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Human Organs for Sale, Legally, in … Which Country?

By Stephen J. Dubner

Here is an oversimplification of a complex problem:

1. Thanks to the miracles of modern medicine, a sick or dying human being can receive a transplanted organ from another human being.

2. Some of those organs must inevitably come from cadavers: i.e., you can’t give your heart to someone else and still live.

But some transplanted organs can come from living people. Chief among them is the kidney: we are born with two but can live with one.

3. As the science has improved, there has been a huge increase in demand for transplantable organs. But the supply has not kept up with demand. The kidney waiting list gets longer every year, and every year more people die while still on the waiting list. The supply of kidneys from both cadavers and living donors is insufficient.

4. There are fewer cadaver organs than one might wish for because:

a) Traffic fatalities continue to fall.

b) Improved emergency-room care keeps alive people who in the past may have died.

c) Not that many people in the U.S. choose to be organ donors upon their death. (This could be significantly improved if the U.S. adopted a “presumed consent” rule, as some countries have.)

5. There are fewer organs from living donors than one might wish for because too few people are altruistic enough to undergo surgery and give an organ to someone they may or may not know and receive no compensation for said act.

6. Therefore, a movement is afoot to create a market for human organs in the U.S. whereby “donors” would be compensated for their time, trouble, and organ. There are many objections to this market:

a) Some say, for instance, that it would exploit poor people (although poor people are often the ones who need organs, which are currently not available).

b) Others say that such a market would be impossible to properly design and regulate (although this “kidney exchange” program, created by market-design expert Al Roth of Harvard, shows that one problem can have many clever answers). Also, compensation could come in various forms, ranging from cash to tuition to lifetime healthcare.

c) There seems to be a natural repugnance toward buying and selling human organs — illustrated nicely in this presentation by the economist Julio Elias, who has written with Gary Becker on a potential market for organs.

Considering all of these factors, it is hard to imagine that the U.S. will have an organ market any time soon. There is a fervent ongoing debate over our organ shortage, including an actual debate scheduled here.

While there has been some movement toward compensating donors in Israel and in Holland, there is just one country in the world that has apparently gotten rid of its organ shortage by creating a market. Before you read the name of that country in the following paragraph, take a guess. Now guess again, and again — maybe 20 more times.

Benjamin E. Hippen, a transplant nephrologist (and scholar) in North Carolina, recently published a paper called “Organ Sales and Moral Travails: Lessons From the Living Kidney Vendor Program in Iran.”

Yes, Iran.

“Although Iran clearly does not serve as a model for solving most of the world’s problems,” Hippen writes, “its method for solving its organ shortage is well worth examining.”

Here are a few facts from Hippen’s paper:

    Insofar as the kidney procurement system in Iran can be characterized as a “market,” it is a highly standardized and regulated market with only modest room for negotiation. …

    Vendors are paid in two ways. First, the Iranian government provides a fixed compensation to the vendor of approximately $1,200 plus limited health insurance coverage, which currently extends to one year after the exchange and covers only conditions deemed related to the surgery. Second, the vendor receives separate remuneration either from the recipient or, if the recipient is impoverished, from one of a series of designated charitable organizations; this amount is usually between $2,300 and $4,500. …

    The most contentious disagreements in the literature regarding kidney vending in Iran have to do with the personal, physical, and financial consequences for vendors themselves. This issue is complicated by an absence of routine follow-up. …

    Despite a flourishing kidney vendor program, biologically related donation has consistently constituted 12 to 13 percent of all donated kidneys, and that fraction has persisted in tandem with the rapid rate of growth in kidneys procured (without compensation to the donor’s estate or family) from deceased donors. …

I wrote to Hippen to ask what sort of reaction his paper has received. He said it has been received “cautiously.” One prominent transplant surgeon, he said,

    … is reluctant to go out of his way to include Iran in the public discussion. While he has no quarrel with the paper that I’m aware of, he (legitimately) worries that it isn’t the whole story. I share the concern, which under the circumstances is not definitively answerable. The other concern, phrased in various ways, is that it is just unfortunate that all of this information is coming from Iran, for obvious reasons. Can’t do much about that.

People who are ideologically opposed to a market in organs, Hippen told me,

    … don’t dispute the data, but deplore the example. I freely concede (and take pains to highlight) that a crucial moral failing of the Iranian system is that there is insufficient data on the long-term outcomes of organ vendors, and the data that exist suggest that vendors are disproportionately impoverished, which in turn may put them at long-term risk for kidney disease. The Iranian transplant professionals I corresponded with in the course of writing the paper share the concern.

When I asked Al Roth about Hippen’s paper — which he said he admired — he raised a separate point of concern.

Not only is the health and welfare of the vendors hard to quantify, Roth said, but it is also hard to get reliable data on “what percentage of patients with E.S.R.D. (end-stage renal disease) fail to get treatment, and how much this contributes to the absence of a transplant waiting list.”

These considerable caveats aside, here is what Hippen thinks the U.S. should make of the Iranian organ market:

    The portion of the National Organ Transplant Act of 1984 which prohibits the sale of organs should be repealed. … Because so much is still unknown regarding how organ sales would work in the United States, individual transplant centers and organ procurement organizations should be permitted to experiment with how to implement a system of organ vending. 

This proposal strikes me as rational and wise, though it may never be tried out here. The repugnance factor in this country, as Roth and Elias have pointed out, may simply be too large to overcome.

But if data, like justice, is truly blind, then it is probably worthwhile to look toward a country that many Americans hate in order to save the lives of the people they love.

(If you’ve made it to the end of this long post, you may be interested to know that I’ll be discussing this topic sometime shortly after 6 a.m. E.D.T. on Wednesday, April 30, on the new public-radio show The Takeaway.)