The Case for Selling Human Organs

National Organ and Tissue Donor Awareness Week is, by order of Congress, celebrated this week. It's been 34 years since Dr. Christian Bernard performed the world's first heart transplant in Cape Town, South Africa, but the modern era of organ transplantation essentially began when the anti-rejection drug cyclosporin was introduced in 1981.

In 2000, 22,827 organs were transplanted in the United States. Since 1990, a total of 185,347 organs have been transplanted into patients in the U.S. That's the good news.

The bad news is that, according to the nonprofit United Network for Organ Sharing (UNOS), there are now 75,863 men, women and children on the national organ transplantation waiting list. That's up from 20,481 a decade ago. Cadaveric donors--that is brain-dead donors--increased from 4,011 in 1989 to 5,984 in 2000, according to the U.S. Department of Health and Human Services (HHS). An average of 3.6 organs for transplant were taken from cadaveric donors. Meanwhile living donors surged from 1,918 in 1989 to 5,532 in 2000.

Despite these increases, an average of 15 people still die every day while waiting for an organ that could have saved their lives. "With the success and acceptance of organ transplantation, it has become routine therapy for many diseases," UNOS President Patricia Adams says. "We have the know-how to save tens of thousands of lives. What we don't have are enough donated organs to make it possible."

HHS Secretary Tommy Thompson announced plans to address the organ shortage by exploring the idea of creating a national online registry where people can officially record their desire to be organ donors after they die. Thompson has also launched a campaign to get corporations to discuss becoming donors with their employees. Finally, Thompson wants to create a national medal to honor the families of organ donors.

All of these are decent, salutary goals. And they will do absolutely nothing to end the shortage.

The normal way to handle shortages is to let prices rise to the market-clearing price. With organs, it might work this way: A cadaveric donor's family might be able to sell their dear departed's organs to patients who need them. Better yet, consenting living donors would be able to bargain with transplantees or their insurance companies for the sale of, say, a kidney or a piece of liver (both can be surgically removed without causing much permanent harm to the seller). But there is nothing resembling a market in human organs in the United States.

Why? At the very beginning of the organ transplant era some people feared that their doctors might hasten their deaths in order to obtain transplantable organs. Others worried that people living in rich countries might pay poor people living in developing countries for their organs. These fears have given rise to one of the most durable urban legends of all time: the one about the guy who goes to Spring Break in Florida and wakes up 3 days later in a hotel room with a hole in his side through which someone has extracted one of his kidneys.

The taboo topic in the organ transplant community is payment for organs. When it is discussed, euphemisms like "rewarded gifting" or "compensated donation" are used.

In 1983, Dr. Barry Jacobs publicly suggested that the U.S. government consider setting up a fund to compensate the families of cadaveric donors. Dr. Jacobs also proposed to set up a business that would buy kidneys from living donors for transplantation in American patients. Spearheaded by U.S. Reps. Henry Waxman and Al Gore, Congress rushed the passage of the National Organ Transplantation Act in 1984 to ban the sale of human organs from either dead or living donors.

National Organ and Tissue Donor Awareness Week is an appropriate time to rethink this policy. In the long run, the organ shortage may be solved with biotech miracles like transplantable animal organs genetically tailored to match individual human immune systems, or by repairing damaged organs using human stem cells. But in the short run, monetary incentives will matter. As one transplant physician pointed out to me years ago, everybody else in the transplant business--from doctors to hospitals to pharmaceutical companies--gets paid. And, of course, the recipient gets something far more valuable than money. Given all that, it seemed reasonable to him that the bereaved families of brain-dead donors should be paid something, too.

But what about compensating living donors? It should be noted that in the United States we already have robust markets for blood, semen, human eggs, and surrogate wombs. Extending markets to include non-vital solid organs such as kidneys and pieces of liver, which can be obtained with reasonable safety from living donors, is not such a stretch. Keep in mind that of the more the 75,000 people on the waiting list for organs, 48,639 need kidneys and 17,413 need livers.

The Journal of the American Medical Association published its "Consensus Statement on the Live Organ Donor" in its December 13, 2000, issue which offers this guidance for determining when living organ donations are appropriate:

"The person who gives consent to be a live organ donor should be competent, willing to donate, free from coercion, medically and psychosocially suitable, fully informed of the risks and benefits as a donor, and fully informed of the risks, benefits, and alternative treatment available to the recipient. The benefits to both donor and recipient must outweigh the risks associated with the donation and transplantation of the living donor organ."

All of that is quite reasonable; the emphasis on true donor consent gets around the grisly reality in communist China, where organs are harvested from prisoners without consent. For the transplant recipient the hoped for benefits are clear-they are freed from dialysis, their health improves, they avoid dying. But how can doctors and ethicists be certain that the benefits outweigh the risks for the living donor? One good way to make sure that the "benefits to both the donor and the recipient must outweigh the risks" is to offer appropriate monetary compensation to a living donor for a kidney or a piece of liver.

When that happens, it will finally be time to celebrate National Organ and Tissue Donor Awareness Week.