BMJ  2008;336:1343 (14 June), doi:10.1136/bmj.a179

Head to Head

Should we pay donors to increase the supply of organs for transplantation? No

¹ Centre for Transplant and Renal Research, Millennium Institute, University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia

Paymentfor livingkidney donation is illegal in most countries. Arthur Matas (doi: 10.1136/bmj.a157) believes that legalisation is needed to shorten waiting times, but Jeremy Chapman argues that it will reduce the supply of all organs

Transplantation is one of the greatest advances in medical therapy in the second half of the 20th century but is threatened by the global daily carnage brought about by paying for organs.¹ The race to the lowest cost donor is on, with the Philippines, Pakistan, or China set to lose the most by winning.

Cost of sale

Sale of organs is advocated by the rich as a fundamental human freedom, but this right is exclusively exercised by the poor. Solving poverty is unachievable, but if there were no poor people in the Philippines or indentured "workers" in Pakistan sales of their organs would be unlikely to continue.²

Wealthy people are also placed in jeopardy by legalised organ sales. Every patient able to pay will be faced with the question, "Should I wait for deceased organ donation, seek a family donor, or simply buy one?" The allure of using money leaves the individual ever in doubt, many preferring that a stranger rather than a family member takes risks on their behalf.

Some recipients of vendor organs die and do not return home, making it impossible to ascertain the true outcomes of purchased organ transplants. Those that arrive home require care immediately, with many going straight from airport to hospital, since the transplant units aim to discharge patients and get them out of the country before problems arise. The risks of vendor transmitted viral diseases such as hepatitis and HIV are high,^{3 4} and heavy induction over-immunosuppression results in high rates of infection and malignancy. It is hardly surprising that payment is required on arrival and not on departure.

Who profits?

Evaluation of living kidney donors is complex, and less than half of potential donors are found medically suitable.⁵ Evaluation requires sophisticated testing and knowledge of the donor’s medical history and current symptoms, which people trying to sell their organs often hide despite potential consequences for themselves or the recipient.

Selling organs does not help people lift themselves from destitution. In the bazaars of India and Pakistan, people sell kidneys to pay off debts, but average family income declines by a third, more live below the poverty line, and 86% report deterioration in their health.^{2 6} The only people who clearly benefit are the intermediaries who take money as the kidney transits from the vendor to the recipient: organ brokers, transplant surgeons, hospitals, government officials, and the wealthy health insurance companies of the West and the Middle East.⁷

Wider effects

Organ sales distort the vendor country. Sales of kidneys and livers boomed in China between 2004 and 2006. Executions also boomed and were measured with precision since each execution meant one liver transplant. China has recognised the grotesque nature of this trade, which was highlighted by the criminal who murdered a vagrant and forced a surgeon (who later informed the police) to remove the organs for sale. The changes brought about by the Chinese government have yet to fully curtail this business, but the number of executions and liver transplants fell from 3500 in 2006 to around 2000 in 2007.

Organ sales also destroy donation. In countries where paid organ transplants occur, such as Iran, there is little or no donation. In the countries where many, most, or all transplant recipients travel overseas for an organ, the domestic transplant programmes are underfunded and failing.

Regulated market is a myth

Ethical proponents of organ sales advocate a regulated market, managed by government to buy kidneys on behalf of the community. The last vestige of human altruism is at stake. Apart from the devastating consequences of American or European adoption of organ sales on less easily regulated environments in Asia or Africa, the consequences at home destroy the proposition. Which family member will donate if the government will pay someone else $100 000 (£50 000; 63 000) to provide a kidney?⁸ Which recipient will risk a family member’s health when government will pay? And if a kidney is worth money before death, families or individuals will demand money for consent to retrieval of organs after death. Surely the payment must be higher after death because you can use organs that cannot be retrieved from live people?

The consequences of regulated organ purchase will be an implosion in organ donation, reduction in kidney transplantations and destruction of heart, lung, liver, and pancreas transplantation. Purchase of organs is not the answer.

---

Competing interests: None declared.

References

1. Transplantation Society Presidents’ statement. Transplantation (in press).
2. Naqvi A. A socio-economic survey of kidney vendors in Pakistan. Transplant Int 2007;20:909-92.[CrossRef][ISI][Medline]
3. Prasad GV, Shukla A, Huang M, D’A Honey RJ, Zaltzman JS. Outcomes of commercial renal transplantation: a Canadian experience. Transplantation 2006;82:1130-5.[CrossRef][ISI][Medline]
4. Kennedy SE, Shen Y, Charlesworth JA, Mackie JD, Mahony JD, Kelly JJ, et al. Outcome of overseas commercial kidney transplantation: an Australian perspective. Med J Aust 2005;182:224-7.[ISI][Medline]
5. Report of the Amsterdam forum on the care of the live kidney donor: data and medical guidelines. Transplantation 2005;79(suppl 2):S53-66.[CrossRef][ISI][Medline]
6. Goyal M, Mehta RI, Schneiderman LJ, Seghal AR. Economic and health consequences of selling a kidney in India. JAMA 2002;288:1598-3.
7. Jha V, Chugh KS. The case against a regulated system of living kidney sales. Clin Pract Nephrol 2006;2:466.
8. Matas AJ, Schnitzler M. Payment for living donor (vendor) kidneys: a cost-effectiveness analysis. Am J Transplant 2004;4: 216-21

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