Sunday, 10 April 2011

A donor kidney market: pro/con

Los Angeles Times debates the issue of whether there should be a market for kidneys for transplants.

People who need kidneys are dying unnecessarily, and an organ market would save lives.

Dr. Benjamin Hippen is a transplant nephrologist at the Carolinas Medical Center in Charlotte, N.C.

The most compelling reason for setting up a market for organs is that there really isn't any other plausible solution to the growing disparity between the demand for and supply of organs. Even if we were to maximize organ procurement from deceased donors, we still couldn't meet the demand.

As that demand grows, it's not just potential kidney recipients who get desperate — it's also potential donors, who often have a close-up view of what their loved ones are going through. We then see people with health problems, like high blood pressure or obesity, say that they're willing to take on a certain amount of risk so that their loved one can live a better life.

A regulated market would be, in some sense, safer — the pressure would be taken off folks who want to be donors but perhaps shouldn't be for medical reasons. Transplant professionals could then select the healthiest donors, who are at the lowest risk for long-term complications. With a regulated market, we could say to high risk-donor candidates, "No, you shouldn't be a donor, and your loved one isn't going to suffer as a consequence of that decision."

There's also a significant difference between what it costs to maintain a transplant versus what it costs to maintain someone on dialysis. In 2007, $28 billion was spent nationally on people on dialysis; about $2.2 billion was allocated to kidney transplantation. So transplants are vastly more cost-effective, and in general they confer a longer survival benefit. Also, a larger proportion of people are able to go back to work compared with people on dialysis.

The unregulated, underground black market in organs in developing countries has been catastrophic for both donors and recipients. But the reason that someone who is desperately poor may be able to sell their kidney on the black market is that people in countries of comparative wealth have failed to solve their own supply problem. That is a policy failure. If the demand for organs could be met through legal, ethical strategies, some of the driving forces that support black markets would disappear.

If, indeed, the current system isn't meeting demand, then there's a sense in which it's unethical not to establish regulated incentives for living donors or to think more carefully about not doing so. The cost is being paid by the people who are dying on the waiting list, getting sicker on dialysis or selling their kidneys under terrible circumstances.
An organ market would exploit the world's poor and set the precedent for medical transplant tourism that puts everyone at risk.

Dr. Francis Delmonico is the director of renal transplantation at Massachusetts General Hospital and a professor of surgery at Harvard Medical School. He is also the medical director of the New England Organ Bank in Newton, Mass.

Despite the good intentions of those who would suggest that an organ market could be regulated, it's impossible to do so. A market for organ sales enables brokers and extra payments, and in a global society, the market could not be restricted to the United States.

Right now, our country sets the tone on this issue. Once we say it's OK to have a market here, it condones markets everywhere else in the world, and with medical tourism being what it is, those in search of kidneys will go to the place where it's the cheapest price — Americans won't be limited to undergoing transplants locally.

From there, transplant tourism in global markets brings unanticipated consequences. It increases the risk for diseases like hepatitis, tuberculosis or malignancy, and it also opens the door to a variety of unethical practices involving the donor and their medical care.

The central problem of organ sales is that it's a victimization and exploitation of poor people, notwithstanding good intention. The source of these organs is always the lowest socioeconomic class of a particular country — we know that has been the case in the Philippines, in Pakistan, in Egypt and in Iran. And the payment isn't that substantial of an amount, so rather than making them better off or helping them, the money is quickly used, and the donor is left with one less kidney. It's a reality that there's no escaping.

It's true that there has been a plateau of living donors in this country, and something has to be done. For that reason, I do believe in eliminating disincentives for donors. The living donor who doesn't have health insurance should have it — and even life insurance — provided for them, as it pertains to the donation event.
A market is kidneys is just one example of what economists refer to as "repugnant markets".

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