Should organ donors be paid?

An interesting piece from my graduate school's alumni magazine: http://magazine.uchicago.edu/0778/features/organs.shtm

What do you think?

Brad

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Should organ donors be paid?

With 96,000 Americans on the organ wait list and only 29,000 transplants performed last year, the transplant community constantly tries to encourage more people to donate. Yet some observers believe the volunteer system will never meet the need. Market proposals to increase the organ supply, MacLean Center for Medical Ethics Director Mark Siegler, MD’67, noted in his Ryerson lecture, “are attracting a lot of discussion in Washington.” The currently illegal practice of paying donors is also a hot topic within the University, where medical, business, and law faculty have taken part in the national debate.

Proposals range from a free-market system, in which individuals pay for organs, to a regulated system where the government (Medicare or Medicaid) or private insurance pays donors, at suggested rates from a few hundred to tens of thousands of dollars. The idea isn’t new: in a 1997 Business Week column GSB professor Gary Becker, AM’53, PhD’55, asserted that “the federal government might be designated as the only authority with the power to buy organs for transplants and would allocate them to hospitals with patients that need transplants.” In a working paper Becker and Julio Jorge Elías, AM’01, PhD’05, argue that monetary incentives could increase the organ supply, eliminating the long waiting list “without increasing the total cost of transplant surgery by a large percent.” They estimate the value of a kidney at around $15,000 and a liver around $35,000.

Yet cash might not be the preferred incentive, notes law professor Richard Epstein, who organized a July 6–7 Law School conference on transplant policy and in April 2006 argued for a market system before the President’s Council on Bioethics. A “package of benefits to cover illness or death,” he says, might serve a donor better. He’s not sure which forms the transactions would take “because no one’s allowed to try them.” Several hospitals, including Johns Hopkins, have begun successful paired-kidney exchange programs, showing, Epstein says, “that markets run better than you think.”

Market incentives, however, raise concerns. Moral objections include the arguments that buying and selling organs demeans human beings, commodifies the body, and changes the relationship between doctors and patients into a commercial exchange. The practice also could exploit the poor, who would be more likely to accept money for organs. Yet patients already pay for services and medications, Siegler says, and the poor, unfortunately, get exploited in many areas of life. He’s more concerned “about the utilitarian aspects of shifting from a voluntary, altruistic system to a commercial system.” Until the 1970s the United States used commercial blood banks, he notes, and studies showed the paid-for blood was more likely to carry hepatitis than volunteer blood; paid organ donors likewise may prove riskier. Siegler also worries that paid donors would replace, rather than supplement, volunteers. “If you do the experiment of a market system and end up with fewer organs,” he says, “you not only spend a lot of money but you also cost a lot of lives.”

For Chicago transplant surgeon Richard Thistlethwaite, the moral concerns are convincing. Thistlethwaite, president of the International Pediatric Transplantation Association, spoke against financial incentives at the group’s March meeting. Although increasing the supply is a dire need, he says, market proposals are “not about the recipient but the donor.” Asking for organs in exchange for money, he says, violates “human dignity,” changing donors “from an end in themselves to a means for someone else.” In Iran, which has a highly regulated paid system, “the majority of donors are worse off afterward,” he says, because they don’t seek follow-up care. The $1,300 government fee doesn’t improve their lives. India, which banned paid transplants in 1994 but where the practice continues illegally, faces a similar situation. The poor who donate don’t have sick leave and often lose their jobs during recovery. Yet in the United States, Epstein argues, donors would continue to be physically and psychologically screened, and they would receive much more money and possibly health care.

While proponents contend that individuals should have the autonomy to decide whether to donate an organ, for Thistlethwaite absolute autonomy is “an extremist view that could justify anything.” In the United States “you can’t sell yourself into slavery” and “people have to wear seat belts. Autonomy doesn’t trump everything else.” In the free market a woman can sell her egg for about $10,000. “But if it’s the right race and athletic ability, it could get $100,000.” To him such pricing, and college-newspaper ads soliciting egg donations, are “an atrocity.” And if the government set the price like many proposals suggest, he says, the autonomy argument becomes moot.

Then there’s the exploitation issue. No matter how much you pay donors, Thistlethwaite says, it’s “the upper class preying on the lower class.” It may work in an economic model, he says, but not in a “justice model.” And even with their health costs covered, poor people may not seek out postsurgical care. Although anecdotal evidence shows health risks to donors are rare, long-term studies haven’t been done on a large enough population. In the end, he says, “the ethical justification for doing this to people doesn’t exist.”

For Epstein, on the other hand, ethics demands the United States try a market system. In a May 2006 Wall Street Journal column decrying the Institute of Medicine’s recommendation against financial incentives, he argues that potential lives saved outweigh other concerns. “Only a bioethicist could prefer a world in which we have 1,000 altruists per annum and over 6,500 excess deaths over one in which we have no altruists and no excess deaths.” And with the money saved from reducing “the horrifically expensive dialysis program,” the country could provide organ donors with social services.

Epstein isn’t holding his breath. Though the President’s Council on Bioethics plans to issue a report on the topic in coming months, council member and Chicago professor of medicine Janet Rowley, PhB’45, SB’46, MD’48, notes that a market system is “highly unlikely to happen”—at least until “the list gets so big that it’s politically effective, or if someone who’s a big name dies” waiting for a transplant.