Medicine

Virginia Postrel on How to End The Kidney-Transplant Waiting List

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Over at The Atlantic, former Reason Editor Virginia Postrel has a meticulously researched and argued article about how to end waiting lists for donated kidneys. A snippet:

Altruistic blood donors often receive freebies like movie tickets or paid vacation hours that would be illegal for kidney donors. Plasma and sperm donors routinely receive cash, as do egg donors and surrogate mothers, who get tens of thousands of dollars.. If transplant centers could pay $25,000 or $50,000 to each living kidney donor, many more people would line up to contribute.

Such payments could even save taxpayers billions of dollars. Long-term dialysis is a federal entitlement. Under a special law, Medicare covers everyone, regardless of age, who has made minimal Social Security tax payments-about 319,000 of the country's 400,000 dialysis patients. Compared with dialysis payments, every transplant from a living, unrelated donor saves an expected present value of almost $100,000 in medical costs, according to a 2003 American Journal of Transplantation article by Matas and Mark Schnitzler, an economist then at Washington University in St. Louis and now at the Saint Louis University Center for Outcomes Research.

Eliminating the waiting list would thus save taxpayers $8 billion, or $4 billion if each living donor received a lump-sum payment of $50,000.

The story discusses promising new methods of expanding the donor base and matching donors with patients. It's a rich story that focuses on the human dimension of the exchange, which is made needlessly and often-fatally complicated by bad laws and policies. Read the whole thing here.

Postrel donated a kidney a few  years back, a story that makes up part of this Reason.tv documentary, "Organ Transplants: Kidneys for Sale." Watch below or go here for downloadable versions, embed code, and more.

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  1. If it is an OEM item and you are not crazy you should be able to sell it.

  2. Repost from August:

    From my previous comment (reason.com/blog/show/125618.html): I’m pretty sure I already mentioned this, but I’ll soon be offering a satire called something like “Inside Bombay’s Bustling BodyPartsMarket”. Perhaps I’ll make it a condemnation, except the condemnation will be because the government is involved.

    I’m sorry, I’ve been busy, but I’ll try to get that done one of these days. However, it might not be before Reason does it themselves, but seriously.

  3. I wonder what the fair market value of a kidney really is. Let’s say you restrict it to just a USA network. At $25-50k, people would be lining up, hoping that they’d hit the lottery and someone that matched them fell ill.

    I don’t know how restrictive matching issues are with kidneys, but my guess is the market would settle on ~$5,000 for a kidney if you restricted it to people over 21.

  4. Altruistic donors are “paid” – they’re paid by the good feeling they get from donating blood. Giving cash actually decreases donations, as you can’t usually pay enough to justify the time and inconvenience required while you strip the act of its altruistic reward. Paying also provides a finanical incentive to lie during the screening questionaire, which functions to protect the blood supply. Noncellular blood components can be sterilized by heat or detergent, so a screening questionaire is not needed – you can pay for these – and indeed, there are plasma centers all over skid row.

    Selling kidneys would strongly incentivize people to lie about their risk factors for infectious disease.

  5. Altruistic blood donors often receive freebies like movie tickets or paid vacation hours that would be illegal for kidney donors. Plasma and sperm donors routinely receive cash, as do egg donors and surrogate mothers, who get tens of thousands of dollars..

    I agree that kidney donation for money should be legalised, but those examples are not quite the same thing. Your body can make up for blood, or plasma or eggs or sperm that you donate.

  6. Shut the fuck up, LoneWacko.

  7. I’m sorry, maybe Postrel didn’t get the memo. Receiving money in exchange for healthcare is no longer in vogue. This is a non-starter.

  8. I agree that kidney donation for money should be legalised, but those examples are not quite the same thing. Your body can make up for blood, or plasma or eggs or sperm that you donate.

    That’s why the compensation for a kidney would probably be a few bucks more than donating blood. Just a few. Like maybe I get four movie tickets instead of only two.

