Whose Kidney Is It, Anyway?

Creating private markets for body organs.


(Steven Chapman is on vacation. This article originally ran in June 2005.)

Socialist and communist governments have nationalized all sorts of things: oil and gas fields, phone companies, steel mills, coal mines, airlines and farms. Now the American Medical Association, which generally does not favor collective ownership of the means of production, has proposed to go even further. It suggests nationalizing corpses.

The United States has a severe shortage of kidneys, livers, lungs and other human organs needed by patients awaiting transplants. The AMA thinks we might close the gap between supply and demand by confiscating body parts from people who no longer need them.

Today, you have to agree in advance to donate your organs in case of your untimely demise. In a system of "presumed consent," by contrast, you would automatically surrender them, unless you gave specific instructions to the contrary.

"Presumed consent" is a nice euphemism for something that falls well short of real consent. It's bad enough that the government expects to live off the sweat of your brow while you are among the living, or that it insists on collecting estate taxes when you have the misfortune to die. But now it's going to extract a literal pound of flesh before allowing you the peace of the grave?

No one denies that a problem exists. Nearly 90,000 people are on waiting lists to get transplants that can mean the difference between health and sickness, and even life and death. Every year, an estimated 7,000 or more patients who need organ transplants die without getting them. Clearly, something needs to be done.

The AMA says some other countries have boosted their organ donation rates through presumed consent laws. But David Kaserman, an Auburn University economist and co-author of the book "The U.S. Organ Procurement System: A Prescription for Reform," says that while countries with such laws do get more organ donations, "all the studies agree that it is not enough to solve the problem."

Americans and Europeans often have drastically different sensibilities. People in this country are not likely to react positively to the ghoulish notion that the government has presumptive title to their remains.

In many places, Americans don't even like the idea of being required to make a choice about organ donation. When Virginia adopted a "mandated choice" policy, forcing people to decide whether to become organ donors, 24 percent simply refused to indicate a preference. In Texas, mandated choice was enacted—and then repealed after a backlash that reduced the supply of organs. Some people apparently get touchy when you're trying to talk them out of their vital parts.

If you want to induce people to provide something that other people want, there are basically three possible approaches. The first is to encourage them to do so out of the pure joy of helping others. That hasn't worked. The second is to take it from them, an approach that "presumed consent" uses. That probably won't be enough, either, and it has the added downside of infringing on personal autonomy.

The third is to appeal to their own self-interest—by paying them. People could sign contracts agreeing to donate any organs suitable for transplant when they die, with the money going to their heirs.

That option, however, is currently illegal. For some reason, the AMA and Congress are put off by the concept of letting people be compensated for giving up something valuable. But why? We have no problem with paying people to shed blood, sweat or tears. What's wrong with rewarding those who agree, upon death, to surrender body parts that others need?

Based on experiences elsewhere, this approach is bound to work. There is a thriving market in the United States to induce women to furnish ova for infertile couples: A recent ad in Stanford University's student newspaper offered female students $50,000 to share their eggs. For that matter, India has to contend with an illegal trade in kidneys sold by people who are still alive.

Right now, we're paying people zero to hand over their organs, and many of them are not tempted by the offer. At a modestly higher price—Kaserman figures less than $1,000 per organ—the number of volunteers would quickly rise to meet the demand.

We could try conscripting donors, as the AMA proposes. Judging from the record of history, though, humans respond far better to tangible rewards than to coercion. Some skeptics think organ donation is too noble a cause to leave to the market. But really, it's too important not to.