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Selling kidneys: An indecent proposal?
- R K Mohindra (1 July 2006)
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No harm in selling kidneys in a world where body and soul are on sale every day (and night)
- Kuldip P Anand MD, Ajit Kashyap MD, Surekha Kashyap MD, Command Hospital (Central Command),Lucknow 226 002,India (5 July 2006)
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A two-part payment scheme for live kidney donors.
- Stephen Jan, Mardi Thompson, Chair of the National Council of Consumer Advocates for Kidney Health Australia (20 July 2006)
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R K Mohindra, SpR Cardiology Freeman Hospital, Newcastle yupon Tyne, NE2 3NT
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In her article Sue Rabbitt Roff1 raises several examples where money does change hands and then argues that the step from not paying for organs to paying for organs is small and justifiable. Let us consider her arguments in turn. A fixed compensation model with the price set by specialists and prize winning economists may well increase the supply of organs but it is unlikely to preclude a (black)market from developing. Logically a person selling their kidney is likely to be donating for the money. They know it is a one off transaction. Where the market price is higher that the offered price the donor will be entitled to ask why shouldn’t they get the market price? Alternatively where the market price of kidneys is lower that the offered price kidney brokers could operate. A broker could obtain a kidney from a donor at a low price and then make a profit on the supply of the organ to a recipient where the price was higher. Their activity would increase the supply of kidneys. At a level of societal values is this a price worth paying?2 Justice demands that a kidney donor who subsequently suffers renal failure should have an equal or perhaps better chance of receiving a transplant compared to the recipient of the kidney. Where the flow of organs is from people in poorer countries to those in richer countries commodification of organs will be unlikely to make this reality. The sale of regenerative body tissues is not analogous to the sale of non-regenerative tissues. Kidney donation would be a one off sale of a vital organ. Essentially a capital transaction rather than income stream possibility. Within an expenses model of compensation the actual decision faced by a live organ donor is whether to donate or not. Compensation for the additional pecuniary and time costs of donation means that the altruism of the donor need not extend to donation of time, money and an organ. The fact that a compensatory payment is made does not support the proposition that the donation itself should be transformed into a purely commercial transaction. Drug testing and similar research is generally undertaken by commercial pharmaceutical companies as part of their product research and development. Research subjects knowingly enter a process that is aimed at ultimately generating commercial reward for the pharmaceutical company. The payment to the research subjects for their role in what is in essence a commercial process again does not support the reduction of altruistic organ donation to a commercial activity. Compensation for injuries paid in personal injury cases or by the UK Criminal Injuries Compensation Authority (CICA) are fundamentally grounded in justice. These sums are the payment a wrongdoer must make to an innocent victim to make up for the harm done to the innocent victim by the wrongdoer. The CICA is a statutory body3 that steps into the shoes of the absent wrongdoer providing compensation to the innocent victim where the wrongdoer cannot be found. Surely this is not the correct analogy upon which to base a case for the commodification of organ donation. The fact that monies change hands in the context of other areas of medical practice or science do not constitute an argument in favour of commodifying human kidneys for transplantation. The core argument in favour of commodification rests on the need to increase the supply of available organs. This is set against two arguments (1) the hard fact that paying for kidneys means that the supply of organs will flow from the poor to the rich and; (2) there is intrinsic societal value in an organ donation program based on altruism. 1 Roff SR. Thinking the unthinkable: selling kidneys. BMJ 2006;333:51 2 Mohindra R. An ethical monopoly. Really? bmj.com 2002. www.bmj.com/cgi/eletters/325/7356/114[24287. 3 Criminal Injuries Compensation Act 1995 Competing interests: None declared |
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Kuldip P Anand MD, Professor and HOD, Department of Medicine Command Hospital (Eastern Command), Kolkata 700 027,India, Ajit Kashyap MD, Surekha Kashyap MD, Command Hospital (Central Command),Lucknow 226 002,India
