understand economics. Poor people should be allowed to decide for themselves how much their risk is worth. We already pay poor people for risking death now, with the volunteer army, and with paying women for surrogate childbearing, and paying sperm donors, even blood donors.

        Our current organ donor system, and what you are advocating, is nothing less than callous, cruel, paternalism.

        I am not a libertarian – in fact, I’m strongly against libertarian principles. If we had a well – regulated socialist democracy, with low economic inequality, *then* we could pay for organ donation without exploiting poor people.

    2. “The system we have works just fine.” Unless you’re one of the people who will die today because no organ was available.

      1. I don’t think that what we have works fine, but I don’t think paying for kidneys is the solution. That’d be more like casting out the devil with beelzebub.

        Under a regime of selling kidneys, most sellers would, as NCG points out, those that are desperate enough that they need the money. Money has diminishing marginal returns when it comes to quality of life, and for anybody sufficiently affluent, the increase is pretty small compared, considering that there’s always some risk to surgery, no matter how routine the procedure is. For example, money as an incentive would have exactly zero effect on whether I would donate a kidney (which I might still do for other non-financial reasons).

        It seems like such a system would easily run the risk of being a modern version of debtor’s prison.

        And no, I don’t have a good solution, either.

      2. “Unless you’re one of the people who will die today because no organ was available.”

        Or unless you’re one of the people who sold their organ.

        G-d d-mn, Mark, why is today always a day to play ‘look at me, I’m a respectable right-winger’!?

    3. It seems relevant to bring up the story of the Chinese teenage who sold his kidney for an iPad+ iPhone.
      Is this really where we want to be? NCG’s point about poverty is precisely what this is about — a market in kidneys is a market in “how low can you go”.

      It’s also so far from true that this is “the most promising alternative” that it’s not funny. Right now, a vastly more promising alternative (in terms of not being so politically contentious as to be useless) would be to switch from the current system of donation —
      I have to opt-in, AND then all my family members have to agree (because otherwise there’s so much chance of legal hassle that most hospitals just couldn’t be bothered) — to a system based on opt-out, which dramatically simplified and specific rules about when and why family members can object.
      This stuff is hardly merely theoretical. We all know the studies of bordering European countries with similar cultures but vastly different organ availabilities because of opt-in vs opt-out.

      1. The waiting list for kidneys is so long that taking every useable kidney from every person who died in the US wouldn’t be enough to end the wait for people needing kidneys.

  2. I’ll put it another way. Of course it is terrible that we get sick and die, and when my turn comes I will be as desperate as anyone else, no doubt.

    I just don’t think there should be a buyout for death.

  3. Odd, I blogged about this a short while ago:

    Allowing payment is not the first step to take. Far better to institute a policy that people who need organs have priority if they have themselves signed donor consent forms, and even higher priority for those who have signed consents for living donations (bone marrow).

    That is, when a pair of corneas (or a heart, or liver, or kidney, etc.) come available, they only go to someone who was not already signed up to be a donor if they are unsuitable for every registered donor who could benefit from them.

    If you’re a child, your parents should be donor registered — otherwise, all children of donor parents will have priority.

    1. I didn’t read the other comments before posting mine. Needless to say, I agree with JMG.

  4. There is one really simple move for cadaveric organs: go from organ donation being “opt-in” to it being “opt-out”. Don’t believe in organ donation for religious, cultural, or arbitrary reasons? That’s fine; carry an “Organ Keeper” card, otherwise your innards are fair game once you’re done with them. Not only do you have to confront your own mortality by agreeing to be a donor: even then, you sometimes have extra barriers to participation. When I got my Massachusetts Drivers License a decade ago (and, yes, this may have changed since then) you not only had to request an Organ Donor Card; once you had it, you had to sign it before witnesses and keep it in your wallet. I wonder how many usable organs had to be discarded because a well-meaning person who met an unfortunate and premature death had never signed their organ donor card.