    As for eggs, depending on how you look at it, you don’t compensate for it. A woman has all the eggs she’s ever gonna have. They’re like brain cells. She don’t make more.

  9. As is so often the case, it’s pretty clear from the comments that H&R readers are reading only the selection in the post and not the whole article. It is not only about financial incentives–most of it is about various innovative barter arrangements–and it explicitly makes the point Tacos mmm… makes. That point is in fact a major part of the discussion of kidney chains. I know you’re busy, but please read the whole thing: http://www.theatlantic.com/doc/200907u/kidney-donation

    In response to Kunal, your body does in fact make up for the kidney. The remaining kidney grows to do the work of two. And, as you’d know if you read the piece, kidneys almost always fail together, so having two is not much of an advantage. (Also, women do have a fixed number of eggs.)

  10. As is so often the case, it’s pretty clear from the comments that H&R readers are reading only the selection in the post and not the whole article. It is not only about financial incentives–most of it is about various innovative barter arrangements–and it explicitly makes the point Tacos mmm… makes. That point is in fact a major part of the discussion of kidney chains. I know you’re busy, but please read the whole thing: http://www.theatlantic.com/doc/200907u/kidney-donation

    I usually do get around to the articles, but not at work. Hit and Run just fills the coffee breaks.

  11. As is so often the case, it’s pretty clear from the comments that H&R readers are reading only the selection in the post and not the whole article.

    If “I didn’t RTFA” wasn’t so common, it wouldn’t have an acronym.

    The remaining kidney grows to do the work of two. And, as you’d know if you read the piece, kidneys almost always fail together, so having two is not much of an advantage.

    Did not know that.

    I could see giving up a surplus kidney that’s not doing me any good if I was paid (well) for it, but am unlikely to do so (except for a close friend or relative I actually like) for free.

    I will read the article, Virginia. Promise.

  12. > I wonder what the fair market value of a kidney really is.

    Hmm … roughly that of a goose liver?

  13. I forgot the shout out for Wash U and SLU.

  14. I disagree with offering money for kidneys. I’ve had 2 kidney transplants. The mission is to teach people why it is necessary. There are too many misconceptions and social problems already. There is no religion on earth that disagrees with organ donation. Presumed consent would be a nice alternative, but even this approaches socialism in my book. It’s all about education. Finally, let’s not forget that a transplant is not a cure. It is simply a better alternative, if it works —and they don’t always work! Has the author built in a failure rate, a five year half life of the graft, or the cost to the recipient of immunosuppressive meds? It’s not a simple solution that you can throw money at and expect it to be fixed. This reaches deep into the cultures of the people in our country. Much more thought must be given to this…in my opinion.

  15. Using Halcomb to advance your disparagement of dialysis would be like using an early Regan quote to tout FDR’s programs. You misappropriated Epoman’s writings.

    If you and Satel, want to create an organ market to “save” those replacing their renal function with conventional incenter hemodialysis then you two should also advocate for optimal dialysis.

    A complete case must address the impact of a kidney market on the altruistic donation of postmortem hearts, lungs and livers (although there can be living liver donation it’s medically difficult procedure and not analogous to donating a kidney).

    How would paying kidney donors effect the decision of postmortem donation? That is a hard calculus to explain in the comments section but I think it would weigh against donation. I worry that a kidney market would decrease altruistic donation of truly life saving organs.

    The discussion should start with the irreplaceable organs.

  16. As the death toll from the organ shortage mounts, public opinion will eventually support an organ market. Changes in public policy will then follow.

    In the mean time, there is an already-legal way to put a big dent in the organ shortage — allocate donated organs first to people who have agreed to donate their own organs when they die. UNOS, which manages the national organ allocation system, has the power to make this simple policy change. No legislative action is required.

    Americans who want to donate their organs to other registered organ donors don’t have to wait for UNOS to act. They can join LifeSharers, 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.

    Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. Non-donors should go to the back of the waiting list as long as there is a shortage of organs.

  17. I admire Dave Undis’s indefatigable concern with the issue, but LifeSharers has yet to get anyone a transplant–in part because it is 100% focused on deceased donors. The most important paragraph in my article, which also explains why the popular “opt-out” solution (which is problematic for other reasons as well) will not solve the kidney shortage, is this one:

    To end the list, we first have to give up the idea that “organ donor” means someone dead. Deceased donors are, of course, essential for hearts. But not for kidneys. And not enough people die in exactly the right way to meet the need for kidneys. The best estimate is that there are between 10,500 and 13,800 brain-dead potential organ donors each year. More than half already become donors, and not all their kidneys can be used. If every single person who died the right way became an organ donor, an optimistic estimate would be that 7,000 more kidneys a year would be available for transplant. Since the list is now increasing by 6,000 a year, that would be enough to end it-in 80 years.

    As for Bill Peckham, he may be content with life on dialysis, but many people are not. Yes, better dialysis would improve medical outcomes, but a transplant is far superior. The quote I chose from Epoman is from the site’s introductory page and is clearly something he wanted everyone to read. He did die at a tragically young age, and (as Bill Peckham knows) he did try to find a transplant toward the end of his life. That he did enormous good in helping people live better on dialysis does not negate the difficulties of that life. Whether a transplant might have saved him, we can’t know. One of the most important things about normalizing living donation–regardless of the issue of payment–is that it would make it more likely that patients would get transplants sooner rather than later, before their health deteriorates.

  18. Address the impact of a kidney market on the altruistic donation of postmortem hearts, lungs and livers.

  19. I would work to have a transplant if I didn’t have recurring FSGS. I remember the emotional strain a failed transplant puts on recipient and donor yet I would take the risk if my odds were “normal”. If I thought I had a normal shot I’d take it.

    I think everyone is saying that kidney donation is a good thing – the issue is your characterization of other forms of renal transplantation. You are comparing worst cases to best cases – that is disingenuous.

    Is a good kidney transplant better than good dialysis? Yes. But it is not so much better or good dialysis is not so bad that we have to risk throwing our heart and lung needing brethren under a kidney market bus.

  20. Above I wrote
    other forms of renal transplantation

    That should have been
    other forms of renal replacement

  21. In response to Bill P., here’s no particular reason to think that deceased donors give because they or their families are thinking specifically of helping kidney patients and not, say, heart or lung patients and, hence, no reason to think that trying to build support for living kidney donation would displace deceased organ donations. The “gift of life” after a tragic death would still be a gift of life. This issue seems like a complete red herring to me.

    What you may not realize, because you’re inside the world of dialysis, is that most people have not spent 5 seconds thinking about it. Dialysis is a “set it and forget it” entitlement. Medicare covers it, so who isn’t affected ever has to think about it. And, as you well know, most dialysis is exactly the way I described it and not an easy thing under the best of conditions. You’re just used to it.

  22. Should be “there’s no particular reason” and “anyone who isn’t affected.” That will teach me to post without previewing.

  23. I should note also that if you are concerned with displacing altruistic donation of hearts and lungs, that displacement would probably occur with any increased focus on living donation of kidneys, regardless of whether payment was involved. And, of course, there could also be payment for deceased donation, or at least a token thank you of, say, a state tax credit for funeral expenses, something a number of states have wanted to do. A few years ago, the now-infamous Governor Sanford actually vetoed such a bill in South Carolina.

  24. I am more aware than you of the average urinator’s lack interest in, or knowledge of, renal replacement …

    If a kidney is worth 25K why should I give you my Mom’s liver? You’d never get one out of the Blagojevich family if they thought it was a “fucking valuable thing.”

    It’s a priceless gift; it’s a valuable commodity. You’re assuming hearts et al will continue to be viewed as potential gifts once kidneys are seen as commodities.

