Healthcare: Spare Parts

A year and a half ago, Velangani Vitalravi sold one of her kidneys to Indian publishing executive A.S. Reddy. Vitalravi used her money to buy land in her native village of Ambattur, where she hopes to build a house for her husband and two children. More recently, her husband sold one of his kidneys to pay off family debts.

The Vitalravis are not that unusual in India, where kidney donation is often a straightforward commercial transaction. When Reddy's kidneys failed in November 1988, he had only to wait three months for a transplant operation. (U.S. patients typically wait more than a year.) His physician, Dr. K.C. Reddy (no relation), simply purchased a kidney from a living donor. Mr. Reddy, father of two girls, explains, "I had no choice but to pay for a kidney." A year and a half later, his new kidney works fine and he feels good.

Among transplantable organs, kidneys are unique. Someone like Velangani Vitalravi can donate a kidney without impairing her health. Donating a kidney is by no means pleasant, but it isn't particularly risky.

Dr. Reddy's transplant team has performed more than 600 kidney transplants—all of which involved kidneys obtained from living donors. More than 450 transplants were done using kidneys purchased from unrelated donors. Originally, Reddy's team let donors and recipients negotiate a price for kidneys between themselves or let middlemen obtain donors. But Reddy became concerned that the donors were exploited by middlemen.

So he designed a system he calls "rewarded gifting." He cheerfully acknowledges that it is really buying and selling organs. His clinic chooses the donors from a pool of volunteers. He cuts out the middlemen who might blackmail or use loan sharking to force a donor to sell a kidney. He counsels each donor to make sure that they all understand what they are doing. Reddy permits no direct negotiation between the recipient and the donor. He offers the donor a flat fee of 27,500 rupees ($1,800), complete medical expenses related to the donation, and a three-year health insurance policy. A third of his donors are relatives of previous donors.

Keep this payment in perspective. The average annual wage in India is 3,600 rupees, so the typical donor receives the equivalent of more than seven years' wages in one lump sum. One of Reddy's donors bought a small farm; one set up a shoemaking shop; and another started a poultry business. Tristam Engelhardt, a physician and bioethicist at Baylor College of Medicine, points out, "In Bangalore, India, if somebody could sell his kidney, that guy would be put into the middle class at once."

Of course, some donors squander their money. "What can I do?" asks Reddy. "It's a free country. A man can do what he wants with his own money."

A complete operation in Reddy's clinic—including hospital costs, testing, donated organ, and costs for obtaining the organ, but excluding the price of the expensive immunosuppressive drug cyclosporine—costs an Indian recipient $5,000; for a foreigner, the cost is $8,000. This compares favorably to the average of $51,000 for such an operation in the United States. Or course, American patients don't have to pay directly for their transplants since they are covered by Medicare.

In the United States, Medicare also pays more than $3 billion a year to provide life-saving dialysis to the 110,000 Americans who suffer from kidney failure. This is not an option in India, where dialysis facilities are few and expensive. Also, there are no intensive-care units which can supply cadaver kidneys. If Indian doctors are to save any of their patients, transplantation using kidneys purchased from live donors is their only option.

Reddy puts it succinctly, "Either I buy or they die." Not only have Indian citizens benefited from this market in kidneys—hundreds of patients from the Middle East and the Far East have received transplants in Bombay and Madras hospitals.

Recently, pressure from a number of international medical societies, such as the prestigious International Transplant Society and the Middle East Transplant Society, has caused some reputable Indian transplant surgeons to stop operating on foreigners. Foreigners in need of new kidneys must now turn to surgeons who operate out of smaller, less modern hospitals.

Reddy resents the Western pressure and strongly defended his transplant program at a conference on "Ethics, Justice, and Commerce in Transplantation" this past November in Ottawa, Canada. Ashok Kirpalani, a nephrologist at Bombay Hospital, fears that pressure from the West may persuade the Indian government to make paid donation illegal.

Says Kirpalani, "If we make it illegal, then only the crooks and the quacks will do transplants. It would be like illegal abortions used to be in your country—thousands died from illegal abortions."

Ironically, even as the United States pressured India to end the sale of organs to foreigners, it pursued policies that may cause more Americans to need those transplants.

In 1984, Congress passed the National Organ Transplant Act, which outlawed the buying and selling of transplantable organs in the United States. As Brooklyn College economist Emanuel Thorne dryly notes: "When something is valuable, you can't just legislate that it is not valuable." Besides outlawing commerce in organs, Congress created a monopoly called the United Network for Organ Sharing to allocate donated organs.

The result of all this government regulation is a rapidly growing shortage of transplantable organs in the United States. Over the past three years, the number of patients waiting for a transplant has increased by more than 60 percent. Cadaver organ donations have not increased for four years. In fact, the number of donors declined from 4,069 in 1988 to 3,993 last year.

In the United States, public policy assumes that an organ should be donated out of altruism, not for commercial concerns. Traditionally, kidney donors have been blood relations of the patient. And yet, even within families, donors do not always give organs out of simple altruism. James Light, a surgeon at the Washington Hospital Center in Washington, D.C., estimates that 15 percent to 20 percent of related donors receive some financial compensation from the patient. Forbidding these commercial transactions only exacerbates organ shortages.

As the U.S. kidney waiting list lengthens and Indian medical standards improve, Americans may begin seeking transplants in India. "I have no doubt that it will occur," says Alan Hull, a nephrologist in Dallas. He continues, "As the waiting list grows, I have to say to patients, 'Look, you have a rare blood type and you're a high reactor. The waiting time for you will be 5 to 10 years, which is longer than your life expectancy; so while I'd love to give you a transplant, I don't think I can offer it to you.' That person has money, and there's a kidney in Bombay, their chances are 50/50, let's say, you know what will happen—they're going to buy one. When you bring that scenario up at medical society meetings, no one wants to talk about it."

Reddy is reluctant to take American patients, since they can obtain dialysis for free at home. If, however, a patient's physician referred him to Reddy's clinic, explaining that the patient was not doing well on dialysis and was in urgent need, then Reddy says that he would feel a humanitarian obligation to take him on as a patient.

Reddy would also consider participating in a well-regulated international program in which he would buy kidneys from donors in India and ship them for transplantation to centers in the United States. He would engage in such a program only if the donors received most of the money paid for the kidneys. Technologically, this type of international trade in organs is now possible thanks to the preservation fluid Viaspan.

Some Western bioethicists argue that buying and selling kidneys in the Third World is a horrible example of the rich exploiting the poor. Baylor's Engelhardt responds, "If rich first-worlders can buy organs from the poor third-worlders, the poor third-worlders will all of a sudden have a great deal of capital at the cost of very little risk. If one forbids third-worlders from selling their organs, one condemns them to remaining poor and to working at much higher-risk endeavors in order to earn a living. We're exploiting them in order to feel good about a set of moral concerns that we can't articulate in general secular terms."

The Indian market in kidneys works. The U.S. government-mandated organ allocation scheme, which relies solely on altruism, is unable to end the organ shortage. It is high time for the transplantation community, policymakers, and the public at large to consider seriously proposals that will offer compensation to cadaver donors' families and, in the case of kidneys, to living donors themselves. Every day we wait, more people needlessly die.

Ronald Bailey is a staff writer at Forbes.