Dying People Shouldn't Have to be Beggars

It's time to consider the economics of organ transplants


It is not from the benevolence of the butcher, the brewer or the baker that we expect our dinner, but from their regard to their own interest. … Nobody but a beggar chooses to depend chiefly upon the benevolence of his fellow-citizens.—Adam Smith, The Wealth of Nations

Consider the economics of an organ transplant. Everyone involved gets something of value. The doctors and nurses are paid. The hospital receives money. The organ recipient gets something that will save her life. And the person donating the organ gets a nice, warm feeling inside.

We can all admire the selflessness of the donor. But if pure altruism is such a wonderful motivator, why don't we rely on it to get medical professionals to provide their services?

Simple: Because we would find that there are far more people demanding free care than people supplying it. To make sure that we can obtain the treatments we need, we elect to pay, not hope. It's too important to rely on altruism.

Our approach changes, though, when it comes to procuring kidneys and livers. In fact, since 1984, it has been illegal to pay someone to surrender a body part, even posthumously. Campaigns to browbeat Americans into signing organ donor cards, however, haven't sufficed. The transplant organ shortage has grown.

Since 1989, kidney donations have doubled. But the number of patients in need of them is five times higher than it was then. Last year, 4,456 people died while waiting for a kidney transplant. The story with livers follows the same line.

Among the losers from this guaranteed-shortage policy are victims of cancer and other lethal diseases who need bone marrow transplants. Some of them have filed a lawsuit, which goes to court in Los Angeles this week, asking to be allowed to offer compensation to donors—which is now a felony punishable by five years in prison.

One of the people involved in the lawsuit is Doreen Flynn of Lewiston, Maine, a single mother with five kids—including three afflicted with a rare, fatal blood disease that can be cured only with a bone marrow transplant.

The ban is particularly indefensible in this realm. Someone giving up a kidney loses an important organ for good. But bone marrow donors produce new marrow to replace what is lost. Given that it's legal under federal law to buy and sell blood and sperm, why is bone marrow treated differently?

Monetary incentives would offset the downside of letting strangers perforate your flesh with sharp instruments. Someone who provides marrow has to go through a longer and less enjoyable process than supplying blood or sperm.

Typically, marrow donors have to get injections for five straight days. They then undergo a blood-collection process that takes three hours and sometimes has to be repeated.

Often, donors are anesthetized so a needle can be inserted into a hip bone. In that case, says the American Society of Clinical Oncology, they may need a week to fully recover.

Donating is not an excruciating experience, but it's unpleasant and time-consuming enough that about the only people who do it are those with a strong motive (say, a friend or relative in need).

One result is that one of every three volunteers matched to a recipient backs out, leaving the patient high and dry. According to the Institute for Justice, which is handling the case, 1,000 people die each year for lack of a suitable marrow donor.

If Americans could be paid for bone marrow, more would step forward. Nobel Prize-winning economist Gary Becker of the University of Chicago, in a 2007 paper written with Julio Jorge Elias of the State University of New York at Buffalo, figured the kidney shortage could be eliminated for $15,000 per organ.

That's not much, considering that it means the difference between living and dying. It would add only 10 percent to the total cost of a transplant.

The fee would be much lower for bone marrow, simply because the donor can quickly regenerate what is lost. In the California lawsuit, the plaintiffs only want to be able to try offering compensation in the form of a scholarship, a housing allowance or a gift to a designated charity.

There is certainly no better option on the horizon. The benevolence of our fellow citizens can be striking. But it's not something to bet your life on.


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  1. What could go wrong with that?

    1. You realize, of course, that if the survivors were paid for decedents’ kidneys, there would be precious little market for live-donor kidneys.

      1. MikeP, he’s a troll. He makes sure he doesn’t realize anything.

      2. He also fails to realize that those are the results of an illegal black market, and why it actually bolsters the case for a legal market…

  2. How much for the women?

  3. that’s just silly. the person who contributes the most should always be the most poorly compensated. duh…

  4. Its classic Marxism – from each according to his abilities. . . .

    You’re able to get by without that kidney or liver lobe, ergo . . . .

    1. I remember in medical school one of the most heated debates we had was involving organ transplants and affordability.

      Probably the biggest barnburner was someone of means who could afford a new liver, but happened to have a hx of alcohol abuse, effectively causing his need for a replacement liver. It was argued that he should not receive a new liver even though he could pay v. say a younger, more viable recipient with a natural pathogenesis. Even though the younger patient’s family lacked the funds to pay for the procedure and subsequent therapy upfront.

      I argued quite passionately that the one who could pay had first crack at the organ, even though he was older and had a hx of alcoholism. Then thrown into the mix was should he be stipulated to remain abstinent of alcohol so he could qualify for the procedure. I argued no, if he survived the procedure he had the right to do as he wished upon recovery and discharge, even though the younger patient was denied the liver because of ability to pay.

