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Cash for human kidneys: A bad idea is back

In 1983, along with many other kidney doctors, I received an unsettling letter from a new organization established to set up a market in human kidneys.The International Kidney Exchange, Ltd, as the venture was known, offered a simple business model:  buying kidneys from live donors and selling them to people in need of transplants. 

The negative response was immediate and overwhelming. Within a year, the National Organ Transplantation Act, sponsored by Rep. Al Gore Jr. (D-Tenn.) and Sen. Orrin Hatch (R-Utah), was enacted, outlawing organ donation in exchange for what was termed “valuable consideration.” 

{mosads}Unfortunately, this idea hasn’t gone away, fueled by the shortage of kidneys and waiting lists that continue to grow. Last year alone, more than 35,000 people joined the US kidney transplant waiting list, and every day, 12 people died while waiting for kidneys. 

Such statistics are behind a renewed campaign to legalize human organ sales in the United States, with support coming not from a rogue organization  but from respected transplant professionals, economists and ethicists who argue that it’s an idea whose time has come. 

I beg to differ. Permitting organ donation in exchange for valuable consideration—whether money, health insurance, or some other cash equivalent—was a bad idea in 1983, and it’s a bad idea now. 

I’ve arrived at this position based on my three decades of experience as the medical director of one of the largest kidney transplant programs in the United States, performing more than 100 live donor transplants every year. In this role, as I examine potential live kidney donors, I have seen first-hand how far people will go to try to help loved ones. Many unsuitable donors try to persuade me to allow them to donate anyway, despite high medical risks. Others take steps even more extreme—and dangerous. Consider the 37-year-old woman who, without telling me, stopped her anti-depressants knowing that a history of depression might make her ineligible to donate to her friend. Or the 51-year-old cocaine addict who wanted to help her brother and forged a letter from her physician stating that the cocaine was treatment for a nasal condition. Had we not uncovered this, the outcome for donor and recipient would likely have been disastrous. 

Some go to other transplant centers and change their stories or covertly take medications to normalize their blood pressure or blood sugar in hopes of passing the evaluation, putting their own health at risk and potentially leading to the donation of unsuitable kidneys. 

Now imagine if there were a significant financial reward at stake, increasing the incentives to lie or dissemble. Many would surely do their best to disguise any medical conditions that might prevent them from donating in order to collect the reward, thereby adding to their own medical problems and potentially donating kidneys of lesser quality and thus harming the recipients. After all, they would now be donating to a stranger in order to enrich themselves or to address an urgent financial need, not to save a loved one. 

Doctors, too, would be confronted with terrible dilemmas. Take the potential donor who desperately needs cash or cash equivalent to prevent foreclosure on a home, pay for education for their children, or keep their business open. What is the responsible caring physician to do? It’s easy to say that this would not factor into a medical decision, but doctors are human. It’s hard to see how such considerations could be entirely avoided.   

Finally, there is no way around the fact that the world’s poorest people would be those most incentivized to donate. Despite the ban on human organ sales in almost all countries, black markets in live donor kidneys have flourished for decades, and multiple studies of paid donors around the world have shown that the flow of kidneys is inevitably from poor to wealthy. In all these markets, it is well documented that the donors end up worse off than prior to their donation, despite temporary financial relief. In a world of increasing disparity between the rich and poor, is this the direction we want to go, buying body parts from the poor? 

Even aside from the ethical issues—and these are, in my view, huge and insurmountable—there is the question of whether a market in kidneys would even succeed in making more kidneys available.  Would you ask your brother or sister to donate a kidney to you, however small the risk, if a kidney from a paid stranger were provided by the government? 

None of this is to say that the current situation is acceptable. We can—and must—do a far better job eliminating barriers to those who want to donate. One promising avenue involves assuring financial neutrality for our live organ donors—in other words, if you make the life-saving gift of a kidney, you won’t end up financially worse off than you were before. 

That isn’t the case today. Currently, it is estimated that on average a live kidney donor incurs $5,000 in of out-of-pocket expenses (including travel, housing, child care) as well as lost wages, a financial disincentive that prevents many people from donating. Not surprisingly, a recent study has shown that since 2005, among those at the highest income level, rates of live kidney donation have in fact increased, whereas at the lower income levels decreased. 

If we really want to address the shortage of kidneys available for transplant, we should commit to full reimbursement of the costs of donation. We would not be starting from scratch here. When the U.S. Congress passed the National Organ Transplant Act in 1984, it foresaw that this might be an issue and, while outlawing buying and selling organs, specifically allowed for the reimbursement of “the expenses of travel, housing, and lost wages incurred by the donor of a human organ in connection with the donation of the organ.” In addition, the 2004 Organ Donation and Recovery Improvement Act (P.L. 108-216), signed into law by President George W. Bush, paved the way for creation of the National Live Donor Assistance Center, which under a federal grant reimburses some donor expenses. 

We need to build on this foundation and fully reimburse all costs imposed on live kidney donors. The annual cost of a kidney transplant is less than 25 percent of the cost of maintaining a patient on dialysis, so every live donation saves the government money. Investing small sums to enable family members and friends to afford to donate their kidneys makes common sense, financial sense, and ethical sense. Unlike cash for kidneys, this is truly an idea whose time has come.  

Cohen is medical director of Kidney and Pancreas Transplantation at New York Presbyterian Hospital/Columbia University Medical Center, professor of Medicine at Columbia University College of Physicians and Surgeons, and an OpEd Project Public Voices Fellow.

Tags Al Gore Orrin Hatch

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