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.


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  1. You would think if its yours you should have the right to sell it if you so chose. But I doubt a government that will not even allow you to ingest psychoactive compounds into your own body will suddenly let you sell a body part. Althought I bet Ted Kennedy’s part are well preserved from being pickled in alcohol.

  2. Kerry’s article was ten thousand times better. I don’t even care if Steve wears boxers or briefs.

  3. What about one more tax credit to add to the collection to raise the number of organ donations. These can easily be verified by SSN. Make that a refundable credit and you’ve got a deal! Isn’t that “presumed” to be the reason for all this tax policy: encouragement of good deeds? There’s precious few tax credits that really promote “the greater good”. Why not one more?

  4. Good piece on a tough topic. Remember, every single person involved in organ donation (doctors, hospitals, recipient) gets compensated in dollars or organs for the donation–except the donor.

  5. My solution:

    When people are put on the waiting list for an organ (assuming it’s a ‘first-come-first-served’ sort of queue), simply back-date the person’s waiting time to the day they signed their organ donor card.

    (e.g. Let’s say you find out tomorrow that you need a kidney, but you signed my organ-donor card 2 years ago. You get credited with two years of waiting, and are therefore higher on the list than someone who has needed a kidney for 1 year, but never agreed to be a donor.)

    Outcome… Much greater incentive to be an organ donor (because it benefits you significantly should you ever require an organ).

    Zero cost, more donors, no change in demand for organs.

  6. Hey. Why don’t ya save us all some time and just post everyone’s comments to this from the June 05 Hit & Run.

    Moving on…

  7. Excellent plan, Russ R.

    Simple, cheap, effective.

    It will never fly. Not enough “controllability”. It doesn’t take into account the “disadvantaged” nor allow for extra credit for women and minorities. But with a few “tweaks”, I’m sure it could be made workable. Perhaps a Federal department to administer it would help.


  8. That’s recently been proposed in the UK.

    It created a bit of discussion in the sometimes liberal* sometimes social democratic LibDems – thankfully a large number of people were for for explicit consent being required. Even people who had things to gain through presumed consent. I’m glad my principled argument based around ownership went down well.

    * liberal in the British sense, not the US sense

  9. Excellent plan, Russ R.

    Simple, cheap, effective.

    Sadly no. Organ donation upon death will have little impact even if everybody signed up. Few people die in a way that leaves their organs fit for transplant. Even if we collected all of them, the demand would still be far greater than the supply.

    Healthy organs need to be harvested from healthy people. Given the large and various costs incurred by the donor, it’s simply inconceivable that we can get substantial increases in organ donation without direct monetary compensation to the donors.

  10. Maybe if the healthy organs were harvested from “healthy undocumented aliens”, we could solve two problems at once.

    (I’m kidding. Seriously. Kidding. I like Russ’s plan.)

  11. I propose an organ donation system based on willingness to donate:

    A better solution would be to introduce a two-tier organ transplant system where the tiers are based not on ability to pay, but rather on willingness to donate.

    Under such a system, a patient in need of an organ transplant would be placed in one of two queues: if she had previous signed an organ donor card allowing her organs to be harvested in the case of her death, she’d be placed in a priority queue. If she had not previously signed an organ donor card, she’d be placed in a secondary queue. Those in the secondary queue would only receive an organ donation if the organ was incompatible with everyone in the priority queue, or if the person in the secondary queue was on the verge of death and everyone in the priority queue could safely wait.

    This system would increase the number of available organs, but wouldn’t create wealth-based disparities in who gets them.

  12. Kerry Howley definitely writes better articles on this sort of stuff.

    Several months ago the Economist noted that Iran, of all places, has a working kidney market.

  13. Keir Wilmut wrote: “I propose an organ donation system based on willingness to donate: A better solution would be to introduce a two-tier organ transplant system where the tiers are based not on ability to pay, but rather on willingness to donate.”

    LifeSharers has implemented a system like this on a grass-roots basis in the United States.

    Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at http://www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

  14. Implied consent donation will cause some huge problems within certain religious groups. Orthodox Judiasm has taken a step forward on this front with their “Halachic Donation” campaign, where organs can be donated within the rules of Jewish law.

    Personally, I believe that people, dead or alive, should be able to sell or will any part of the body that is still useful to someone else. It’s the ultimate “pro-choice”.

    That leads me to a bit of a tangent. I’ve always felt that it’s ok to pay women to carry unwanted pregnancies to term, so that wealthly, childless couples can adopt. It should make the anti-abortion people and the underpriviledged both happy. Who cares if it’s “baby selling” if there is consent all around, a life is saved, and the child grows up in a home that is prepared to care for it?

    I guess the government finds that letting people have control of their own bodies is too scary to contemplate.

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