    My position remains that the discussion should start with the irreplaceable organs. Not with kidneys.

    If all you wanted came to pass there would still be hundreds of thousands of people using dialysis to replace their kidney function and then as now there care would benefit from more than 5 seconds of your (the public’s) time.

  25. I own a car. I can sell it if I want to. When I die, my wife can sell it if she wants to. I don’t understand why the same rules don’t apply to my own fucking body!

    Who are you, Bill Peckham, to say that I cannot sell MY kidney if I want to? Why is it any of your goddamned business?

    How it will effect other donations is a secondary concern. How it will effect my freedom to do what I want with my own body is the primary question.

    Eyes, hearts, kidneys, lungs – these are only “priceless” because the state says so. The are not valueless, but that value is being stolen by fiat. The shortages we see now are no different than the shortages that come with any price-control scheme.

    Freedom will fix it.

  26. Overkill your proposed freedom comes with externalized costs.

    Should your next of kin receive the value of the all of your pieces if you were to die in the right way (as Postrel described)? Your demand for the rights of ownership illustrate where a kidney market might lead.

    If an otherwise healthy 20 year old died in just the right way could the next of kin auction off the rights to all their prime grade A parts?

  27. I am a physician and a renal patient on home hemodialysis. I have contraindications to renal transplant and thus at this stage in my disease, I choose the home dialysis option. Unfortunately, there are few people who have access to home dialysis here in America. It is a unique American problem since many other developed nations have half of our outrageous dialysis mortality. Daily dialysis evens the playing field to the point where short daily dialysis has an equal mortality to cadaveric transplant.

    To cary this reasoning further, a large part of the argument many put forth for payment for renal donation is to reduce the rate of dying while on the waiting list for a kidney. the quickest fix for that is to offer more on the wait list optimal dialysis right now without any change in transplant ethics that many such as myself are leery of. It is a unique American problem that so many die while on the wait list.

    In addition, those on the wait list represent only 1/4 to 1/3 of all of us in America that are on dialysis. What will payment for renal donation do for those that choose an alternative treatment. The answer, nothing at all. What will providing optimal dialysis do for those on the transplant list? It will give them a better chance of survival before and after transplant.

    My question is why are the proponents of renal payment so silent about optimal dialysis? I can’t answer that question, but I would really like to hear their reasoning. Thank you in advance.

  28. As a follow up to my post above, why not simply advocate for daily dialysis for all patients placed on the renal transplant wait list. Thus, we could equalize the survival rate during and after transplant. In fact, some on this program may choose to forgo transplant and all of the side effects of anti-rejection meds lending to lower numbers on the transplant list.

    Thus, we would eliminate the survival differences and remove the argument of people dying on the transplant list justifying a walk down new ethical roads since survival would be equal before and after transplant. That is the objection that Bill Peckham has voiced on his website for a long time. Both of us would simply like to here a response from Postrel and Satel on the issue of optimal dialysis which not only saves lives, but also saves taxpayers a lot of money from fewer hospitalizations.

  29. You aren’t going to like this comment, Virginia, but I’m repulsed that you gave your kidney to Sally Satel, a vigorous advocate of drug prohibition. This evil woman supports throwing people into prison for victimless “crimes” and helps to justify a policy which increases the crime and murder rate. Satel has blood all over her dirty totalitarian hands.

    I would have let her die before giving her the time of day, let alone a kidney.

    Satel’s opinions on drugs are as repulsive as if she supported torture or child molestation. People like her should be shunned by civilized society.

    I will give Satel credit for supporting a free market in kidneys. When she supports a free market in drugs, I’ll retract my comments.

  30. My sister Laura Amador and I have been apart of a , coast to coast, kidney paired exchange program involving a altruistic donor, Max Zapata. It is absolutely incredible there are individuals with a high degree of self-sacrifice to donate a kidney to anyone, giving a gift of life; a second chance to live. My sister and I have a website http://www.dancefordonors.org

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