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Our Deeply Unethical National Organ Policy

Wednesday, July 7, 2010

In our zeal to protect the poor from exploitation by the moneyed classes, the organ donor—alone among all the participants in the world of transplantation—receives no benefit.

In America it is a felony to provide a financial incentive for someone to donate a bodily organ. Each year, this misguided and wrongheaded public policy takes the lives of nearly 5,000 Americans with end-stage renal disease and, ironically, costs taxpayers billions of dollars.

The math is simple. In a country the size of the United States, a payment, either direct (cash, vouchers, or tax credits) or indirect (tuition, charitable donations, etc.) of, say, $20,000 to kidney donors would probably produce enough donated kidneys each year to eliminate or drastically reduce the backlog of approximately 83,000 people waiting for their turn to receive a donated kidney. This financial inducement would cost about $1.7 billion. The federal government currently pays 100 percent of the cost for treating most people with end-stage renal disease. With the average annual cost estimated at about $30,000 to maintain one person on dialysis, the taxpayers are paying about $8 billion a year to dialyze fellow citizens in kidney failure. Furthermore, people usually wait about five years to receive a donated kidney unless they are fortunate enough to have a living donor offer one of their two healthy kidneys. Thus, the actual total cost to the taxpayers of maintaining fellow citizens on dialysis for five years is approximately $40 billion.

Each year, nearly 5,000 men, women, and children die in this country while waiting for a kidney to become available.

So in our zeal to protect the poor from exploitation by the moneyed classes, the organ donor, alone among all the participants in the world of transplantation, receives no benefit save the pleasure of performing a noble deed.

At first blush, the policy seems to make perfect sense. After all, few people would condone letting the wealthy use money to induce others, who may be in financial extremis, to provide vital organs for transplantation. Such a practice, the argument goes, would turn the altruistic concept of organ donation into little more than a mercantile opportunity for buying and selling body parts. This is an emotionally compelling argument. It is also seriously flawed, and has produced extremely questionable public policy.

In the case of kidney transplantation, the donor is subject to relatively little post-surgical risk. Statistically, a kidney donor fares no worse throughout his or her life than a person with both kidneys. Life insurance companies impose no rating on premiums for kidney donors because, actuarially, they represent no greater risk to the insurer.

At an average annual cost estimated at about $30,000 to maintain one person on dialysis, the taxpayers are paying about $8 billion a year to dialyze fellow citizens in kidney failure.

Everyone involved in the organ transplantation process benefits handsomely, except the donor. Organ transplantation provides a wonderful example of life-saving science and technology deployed in serving mankind. It is also a thriving industry. The entire transplant team, including the surgeons, nurses, technicians, pharmacists, nephrologists, and other specialists are well-paid for their respective roles in providing organ transplant service. The medical centers at which transplants are performed are also handsomely compensated. The procedure feeds revenue into virtually every facet of the hospital. It occupies rooms, keeps labs busy, requires numerous expensive tests, and staff at all levels benefit. The pharmaceutical industry certainly benefits, as transplant patients remain on various expensive drugs to protect their new organ for the rest of their lives. Then, of course, there is the recipient who is, perhaps, compensated best of all. He or she gets his or her life back. Only the donor, who gives the most and without whom the entire process would grind to an abrupt halt, is required to forego any material recompense for his or her service.

A more serious consequence of this flawed policy is that it costs thousands of lives annually, and consigns thousands of other people to years of expensive dialysis, the bill for which goes to taxpayers.

Each year, nearly 5,000 men, women, and children die in this country while waiting for a kidney to become available. We suggest that most of these individuals would, more than likely, have received a life-saving transplant but for the seriously flawed policy of denying compensation to those who might otherwise donate a kidney to a friend, a loved one, or even a stranger. A sensible, well-regulated program of organ donor compensation could convert most of these patients to transplant recipients. Their lives would improve drastically, the national cost of maintaining them on dialysis would be slashed, and donors would, in many cases, receive life-changing compensation for their generosity. Every time someone dies waiting for an organ in this country, the ethical case against providing compensation for organ donors is turned upside down. Unquestionably, the prohibition against compensating organ donors costs lives.

Yes, some donors might be poor, but what is wrong with a poor person receiving compensation for performing a noble deed?

Too many assume that this would motivate only the poor to donate an organ such as a kidney. Unquestionably, not only the poor, but many people who have considered such a donation would find reasonable compensation a legitimate factor in their decision-making process. Yes, some might be poor, but what is wrong with a poor person receiving compensation for performing a noble deed?

In the case of the authors, a daughter’s love for her father was all the motivation needed to produce a successful and happy outcome for both the recipient and donor. We were, however, both haunted by the reality that a system relying on pure, uncompensated altruism in thousands of other cases results in the unnecessary deaths of men, women, and children in end-stage renal failure.

All first-year medical students have drummed into their heads an old adage, “Above all, do no harm.” Perhaps members of Congress and public health officials should consider the same when considering organ transplant policy.

Harold Gershowitz is a businessman and recipient of a transplanted kidney. Amy Gershowitz Lask is an uncompensated kidney donor.

FURTHER READING: Gershowitz earlier offered, with Stephen Porter and Stephen Fuller, “A Stimulus That Would Work.” Dr. Sally Satel discussed “The National Kidney Foundation’s Bizarre Logic” against rewarding kidney donors, and “The Limits of Bioethics.” Satel lauded Israel’s steps to solve its organ shortage in “Kidney Mitzvah,” and just published a book on compensating kidney donors: When Altruism Isn’t Enough.

Image by Rob Green/Bergman Group.

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