    Another thing you can do, right now, is sign up to donate bone marrow. Practically anyone can do it, and every additional person who has their genotype on file could save a life, if they turn out to be a match for someone needing a transplant. Getting into the database is essentially painless (a little blood for genotyping, they need your contact information, and the cost of genotyping is often covered by people who donate money).

    With a little better coordination between databases, people in the bone marrow database could even be contacted to be told they’re a perfect match to live-donate a kidney or liver tissue, though these are far more invasive procedures than is marrow donation. They could even be paid for such invasive procedures (or, for that matter, for bone marrow) according to Kleiman’s scheme – though it seems inconceivable that Kleiman’s scheme could remotely be just in the absence of a single-payer system overseeing payment of donors and access to transplants, and that even under our existing scheme of supposed safeguards Steve Jobs was permitted effectively to murder someone who needed a transplant and who unlike Jobs was not medically contraindicated for the procedure, abetted by an unknown number of doctors and administrators.

    1. Warren, I didn’t mention it in my short post here, but I proposed default donor w/ opt-out along with preference for organ donors as organ recipients.

    2. Word to both of you. I think the real question is, are there enough people dying every year whose organs were usable who weren’t signed up? If so, we don’t need to have this little moral dilemma. Plus, soon we’ll grow organs in petri dishes, I assume.

      Btw, I supposedly got signed up to be on a marrow list with a cheek swab, that the recruiting lady said 25% or so of people do incorrectly. I’m just saying. (She also said that it doesn’t hurt anymore to donate. But I’ve decided not to worry about that issue yet.)

    3. The proposal to make donation ‘opt-out’ is a very good one and would make a huge difference, as would better public education (as well as private education, by which potential donors tell their families they really mean it. In Ontario, Canada, we have an organ donor card we can sign (opt-in) at renewal of our licence, but even if it’s signed, doctors often consult families of the deceased and don’t do transplants if the family objects. That’s the entirely wrong direction, in my view.

      I think payment for organs is way too risky for the reasons mentioned by other contributors: bad incentives on the poor, risk of perverse practices. In Canada our blood donation system has had to institute crazy ‘safety’ measures because some blood crosses the border from and to the US, where the measures are needed because some states buy blood – so those who give are not very healthy or clean or careful. They’re just desperate. Donated blood does not come associated with the same risks. In short: money is an incentive to bad decisions.

  5. I’m a biounethical sort myself, but there is another problem with paid kidney donors. It’s the same problem as paid blood donors: crappy kidneys. Who would donate under these conditions? Would pricing depend on quality? Would there be incentives to hide information? The last two sentences should be edited by changing the first two words around, and replacing the question marks with periods.

    From purely utilitarian calculations, I’m with JMG and Warren Terra: opt-out organ donation, with incentives for not opting out.

    1. C’mon. If I had a crappy kidney or two, do you think I’d be willing to donate one? I’m with JMG.

    2. And the main incentive should be: if you opt-out, you are automatically at the bottom of the list with the rest of the opt-outs should you require an organ. Need a liver and you opted out? You get put behind alcoholics who didn’t.

      Some other details would be:

      1) Your parents get to decide if they want to opt you out, but you still get put at the bottom of the list should you require an organ, and they will have to sign a waiver saying that they have been notified of this potential consequence. This becomes politically unpalatable? Then all children under the age of 18 are automatically opted in, with no exceptions for religious belief, conscientious objections, etc.

      2) If you are “opt-in” and decide to change your mind to be an “opt-out” (or your parents want to change your status, if you’re under 18), you immediately get treated as “opt-out” when it comes to you receiving organs, but it will take 3 years to be treated as “opt-out” when it comes to donating them. If you are “opt-out” and decide to change your mind to become an “opt-in” (or your parents make this decision, if you’re under 18), you are immediately treated as “opt-in” when it comes to organ donation, but it will take 3 years when it comes to receiving them.