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Dear Sir, The article written bravely by Roff (1) generated discussion in our morning ICU round. There were ten physicians including two nephrologists in the round. Only four out of ten physicians were against the regulated selling of kidneys for renal transplantation. One nephrologist took right sided view and the other stuck to his left sided viewpoint, aptly confirming the presence of two kidneys in human body. Realizing that there is an urgent need for doctors to lead the debate on this topic and help the society in arriving at a correct decision, we offer following points in favour of regulated sale of kidneys. Firstly, regulated sale of kidneys will bridge the gap between demand and supply of kidneys for transplantation. Secondly, it will reduce if not abolish the rampant illegal kidney trade. Most physicians are aware of this illegal trade but adopt an ostrich like behaviour and rarely even get involved in this trade. We are aware of patients from rich countries visiting poor countries for purchase of kidneys and renal transplantation. Some poor villages in South India having a sizeable population of persons who have sold their kidney have been given the name ‘kidneypakkam’ in a lighter vein. Thirdly, monitory compensation to donors is a well known and well accepted practice. We have seen brothers and sisters demanding and taking money for the so called voluntary donation of kidneys. Fourthly, we agree that most of the kidneys will be purchased by rich patients because of the cost involved. There may even be flight of kidneys from poor countries with population explosion to rich nations. $40000 seems to be a fair compensation to a kidney donor. The amount seems to be tempting to even us to offer our kidney services. A collateral benefit of the regulated kidney trade may be redistribution of some wealth in this seemingly unjust world. The negative point of this kidney market is that such business of dealing in human spare parts superficially appears to be indecent and immoral. But where is the justification in denying the sale of a part of human body in a world where body and soul are sold and resold daily? There is always a danger of such business spiraling out of hand and leading to immense social, legal and ethical problems. However we are sure that with proper and honest checks, this business has the potential of producing more benefit than harm. We sincerely hope and pray to God that our thinking is correct. References 1. Roff SA. Thinking the unthinkable: selling kidneys. BMJ 2006; 333:51. Competing interests: None declared |
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Stephen Jan, Senior health economist The George Institute for International Health PO Box M201 Missenden Rd NSW 2050 Australia, Mardi Thompson, Chair of the National Council of Consumer Advocates for Kidney Health Australia
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Roff’s recent article, by providing numerous examples where society (such as through the legal system and the health sector) determines payment for body parts, highlights an important perspective in the debate over whether payment should be offered for kidney donors (1). It dispels the myth that the value of life and limb cannot be put into monetary terms. In this paper we will not enter into the general debate about whether payment for organs should be offered (see 2-4). Rather, we assume the acceptance of the general principle of payment and propose a scheme that we believe maximises the incentive for organs to be donated but at the same time preserves an element of altruism or ‘gift relationship’ in the transaction. Here we propose a two-part payment scheme. This, like other methods of payment previously proposed in the literature, would involve the purchase of organs through the State and then their allocation free of charge to patients on the basis of existing algorithms (4,5). A feature of the proposal put forward here is in how the price paid for an organ would be determined. It would have two components: a base payment which would be paid by government and then a top-up payment sourced from a pool established through private donations but administered by an appropriate government agency. As a starting point for determining the base payment, it would be relevant to consider the cost savings associated with transplant vis-a-vis dialysis. In the US, this has been estimated to be US$90,000 (although this figure increased to US$260,000 when differences in outcomes in terms of Quality Adjusted Life Years were also taken into account) (6).In largely government financed health systems such as the UK and Australia, such cost savings from each transplant tend to be appropriated in full by government. A payment scheme would, in a sense, be a vehicle by which these savings could be shared with the donor and thus one might mount an argument for this proposal on the basis of distributive justice. However, the question of ‘how much?’ seems very much a political question (maybe a 50:50 split?). Probably a fair way of determining these relative shares would be through community consultation. Alternatively, as indicated by Roff, the figure of US$40,000 based on estimates of lifetime earnings and risk associated with the procedure could act as a guide (1,7). The issue here ultimately is that such a payment can be viewed as a means of giving back to the donor some of the economic benefit associated with their role in providing a transplant and that it would be a fixed amount which we propose