Kidney for Sale: Let's Legally Reward the Donor

World Kidney Day, to be held Thursday, is part of a global health campaign meant to alert us to the impact of kidney disease. Sadly, there is little to celebrate.

According to the International Society of Nephrology, kidney disease affects more than 500 million people worldwide, or 10 per cent of the adult population. With more people developing high blood pressure and diabetes (key risks for kidney disease), the picture will only worsen.

There are nearly two million new cases of the most serious form of kidney disease--renal failure--each year. Unless patients with renal failure receive a kidney transplant or undergo dialysis--an expensive, lifelong procedure that cleanses the blood of toxins--death is guaranteed within a few weeks.

Last year, Australian nephrologist Gavin Carney held a press conference in Canberra to urge that people be allowed to sell their kidneys. "The current system isn't working," The Sydney Morning Herald quoted him as saying. "We've tried everything to drum up support" for organ donation, but "people just don't seem willing to give their organs away for free."

Dr. Carney wants to keep patients from purchasing kidneys on the black market and in overseas organ bazaars. As an American recipient of a kidney who was once desperate enough to consider doing that myself (fortunately, a friend ended up donating to me), I agree wholeheartedly that we should offer well-informed individuals a reward if they are willing to save a stranger's life.

If not, we will continue to face a dual tragedy: on one side, the thousands of patients who die each year for want of a kidney; on the other, a human-rights disaster in which corrupt brokers deceive indigent donors about the nature of surgery, cheat them out of payment and ignore their postsurgical needs.

The World Health Organization estimates that 5 per cent to 10 per cent of all transplants performed annually--perhaps 63,000 in all--take place in the clinical netherworlds of China, Pakistan, Egypt, Colombia and Eastern Europe.

Opponents of donor compensation allege that a legal system of exchange will inevitably replicate the sins of the black market. This is utterly backward.

Unfortunately, much of the world transplant establishment--including the WHO, the international Transplantation Society, and the World Medical Association--advocates only a partial remedy. They focus on ending organ trafficking but ignore the time-tested truth that trying to stamp out illicit markets either drives them further underground or causes corruption to reappear elsewhere.

For example, after China, India and Pakistan began cracking down on illicit organ markets, many patients turned to the Philippines. Last spring, after the Philippines banned the sale of kidneys to foreigners, a headline in The Jerusalem Post read: "Kidney transplant candidates in limbo after Philippines closes gates." (Israel has one of the lowest donation rates in the world, so the government pays for transplant surgery performed outside the country.) Similarly, patients from Qatar who travelled to Manila are "looking for alternative solutions," according to the Qatari daily The Peninsula.

True, more countries must develop efficient systems for posthumous donation, a very important source of organs. But even in Spain, which is famously successful at retrieving organs from the newly deceased, people die while waiting for a kidney.

The truth is that trafficking will stop only when the need for organs disappears.

Opponents allege that a legal system of exchange will inevitably replicate the sins of the black market. This is utterly backward. The remedy to this corrupt and unregulated system of exchange is a regulated and transparent regime devoted to donor protection.

My colleagues and I suggest a system in which compensation is provided by a third party (government, a charity or insurance) with public oversight. Because bidding and private buying would not be permitted, available organs would be distributed to the next in line--not just to the wealthy. Donors would be carefully screened for physical and psychological problems, as is currently done for all volunteer living kidney donors. Moreover, they would be guaranteed follow-up care for any complications.

Many people are uneasy about offering lump-sum cash payments. A solution is to provide in-kind rewards--such as a down payment on a house, a contribution to a retirement fund, or lifetime health insurance--so the program would not be attractive to people who might otherwise rush to donate on the promise of a large sum of instant cash.

The only way to stop illicit markets is to create legal ones. Indeed, there is no better justification for testing legal modes of exchange than the very depredations of the underground market.

Momentum is growing. In the British Medical Journal, a leading British transplant surgeon called for a controlled donor compensation program for unrelated live donors. Within the past year, the Israeli, Saudi and Indian governments have decided to offer incentives ranging from lifelong health insurance for the donor to a cash benefit. In the United States, the American Medical Association has endorsed a draft bill that would make it easier for states to offer non-cash incentives for donation.

Until countries create legal means of rewarding donors, the fates of Third World donors and the patients who need their organs to survive will remain morbidly entwined. What better way to mark World Kidney Day than for global health leaders to take a bold step and urge countries to experiment with donor rewards?

Sally Satel, M.D., is a resident scholar at AEI. She is the editor of When Altruism Isn't Enough: The Case for Compensating Kidney Donors (AEI Press, 2009).

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