Should we pay donors to increase the supply of organs for transplantation? No
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.a179 (Published 12 June 2008) Cite this as: BMJ 2008;336:1343
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There is a specific question about who carries the burden of proof in this debate.(1) Altering the present status quo has to be justified. Given that the core argument in favour of the introduction of a market in organs is the lack of present supply of organs the initial burden is upon those who argue that a market in organs will improve the supply in both quantity and quality to establish this fact. A key problem they face is establishing that the creation of a market in organs will indeed be sufficient to significantly overcome any reduction in the flow of altruistically donated organs caused by the introduction of a market. This includes dealing with the question of who will pay for the organs and how under supply will be addressed.
Once that is established then it falls to those who are against altering the status quo to demonstrate why the status quo should not be altered. Not the other way around. The question of the intrinsic value of the loss altruistic donation and the consequent flow of organs form poor to rich is separate from this point.
A second point relates to the exploited poor argument (1). It is true that the creation of a market in organs will create an additional choice for the poor – i.e. the choice to sell one of their kidneys thereby potentially providing them the ability, on one occasion, to convert a body organ to financial capital. The reason why this is ethically questionable is that the effect of this same market upon the rich is to create 2 choices for them. The choice to buy a kidney or to sell one of their own kidneys. This imbalance is unjust because if a rich person donates their kidney and their other kidney fails they can simply purchase a replacement. In the same situation the poor person faces death. The consequence of the market is to increase the risk to the poor and reduce the risk to the rich. This is an affront to the principle of justice.
1. Radcliffe Richards J, Daar AS, Guttmann RD, Hoffenberg R, Kennedy I, Lock M,Tilney N for the International Forum for-Transplant Ethics. The case for allowing kidney sales. Lancet 1998; 351:1950-1952
Competing interests: None declared
Competing interests: No competing interests
A Litany of Errors and Omissions
To the Editor:
Professor Chapman’s essay opposing a regulated market in organs is a litany of errors and omissions which should not go uncorrected. Considerable clarity can be achieved by observing that Dr. Chapman consistently conflates the manifest horrors and abysmal outcomes of illegal, underground organ trafficking (1) with proposals for regulated, above-ground, organ markets in developed countries. (2-6)
Dr. Chapman incorrectly asserts that donation is non-existent in Iran, a country where a legal market (of sorts) in organs from living vendors has existed since 1988. (7) Despite the availability of organs for purchase, living-related (uncompensated) donation has consistently made up 11-13% of all organ procurement since the introduction of the vendor market. Deceased donation did not meaningfully exist in Iran until 2000, when the Iranian Parliament provided legislative recognition of brain death as death. (8, 9) Since 2000, uncompensated deceased donation in Iran has increased 10-fold, and as of 2006 represented 15% of all organs procured that year. (10) Quite apart from the “implosion,” predicted by Dr. Chapman, deceased donation in Iran appears to be flourishing in parallel with a vendor market. In other countries, reliable knowledge about the causal relationships between the activity of deceased donor programs and the availability of illegal organ vending is not amenable to simple generalizations. (11, 12)
Dr. Chapman’s thesis also goes awry in his rendering of the forced choice facing desperate recipients: “Every patient able to pay will be faced with the question, ‘Should I wait for deceased organ donation, seek a family donor, or simply buy one?’” On this formulation, one might suppose that waiting for a kidney is an activity with all the inconvenience of queuing at the supermarket. Of course, the accumulated morbidity and rates of mortality for dialysis-dependent patients (65% 5- year mortality in the United States) (13) makes this “choice” one of life and death for increasingly desperate recipients. For more and more viable transplant candidates, (8% mortality on the waiting list for kidneys in the United States in 2005) (14) the “choice” involved is to die waiting for a kidney.
Also worth highlighting is Dr. Chapman’s eccentric view of “altruism,” particularly since he explains that in the debate over organ sales, “The last vestige of human altruism is at stake.” Dr. Chapman wonders who would actually consent to living donation if the option of purchasing an organ were rendered safe and available. This leaves the unfortunate impression that selfless organ donation only flourishes when living donors are quietly extorted by state-sponsored restrictions on a designated recipient’s ability to get a transplant. In contrast, a market in organs would clarify altruism, by permitting (authentic) altruistic donation to occur in parallel with a regulated organ market. (3)
Conspicuously absent from Dr. Chapman’s essay is any recognition that the desperation of recipients facing untenable waiting times in his native country offers succor to the cross-border organ trafficking all of us deplore. This point was highlighted by Australian nephrologist Dr. Gavin Carney, who recently called for a regulated organ market in Australia, observing that the insufficiency of organ procurement efforts in Australia were driving some of his patients to engage in organ trafficking. (15) Despite a plethora of heady public pronouncements promising reform, organ procurement rates in Australia remain low: 9.4 donors per million population in 2007, (16) which is less than half the rate of procurement in European countries and the United States. Dr. Carney’s proposal was loudly condemned by Dr. Chapman, who instead recommends aggressive efforts to increase deceased donation. Laudable as that may be, such efforts are likely to be insufficient. Chris Thomas, Chief Executive Officer of Transplant Australia and an outspoken critic of of the idea of a market in organs, offered a candid assessment of the prospects of increasing deceased donation in Australia during an interview with a reporter for the World Socialist Web Site, observing:
“The systems [for deceased donor organ procurement] are just not set- up,” Thomas continued. “We don’t have enough intensive care beds. You’d need to keep potential donors in an intensive care setting. Well, there’s a lot of pressure on hospitals to be funding intensive care beds, and you’ve got a lot of pressure with other patients arriving and needing those beds. So if you’ve got someone who’s clinically brain dead and another car accident coming in—and you’re trying to save a life, then the decision’s pretty quick to just move to the patient.” (17)
Mr. Thomas’s comment bears emphasis: Even when deceased donation enjoys widespread public support, as it does in Australia, robust deceased donor procurement programs are labor- and resource-intensive endeavors. If Australia can’t seem to find the resources to substantially increase organ procurement from the deceased, perhaps some reticence is in order before insisting that deceased donation is a panacea for the challenge of organ trafficking in countries with even fewer available resources.