would be a base payment paid upon completion of the procedure. The feature of this scheme is that this would then be augmented by a payment from top-up pool established through private donations. The top-up payment would be calculated and paid at the end of the year e.g. if, in that year, £5 million were collected and 500 kidneys donated, each donor would be allocated a top-up payment of £10,000. The most obvious rationale for a top-up pool is that the additional payment strengthens the incentive to sell one’s kidney. However, it also allows for contributions, how ever small, from individuals who may otherwise be unable or unwilling to take the step of actually donating their organs. The feature of this particular scheme is that it preserves some element of altruism or ‘gift relationship’ by allowing individuals to contribute in this way – addressing an often raised ethical objection that payment undermines altruism as a motivating factor in organ donation (3,8). The key to ensuring the viability of such a fund is that it is appropriately quarantined. This requires government committing firstly to not using these monies for any other purpose and secondly maintaining a fixed base payment thereby avoiding concerns that contributions to the top -up fund are used to offset reductions in government spending on base payments. Essentially, there needs to be a guarantee to potential financial donors that any contribution would directly impact upon the price offered. Clearly, if the situation arises some time in the future that supply increases to the extent where there is no longer an excess demand, government would maintain the ability to suspend the program in the short term to avoid the potential for oversupply. Given that this proposal renders large sums of money as part of the transplantation procedure, the danger for exploitation increases accordingly. The experience of the kidney trade in developing countries such as India certainly indicates the potential for the physical and economic exploitation of donors (and, in many cases, recipients as well). Part of the problem in India and many other settings is that the trade in organs is illegal and uncontrolled. Because it operates outside the law, the authorities have very little ability to implement more pragmatic harm minimisation strategies (9). Ensuring that potential donors are adequately counselled and fully informed of the potential harms is therefore key to the viability of this proposal and needs to be part of the regulatory response. One obvious danger is the coercion of individuals (although such a danger also exists without payments) and clearly regulatory mechanisms need to be equipped to deal with this possibility. Although the principle of payment for organs through a regulated market is not new, the feature of the scheme presented here is the two- part payment strategy. We believe that this offers a means by which the shortage of organs can be addressed by strengthening the economic incentive to do so through tapping into both government and community willingness to pay. Furthermore, it promotes altruism by opening up the ‘market’ to donations from individuals who may not otherwise have been able or willing to donate their own organs. It would also represent a potentially cost-effective use of health care resources because it would take individuals off costly dialysis treatment and, in most cases, significantly improve their quality of life. Finally, from a policy maker’s point of view, it has been shown that payment for organs is a policy that has some public appeal (10). Therefore, this proposal represents an unusually good opportunity to deliver a policy change that would be both popular with the general public and represents a win-win situation amongst the key players, notably recipients, donors, donors’ families and government. References 1. Roff SR. Thinking the unthinkable: selling kidneys. BMJ 2006; 333: 51 2. Radcliffe-Richards J, Daar AS, et al. The case for allowing kidney sales. Lancet 1998; 27: 1950-2. 3. Scheper-Hughes N. The global traffic in human organs. Current Anthropology 2000; 41: 191-211. 4. Friedman EA and Friedman AL. Payment for donor kidneys: Pros and cons. Kidney International 69: 960-962. 5. Erin CA, Harris J. An ethical market in human organs. J Med Ethics 2003; 29:137-138. 6. Matas AJ, Schnitzler M. Payment for Living Donor (Vendor) Kidneys: A Cost-Effectiveness Analysis. Am J Transplant 2004; 4: 216-21. 7. Becker GS and Elias JJ. Introducing incentives in the market for live and cadaveric organ donations. Conference on Organ Transplantation: Economic, Ethical and Policy Issues, University of Chicago, May 16, 2003. 8. Israni AK, Halpern SD, Zink S et al. Incentive models to increase living kidney donation: encouraging without coercing. Am J Transplant 2005; 5: 15-20. 9. Muraleedharan VR, Jan S, Ram Prasad S. The trade in human organs in Tamil Nadu: the anatomy of regulatory failure. Health Economics, Policy and Law 2006: 1; 41-57. 10. Guttman A and Guttman RD. Attitudes of healthcare professionals and the public towards the sale of kidneys for transplantation. J Med Ethics 1993; 19:148-153. Competing interests: None declared |
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