      I was vilified by some of my peers, saying I was cold and callous and I shot back, “Really, and how do all these wonderful procedures continue if no one pays? Cost shifting? I thought we were in the business of acting on the behalf of patients without preconceived notions of moral judgment? Are you going to practice medicine for free?”

      My caveat was since alcoholism is a disease, the man deserved to be treated without prejudice and stipulation and first since he could pay.

      As far as living donors go, in the US it is a requirement that a personal relationship has been established and verified for non-family donors.

      1. I have a disease… Can’t you understand that??

      2. What if some rich bugger wants to buy human livers and kidneys to put in his compost heap?

  5. I was reading the NJ state standards for health education when I found this gem:

    Emphasize the benefits of organ and tissue donation to the health and well-being of society generally and to individuals whose lives are saved by organ and tissue donations, so that students will be motivated to make an affirmative decision to register as donors when they become adults.

    I feel a bit quesy about state educators presuring children to volunteer to give up their organs.

    1. “I feel a bit quesy about state educators presuring children to volunteer to give up their organs.”

      Hey, they already DEMAND that the kids give up their BRAINS . . !

  6. Oh please, this is a libertarian website. It’s not so much that you hate that dying people have to be beggars, it’s that dying people who can afford to buy an organ shouldn’t be beggars. People who can’t afford it and are dying should be beggars of course.

    1. Some people are miserable. Thus, everyone must be made miserable.

    2. failure must be eliminated. it has no useful purpose.

    3. The number of people who can afford $150,000 to save their lives but can’t afford $165,000 is vanishingly small.

      Yet you find them a suitable foundation for a moral position?

    4. Jesus Christ, MNG. Just shut the fuck up.

    5. Only a truly ignorant person assumes that his ideological opponent doesn’t have good intentions. I would never assume that about liberal progressives, although some obviously do not have good intentions. It’s not their intentions that make them outrageously ignorant (though that helps), incompetent, or repugnant. It’s just that even when one takes them at their word and accepts the best of their intentions, their philosophy still fails epicly and makes all of humanity worse off. The goal of libertarianism is to make everyone better off, and, yes, we are compassionate, which means we can even tolerate liberal progressives such as MNG.

      1. The road to Perdition is paved with good intentions.

        Can’t make an omelette….

        1. Can’t make my omelette without smashing someone else’s eggs.

    6. No body needs to “afford” anything.

      Very few people have the cash on hand to buy a car or a home, I’m sure you can pay for the kidney in monthly installments. Jesus, we’re talking about saving REAL PEOPLE’S lives by simply eliminating an immoral law governing the actions of consenting individuals. Wow, grow up.

    7. MNG, you truly remind me of the poor dope in a Russian fable where he was envious of his neighbor’s goat, as the dolt was too poor to afford one. He came across a djinn who gave him one wish. Being of the vengeful and jealous type, instead of wishing for his own goat, he wished for his neighbor’s to die so neither would have a goat.

      I used to think you were reasonable at times, but I’m convinced you are of the passive/aggressive vindictive variety.

    8. Let’s see if I can translate: People who make bad decisions should not have to live with the consequences of those bad decisions. People who make good decisions should.

      Is that about it?

  7. Could you please change the title of the article? It might be misconstrued as supporting health care reform. If dying people don’t have enough money, then they should have to be beggars. That’s life ? or death ? in a free market.

    1. As Milton Friedman pointed out, 1) using such examples is ridiculous to justify an entirely unjust system, 2) if someone is dying and doesn’t have enough money, there are many different conclusions we could reach: A) said person needed to plan better, B) a tragedy befell said person and his relatives and friends should foot the bill as happens normally in society, C) private charity groups should foot the bill

      These are just some options in a free market. Of course, those who are conscientious and compassionate could offer to help the dying person privately if they truly cared. Or, better yet, they could enter the market and provide free services to dying people. Nope, never, that’s what they are asking others to do.

  8. This topic was so much better when Virginia Postrel used to write about it…

    1. BP,

      You know, I met her back when she was editing Reason. Same conference where I heard Friedman speak (met his son, too, and bought one of his books).

      1. One of who’s books? Milton or David? Did any of them (Friedmans or Postrel) have anything of interest to say?

        1. Milton was the speaker–awesome. I spoke to David a bit (bought his book). I was with several other people with Virgina–can’t remember anything specific.

          I also met David Brin and Harry Browne there. I went to dinner with some people, a couple of whom wrote for Reason, but I don’t remember who they were.

  9. Dying People Shouldn’t Have to be Beggars

    Beg? Who’s begging? I demand one of Tony’s or Chad’s kidneys – right now, too, not after they’re dead. It should be part of the healthcare bill.