      3) The only exception to item 2, above, is for people between the ages of 18 and 21. They can change their minds once with no 3-year penalty, so as not to penalize them for their parent’s decision. But no posthumous switching is allowed, even for the 18-to-21 crowd.

      I realize it seems ridiculous to float this policy suggestion in a comments section, but I haven’t read anyone tell me why this is a bad idea in terms of policy. I do realize it is politically infeasible, but frankly, so is selling organs. If we would still have a shortage of, say, kidneys even with 100% organ donation after death, then I’d be much more favorably inclined to allowing donors to sell one (depending on the details of pricing and assuming “platinum-card” level health insurance for anything even remotely related to renal issues).

      And, of course, selling organs doesn’t address heart transplants at all, which is why I’m skeptical of Sally Satel’s call for organ markets. Again, if she’s addressed this somehow, I’d be glad to listen.

      1. And, of course, selling organs doesn’t address heart transplants at all

        Well, somewhat. If Medicare or whatever paid a deceased donor’s heirs a few thousand bucks, in addition to telling them the deceased donor’s generosity had saved a life, this might encourage people to sign up, to assist their heirs and because money is a form of respect and appreciation to which our society gives significant weight.

        I’m not encouraging this, because depraved beneficiaries could be tempted to murder, and depressed or distressed people may decide to “donate” for the benefit of their heirs, in the style of Death Of A Salesman. But you’d be wrong to say it’s impossible to conceive of (at least superficially) ethical and even perhaps salutory forms of compensation for cadaveric donation.

        1. The ethical aspects of organ markets: that’s not my main concern, although as you mention, the possibility of killing relatives for spare parts is troubling. It’s that I don’t understand why they should be considered to be preferable to an opt-out system with teeth, if the real concern is the shortages of donor organs.

      2. Your ideas are very creative, but it sounds like a bit of an administrative nightmare to police all these people’s motivations. I think opt-out is enough, and sure maybe a bump in the line for the opt-inners, but I would be okay with having sick people game the system.

        I don’t think even an alcoholic sits there thinking, it’s okay if I wreck my organs because I can always get a new one. The main reason people wouldn’t opt out would be (besides laziness) that they would like to help someone else, once it’s *clear* that they themselves are done for. At that point, are you really going to be that finicky about whether the helpee is on a list too? I’m thinking no.

        And three years is too long to hold someone to that kind of promise. In fact, holding someone to this strikes me as highly problematic. I wonder if you could even do it legally. (My guess is no.)

        I think a more likely issue would be that people would rather have their organs frozen in case a relative needs one. But again, I hope that soon we’ll just grow new ones in petri dishes and be done with this problem.

        I applaud your proactivity, though. It’s an interesting idea.

  6. Before we go there Mark…
    I suggest we go here first:

    Create a monument on the Mall in Washington DC that honors all organ donators.
    Something like the Vietnam memorial, but this one is open-ended.
    If you donate, your name goes up for all time.
    The largeness of your largesse is made permanent:
    In granite or steel or whatever is chosen by the winning architect.

    Honor people for doing the honorable thing.
    If that doesn’t work…
    Then maybe it is time to throw neo-liberal money nudges at the problem.

    1. I think the proposed solution vastly underestimates the potential for evil in payment for human organs.

      While looking for an English movie about this I saw a few years ago involving organ theft from London refugees who are then left dead in an ice filled bathtub (didn’t find it, but there are a lot of movies about organ theft, must touch some serious nerve) I did discover that organ theft is evidently going on right now in the Sinai. And, this is apparently not the first such episode in the Middle East. And there has been large scale involuntary organ “harvesting” in China and apparently in the Ukraine.

      Imagine a kidnapping scheme when the victims are not needed to collect a ransom, just take out a few organs and dump the remains.

        1. That was a great movie. Very depressing though. I like it when directors tackle serious subjects without too much gratuitously gruesome imagery. I guess that’s not in style now though.