Dr. Chapman’s views, which remain the regnant views of much of the international transplant community, offer no solution to the growing disparity between the demand for and supply of organs, a disparity which fosters the suffering and desperation of recipients of means, which in turn provides ongoing economic support to the horrors and abuses of underground organ trafficking. The persistent failure of organ procurement policies in wealthy nations to address this disparity is tantamount to moral complicity with this despicable practice. A regulated market in organs, limited to countries governed by strict standards of safety and transparency, and enforced by an uncorrupted rule of law, is one possible solution. (3) Until then, the plundering of organs from subaltern populations in developing countries will continue, unimpeded by our politely registered objections.
Benjamin Hippen, M.D.
Transplant Nephrologist, Charlotte, North Carolina, USA
benjaminhippen@gmail.com
References:
1. UNOS Board of Directors Statement on Transplant Tourism. Available at: http://unos.org/resources/bioethics.asp?index=12 Last visited June 14, 2008.
2. Gaston RS, Danovitch GM, Epstein RA, Kahn JP, Matas AJ, Schnitzler MA. Limiting financial disincentives in live organ donation: a rational solution to the kidney shortage. Am J Transplant. 2006 Nov;6(11):2548-55.
3. Hippen BE. In defense of a regulated market in kidneys from living vendors. J Med Philos. 2005 Dec;30(6):593-626.
4. Matas AJ. Design of a regulated system of compensation for living kidney donors. Clin Transplant. 2008;22(3):378-84.
5. Cherry M. Kidney for Sale by Owner: Human Organs, Transplantation and the Market. Georgetown: Georgetown University Press; 2005.
6. Taylor JS. Stakes and kidneys : why markets in human body parts are morally imperative. Aldershot, Hants, England ; Burlington, VT: Ashgate Pub.; 2005.
7. Hippen B. Organ Sales and Moral Travails: Lessons from the Living Kidney Vendor Program in Iran. Cato Policy Analysis, No 614. 2008 March 20, 2008. Available at http://www.cato.org/pub_display.php?pub_id=9273.
8. Larijani B, Zahedi F, Taheri E. Ethical and legal aspects of organ transplantation in Iran. Transplant Proc. 2004 Jun;36(5):1241-4.
9. Raza M, Hedayat KM. Some sociocultural aspects of cadaver organ donation: recent rulings from Iran. Transplant Proc. 2004 Dec;36(10):2888- 90.
10. Ghods AJ, S. Shekoufeh. Iranian Model of Paid and Regulated Living-Unrelated Kidney Donation. Clinical Journal of the American Society of Nephrology. 2006;1:1136-45.
11. Danovitch GM. Cultural barriers to kidney transplantation: a new frontier. Transplantation. 2007 Aug 27;84(4):462-3.
12. Hippen BE. A modest approach to a new frontier: commentary on Danovitch. Transplantation. 2007 Aug 27;84(4):464-6.
13. USRDS Annual Data Report, 2007. Available at http://www.usrds.org/. Last accessed June 14, 2008.
14. Casingal V, Glumac E, Tan M, Sturdevant M, Nguyen T, Matas AJ. Death on the kidney waiting list--good candidates or not? Am J Transplant. 2006 Aug;6(8):1953-6.
15. Benson K. Sell your kidney for $50,000, says specialist. Sydney Morning Hearld. 2008 May 5, 2008. Available at http://www.smh.com.au/news/national/sell-your-kidney-for-50000-says- specialist/2008/05/04/1209839456231.html Last accessed June 14, 2008.
16. Australia and New Zealand Organ Donation Registry 2008 Report. Available at http://www.anzdata.org.au/index_ANZOD.htm Last accessed June 14, 2008.
17. Tiernan L. Australia: $50,000 for a kidney? Doctor’s proposal highlights desperate health, social crisis. World Socialist Web Site, May 16, 2008. Available at http://www.wsws.org/articles/2008/may2008/kidn- m16.shtml Last Accessed June 14, 2008.
Competing interests: None declared
Competing interests: No competing interests