    1. Given the dehumanization involved in turning human organs into saleable commodities, I wouldn’t be surprised if mandatory organ donation is tucked away in HRC somewhere.

      1. “Given the dehumanization involved in turning human organs into saleable commodities…”

        I take it you don’t support prostitution. Or is it OK to offer THAT organ for sale?

      2. I know (or I think) that you’re trying to be funny, but I’ll answer you seriously. If we look at a prostitution transaction in and of itself it is hard to say that it would be anything but an honest transaction. If you look at what such an industry can potentially involve, things like human trafficking, extortion, kidnapping and the use of minors then perhaps it seems more reasonable to assert that it is lowering the value of human life.

        Obviously the concept has limits. You can’t make a sensible argument that someone using their muscles would be dehumanizing but I think the skin has to be the limit (and yes I suppose that allows strippers too).

        1. And yes, this could be the starting point for some very silly counter-examples, but I think the point is still valid.

        2. Those things are only associated with prostitution because it’s illegal! The argument for legalizing prostitution is based on the same premise as ending prohibition on drugs. If I may steal an analogy from Penn and Teller’s Bullshit!: if the government outlawed fishing tomorrow you’d have to purchase your fishing tackle from the Mafia, it doesn’t mean that crime and death are the result of fishing.

          And the issue here is whether or not you have the right to stand between a person who wants to sell and a person who wants to buy and say “you sir are not entitled to your $15,000 and you sir are not entitled to your life”. If you believe that the transaction is “dehumanizing” then fine; but please leave people who don’t alone, you don’t have the right to take a life to prevent a person from being “dehumanized” (death isn’t dehumanzing?).

          1. Here’s a well sourced wikipedia article on human trafficking. I think the issue is far more complex than fishing tackle.

            As for the rest, well, I don’t think it’s as easy as you want it. Of course I don’t have a right to interfere with a purely voluntary transaction. I have the right to object to the moral ethic which makes such a transaction possible, which makes a human no more valuable than the sum of his or her parts, a thing to be used, consumed and discarded. The robber barons and Commissars agreed on this one point if nothing else.

            1. Because when someone donates out of the goodness of their heart, their body parts are not being consumed by another. There is a difference between the transaction that a person does for feel-goods and the transaction that a person does for money. Riiiiiiiiiight.

              1. Yep: the type of transaction in which only one side gains a real benefit is the only kind that is not “dehumanizing”. Adding money to the equation is what makes it dehumanizing. Dare I call our comrade a Marxist?

  10. The doctors and nurses are paid. The hospital receives money. The organ recipient gets something that will save her life. And the person donating the organ gets a nice, warm feeling inside.

    Wouldn’t the donors get more of a cold, empty feeling if they just gave away one of their organs? Just sayin…

    1. The warm feeling is the post-op infection.

  11. I would imagine that the reason that compensation for organs is banned is simply to keep them from becoming subject to the pressures of supply and demand (i.e., the rich shouldn’t be the only ones with access to organs). Course I say that without any current need for an organ.

    1. In other words, the reason that compensation for organs is banned is simply that those making such decisions are economic illiterates.

      It’s not necessarily something to be ashamed of. The decision makers did, after all, spend their time learning medicine and law rather than supply and demand.

    2. Yes, It’s much better to only let the lucky, politically connected, or those willing to cheat to get organs. Anybody but “the rich”. Actually “the rich” can still buy them ….. they just have to buy an airplane ticket first. So the evil vindictive part of the fantasy doesn’t even come true, and we still have this dumb ass shit sittin around to deal with.

  12. This already goes on in America via the black market just like any other thing some value “we as a society” deem as wrong. People need to understand that the only way to address shortages is to give people incentive to produce the commodity. It looks like Becker’s research shows that this will be relatively affordable (especially if one’s life depends on it). Those who are generous enough to donate can donate to separate transplant center for those who truly can’t afford it. I really think this would end up saving more lives (rich and poor) than continuing to adhere to this bogus law.

    1. It might work if those paying were the medical establishments instead of the recipients themselves. As I said upthread, I find myself very uncomfortable with the idea, but as long as the ethic is curing disease and not the desire to make a fast buck.

      The one thing that eases my ethical qualms is that it is an entirely need-based system. No one gets out of bed one day and says: “I’m going to get me a new kidney, this one just doesn’t feel right!” Since demand is contained there wouldn’t be too much supply pressure.

      1. Just to be clear: I’m imagining that the recipients would be paying the medical establishment. I’m not with you guys on too many issues but HRC is one where I’m on your side

        1. What would be the difference between the medical establishments paying for the organs and people buying them directly from others? A market price would be established either way and more than likely the “medical establishment” would act like any other business and use their government granted power to profit. While there would need to be some oversight to the process I think it would work better if it was a person to person process with some kind of mediator organization to connect people.

