Could Organ Donation Incentives Solve Shortages?

Published November 5, 2009

The debate over selling human organs has come into the news again following the arrest this summer of a New Jersey businessman accused of buying and selling kidneys, and the speedy procurement of a liver transplant for Apple CEO Steve Jobs.

The central questions in the ongoing debate have been whether creating financial incentives for organ donation is morally acceptable and whether objectionable unintended consequences could result.

High Demand, Low Supply

All parties agree there is a need for more organ donations. According to the United Network for Organ Sharing, the number of people waiting for an organ in the United States has increased from 31,000 in 1993 to more than 100,000 today.

While demand is high, supply is painfully low. There are only about 20,000 organ transplants each year in the United States.

“The tactics question is the most difficult. The highest resistance is to sales [of organs], even though that offers the greatest gains,” said Richard Epstein, a noted legal scholar at the University of Chicago School of Law. “The best short-run solution is to use state incentives to those who have organs but not from the individuals who receive them.”

Some observers suggest abolishing the National Organ Transplant Act, which makes it illegal for organs to be exchanged for valuable consideration.

“If just some changes are made, the responses will be uneventful, as they usually are,” Epstein said. “I think we should have open markets, watch them develop with intermediates, warranties, and checks of one sort, and they would do fine if left to their own devices. We have such markets for plasma and the like.”

Good Policy or Morally Wrong?

Benjamin Hippen, general and transplant nephrologist at the Carolinas Medical Center in Charlotte, North Carolina, agrees something should be done, but he is unsure whether allowing people to buy and sell organs would be good policy.

“A system of buying and selling which merely mimics the horrors of international, underground organ trafficking in developing countries would only bring further harm to both donors and recipients,” Hippen said. “But our current system, wherein no plausible solutions are offered to the growing disparity between the demand for and supply of organs in developed countries, has given rise to economic support for the underground organ trade in developing countries.

“As it happens, organ brokers in developing countries are an unsentimental lot, and are little impeded by empty moral posturing,” Hippen said. “What they do understand is opportunity costs: If desperate recipients of means stop supporting them economically, the international gray market in organs will be substantially attenuated.”

Regulated Market Suggested

Arthur Matas, director of renal transplant service and professor of surgery at the University of Minnesota Medical Schools, favors incentives but wants them highly regulated to prevent fraud and abuse.

“I think that the organ shortage is a crisis and the ‘old’ remedies are not working,” Matas said. “We need to try something different, and I’m in favor of trials of incentives, but I would only favor a carefully regulated system.”

Hippen also favors pilot trials providing a variety of financial and coverage incentives for donation.

“Whatever is introduced must maintain existing standards of safety for both donors and recipients; the process must be transparent to all parties; and those who do not wish to participate should not be penalized for abstaining from such a program,” Hippen said.

“And whatever program is put in place,” Hippen continued, “must be governed by the rule of law and prospectively monitored and studied. If unintended consequences arise, there should be clear mechanisms in place for intervention.”

Equality Concerns Expressed

Opponents of organ sales claim only the rich will benefit from such a marketplace, and Hippen believes organ allocation should not in any way be predicated on the socioeconomic status of the recipient. However, he concedes this may be an unavoidable consequence of such a market.

Nevertheless, Hippen says the economic impact of organ selling still would be positive.

“It is uncontroversial that kidney transplantation is vastly cost-effective compared to chronic dialysis. A successful transplant pays for itself after 18 months compared with dialysis, and is significantly cost-saving thereafter,” Hippen said. “Since the federal government currently expends $23 billion annually on kidney failure in the United States, even modest increases in transplantation would save taxpayers substantial amounts of money.”

Details, Details

Matas believes donors may have widely differing motives and priorities.

“There should be incentives, and we do not want to get bogged down in the specifics, but there are many possibilities to try: [Paying donors for] one year of term life insurance, lifetime health insurance, college tuition, tax deduction, direct payment,” Matas said.

Several organ-focused groups, such as the National Kidney Foundation, favor at minimum covering donation-related expenses. According to Dolph Chianchiano, vice president for health policy and research at the foundation, the NKF supports legislation to create tax credits for living donors.

Yet it is difficult to know what impact such incentives would have on potential donors.

“In any case, doing nothing isn’t an option. If the developed countries continue to marginalize discussions of this solution, the problem in developing countries will worsen,” Hippen said. “More donors and recipients, rich and poor, will needlessly suffer and die as a consequence.”

Sarah McIntosh ([email protected]) teaches constitutional law and American politics at Wichita State University in Kansas.