On organ trafficking.

Gray1127The New York Times has run several features recently discussing organ trafficking from living donors.  As in, paying somebody to go under the knife and have an organ cut out in order to give it to you.  Typically kidneys, since humans can get by with one but are born with two.  And, yes, currently illegal in this country.  Apparently illegal almost everywhere except Iran.

Which sounds reasonable at first.  Like banning prostitution.  In some ways even akin to banning drug abuse, although that comparison is more of a stretch.  The idea seems to be, protect people from themselves.  If people were allowed to sell their bodies for money, well, they might do it.  And there are adverse consequences.  Nobody wants unnecessary surgery.  There could be health complications during the organ removal procedure itself, and there might be eventual consequences of having only one kidney.  So you’d imagine that only poor people would sell organs, people who think they have no better options in life.

And, yes, it seems rather rotten that poor people would be subject to these adverse health costs if paid organ donation were legalized.  But it is also possible to imagine a regulated system in which paid donors were relatively well compensated.  Currently, despite the illegality, kidneys are sold.  International patients seeking a kidney seem to pay out somewhere on the order of $200,000.  Paid donors receive about $10,000.  The cost of a transplant seems to be around $150,000.  And the cost of dialysis, which is the alternative treatment for patients who need a kidney, is around $80,000 per year.  For the current U.S. system, in which most patients wait four or five years before receiving a kidney, the cost of dialysis over that time is around $350,000.

Given all those numbers, the amount that people who are currently (illegally) selling kidneys seems much too low.  Insurance companies would save the entire cost of dialysis over a multi-year waiting period if more organs were offered for sale.  If the treatments are equivalent, then from the perspective of doctors, patients, and insurance companies, the finances would work out to be nearly the same if paid donors received that entire $350,000.  Only manufacturers of dialysis equipment would be negatively effected.  At the very least, the full difference between what a patient is willing to pay for a new kidney and the actual cost of the procedure, perhaps $50,000, should go to donors.

Those are rather large amounts of money.  Between two and fifteen years of income for many people in this country, if not more.  And, from what I’ve read, the argument is that financial inducements that large are unethical.  To get money, people might act against their own best interests.  This is basically the reason why, for Phase I clinical trials, drug companies are required to offer very low compensation to participants.  By paying them poorly, the participants can be referred to as “volunteers.”  They ingest compounds never before tested for safety in humans, maybe spend the night in a hospital facility, and receive, what, a hundred dollars or so?  And because they are receiving so little money, the argument can be made that these people are acting out of altruism.  They just want to see new drugs developed.

This doesn’t seem reasonable.  Carl Elliott presents a good analysis of the practice in his book White Coat, Black Hat.  It seems that the actual effect of offering small amounts of money is that only the neediest will participate.  Having an extra hundred dollars needs to be a really, really big deal for it to seem worthwhile to participate in many of these tests.  Likewise, having $10,000 probably seems like a really, really big deal to people selling their kidneys for that amount.

But, okay, let’s say that instead of them happening by chance across a middleman in the organ trade, being offered $10,000 and saying sure, why not? and going under the knife, there were a regulated system where donors received somewhere between $50,000 and $350,000.  The people who are already selling organs would be strictly better off.  Patients who need organs would seem to be better off, since they can be treated without doing anything illegal.  And then the issue is: what about people who would not sell an organ for $10,000, but would if you offered them $50,000?

Well, poverty itself is bad for your health.  There’ve been studies suggesting that the stress of financial uncertainty causes some of these health problems.  So it’s possible that, for someone in that situation, their health would actually improve if they were given the opportunity to sell an organ for a large sum of money.

Another issue is, if more people were willing to sell organs at a high price, would there be too many?  But that doesn’t seem like an issue.  If there are too many offers, potential sellers can be screened and only the healthiest given the opportunity to sell an organ.  It’s not even a great prize: for me, since I have never been in dire financial straights, it’s not something that I would ever consider doing.

So, I personally don’t think that selling organs should be illegal.  I think it’s crumby, both how much money is involved in health care in general and that as a result it takes a lot of wealth to receive the best treatments, like to be a patient and receive a kidney, and, yes, I think it’d be crumby if we lived in a country where poor people felt like they had to sell an organ or two while others lucky enough to be wealthy were able to maintain their bodies intact.  But being poor already seems to be crumby: I don’t think that a regulated system offering people the full value of their organs would make it more so.

AFTERTHOUGHT: Maybe I should have made explicit, so that people know I’m not evil, that I’m not proposing a free market solution?  That estimates of the supply and demand curve for the U.S. suggest that you would only *need* to offer poor people $15,000 in order for enough to voluntarily give up organs to meet all demand.  Whereas I want a regulated system specifically so that people get paid more than that, they get paid for the total amount of value they’re giving away.

And, sure, maybe then someone would still try to arrange something illegal – try to pay 180k and offer someone 30k who otherwise wouldn’t be healthy enough to sell an organ and use the other 150k to cover the cost of transplant, but if someone is wealthy enough to pay under the table like that, why would they want a terrible organ?