      2. You don’t support the voluntary trade of organs because it doesn’t “feel” right? You’re not “comfortable” with a person making “a quick buck”? If we must rely on altruism alone then payment for organs is redundant; we might as well leave things as they are! After all it would be wrong to allow people to “make a quick buck” while potentially saving somebody’s life.

        This “don’t think, just feel” mentality is the root of all evil. Put your “feelings” about what’s right and wrong to one side and apply reason: is it really right to rob somebody of money they may desperately need or a vital organ they even more desperately need because you feel uncomfortable with the transaction? It hurts nobody, benefits all involved, but we must block it because it doesn’t “feel” right. I repeat: this “don’t think, just feel” mentality is the root of all evil.

        And I’m going to ignore your troll like comment above which attempts to conflate great entrepreneurs that brought light, wealth and transportation to the poor masses to Russian Commissars.

        1. Well actually, I think he was making the case that buying a kidney for the sake of buying a kidney (“This [kidney] doesn’t feel right.”) should be discouraged. It’s sort of similar to the abortion-as-a-form-of-birth-control argument. It should be legal to allow those in danger to perform the situation, not because someone couldn’t find a box of condoms.

          1. Why on earth would anybody buy an organ that they don’t need?! OK then, maybe we should only allow people to purchase organs via doctors (for example) that can claim they truly need them, is that an acceptable compromise?

  13. You never see the other side of the argument that the doctors, nurses and other staff should do this act salary fee. Or that the hospital should not be paid, or hell – the power company should be providing the electricity for free… why is it only the donor is expected to be ‘altruistic’ WTF ever that means anyway…

  14. If freedom to do what you want with your own body is the goal. So should all it’s parts.

  15. This debate is a classic example of the “If it offends me, it must be wrong.” mentality. How many lives have been ruined because individuals weren’t allowed to do as they chose because some group decided their behavior was offensive? My disgust at this type of thinking is one of the primary reasons I am a libertarian.

    If you don’t like it when people sell their organs, don’t do it. But don’t you dare interfere with the lives of others.

    1. This debate is a classic example of the “If it offends me, it must be wrong.” mentality.

      Dear God, the irony! The entire libertarian viewpoint consists of being offended that other people think differently from them.

  16. i’ve told my children that they should try to sell my organs when i die.
    you’re right , the only one who doesn’t benefit is the donor or his family.

    what b.s.

  17. See, it’s this kind of bullshit that drives up healthcare costs.

    Oh, gee, I need a new heart and lungs. Maybe I can have one of those transplants that cost tens of thousands of dollars and then spend the rest of my life wasting money and resources to treat the nuisance cancer outbreaks that are a side effect of my expensive anti-rejection meds, because I’m just that special.

    Man up and die, people. Man up and die.

  18. Do the math: This can never happen. Imagine the cost of all the additional care, additional social welfare/benefit costs etc. And if it does happen then what? Think it through. Just because we can do something does not mean we should.

  19. Under the current system do we allow people who have not previously signed the organ donor card to receive transplants? It might be worth considering banning transplants to people who at the age of consent did not agree to be a donor.

    1. Great idea, that’ll result in even more needless deaths! You anti-humanist nihilists never stop innovating do you?

      1. Great idea, that’ll result in even more needless deaths!

        There is no such thing as a “needless death”, you dumbass. It is necessary that everybody die.

  20. A better idea (not original to me) than markets here is to establish the simple rule that unless you sign up to be an organ donor, you’re not eligible to be an organ receiver. That would likely eliminate the organ shortage.

  21. No.

    This is another of those nutty causes which the libertarian movement uses to difine itself as “different”. Consider it done.

  22. If freedom to do what you want with your own body is the goal.

    That’s NOT the frickin’ goal!

  23. In my area I tried to register to be a bone marrow donor – just out of the goodness of my heart. I was told that I had to go to a special facility to get the cheek swab, AND pay THEM $25 dollars to process my registration…

  24. Dying People Shouldn’t Have to be Beggars

    That’s similar to saying “Beggers Shouldn’t Have to Sell their Organs to Make Ends Meet”.

  25. There are other barriers to donation. I cannot donate blood or organs because I had a false positive HIV test 30 years ago.

  26. This topic was so much better when Virginia Postrel used to write about it…

  27. Hi. I actually enjoyed reading your current blog post!. Good quality content. I might advise you to write articles much more often. By doing this, with such type of a helpful site I think that you could rank higher in the search engines 🙂 . I also subscribed for your Rss. Keep up this excellent job!

  28. Sometimes I sound like I’m arguing, when I’m actually not. I just have a way of putting my posts stronger than intended.It’s easier to keep out of the conversation and not take the chance of being misunderstood.

  29. voting is precisely what we now have.

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