  7. I think the entire concept of “bioethics” is useless and repugnant. There may or may not be good reasons not to allow certain practices, but in practice bioethics tends to be a cover for religious conservatives oppressing the rest of us.

    We should start at the assumption that biological science does not raise ethical issues just because it is mucking around with human bodies and go from there.

    1. Speaking as a working biologist (on invertebrates, admittedly) who has met actual bioethicists, and also as a longtime habitué of the blogosphere and an admirer of Hilzoy, I suggest to you that you are painting with too broad a brush and do not know whereof you speak. The creatures you describe exist, and are a problem. But they are not the whole picture, and there is no such thing as “just mucking around with human bodies”.

      1. The fact that Leon Kass is taken seriously as a bioethicist is reason enough for me to call the whole enterprise into question. In general, serious fields of science and/or public policy don’t tolerate open charlatans and/or fanatics as members in good standing. (I’m extremely skeptical of the whole economics profession for the same reason; just too many crude political hacks and no real institutional restraints on them.)

        That said, I’m opposed to allowing organ sales in the US; we’re too unequal and unjust a society for this not to have really bad outcomes. Organ selling in Scandinavian countries? Sure. But here, if we allowed that, we’d soon have the Republicans demanding that no one can get unemployment or welfare until they’ve sold at least one kidney.

        1. Kass is a nice distillation of the problem.

          If there is some actual non-religious reason not to do something, it can be articulated without reference to “bioethics”.

          1. There’s actually an entire field, not just Leon Kass. Leon Kass became as prominent as he did because he was Bush’s bioethics guy; there are a whole lot of other people who have done really excellent work. I work with a lot of them, and they are thinking about a bunch of really interesting problems that, honestly, no one else would think about systematically.

            For instance: back when AZT came on the market in rich countries, it became clear that it prevented perinatal transmission of HIV. But doing this the way we did it here required a long course of AZT, which was both badly suited to a lot of developing countries (think: many, many trips to very distant clinics on foot, while very pregnant.) Wouldn’t it be great if a much shorter course worked, maybe even just giving AZT during and after delivery? Much cheaper, much less of a burden on the women, etc. However, we couldn’t ethically do the experiments we’d need to do here: we knew that the long course worked, and since no one thought the short course would be *more* effective (the question was whether it would be *as* effective, or almost), testing the short course would mean depriving people of medicine they could already get. At least, here.

            But consider a very poor country, where the status quo is that no one gets treated at all. Is it ethical to do that experiment there? Pros: since no one was getting AZT to start with, no one would be worse off after this experiment, and those women who got the AZT (and their kids) might be a lot better off. Also, this might show that the short course worked, in which case A LOT more women could be treated, which would prevent their kids from getting HIV. Cons: It seemed to a lot of people like a double standard: if we can’t ethically do the experiment here, how can we ethically do it in another country? Also, doesn’t this seem to open the door to a lot of medical experimentation being done in poor countries *just because* you can (perhaps) do things there that you can’t do here? Not all such studies would have as obviously good a purpose as this one. Also, it bothered some people that the main problem with the long course was cost, and that the whole point of the experiment was to see whether there wasn’t a treatment that was affordable.

            There were decent arguments on both sides. It clarified a lot. And I’m glad people are thinking seriously about this.

  8. I have a proposal for something you could pay kidney donors that would get rid of at least some of the adverse-selection and short-sighted-decision problems: free medical care for the rest of their lives. It would probably still cost less than dialysis, and it only works in a socially-backward country like the US, but I bet you’d see an effect.

    You could also do something like that for other kinds of organ donation — ages ago (iirc), giving a pint of blood entitled you or your family to a free pint in return if needed. Imagine a nice health-care tax credit for your heirs…

  9. There are options other than cash in hand. Pennsylvania I believe pays the funeral expenses of people who donate organs at death.

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