Organs in the American Markeplace

April 2, 2010— -- Would you give up your kidney to save a stranger's life?

How about if you were paid you handsomely to do so?

That is the crucial question tackled by a recent study from the University of Pennsylvania on living organ donation.

In a world where thousands of people die each year waiting for a donated organ to become available, researchers sought to tease out the factors that impact decisions to donate.

They found that the higher the payment, the more people are willing to go under the knife.

The concept of selling one's organs to pay the bills is fraught with disconcerting implications, but if the study's findings hold true, an organ market may be a particularly effective way of boosting donation rates and, consequently, saving lives.

"If someone were to design an [organ donation] system, they would never design a system [like the current one] that allowed thousands to die each year while costing the government $33 billion in medical costs," says Dr. Scott Halpern, the lead author on the study and senior fellow at the University of Pennsylvania's Center for Bioethics.

A market-based solution, in which the government compensated donors a fixed sum for their organs and regulated allocation of the organs, "could easily bridge the gap."

The study, published in the Annals of Internal Medicine, hopes to dispel some of the concerns most commonly voiced against offering payment for organs.

Halpern is not the only voice calling for a drastic change in the way organ exchange is regulated. But whether for theoretical concerns or ethical ones, his call for an organ market is met with apprehension and opposition by medical ethicists and policymakers.

The Proof Is in the Polling

In surveying 342 Philadelphians on their morning commute, Halpern and colleagues found several surprising trends among who would donate and why.

For instance, those living below the poverty line were nearly twice as likely to report that they would give up their kidney to a stranger than those who make $100,000 plus a year -- a trend that plays into the concern that an organ market would exploit the poor.

But contrary to expectation, researchers found that the bias is not affected by providing monetary reward. The poor consistently donated more than the rich at every compensation level, including none. Their willingness to donate didn't increase with compensation any more than that of their richer counterparts.

"This paper takes away the non-proven claim of exploitation of the poor," says Dr. David Cronin, associate professor of surgery at the Medical College of Wisconsin. "The poor have an opportunity to be compensated for donation. Why should they be further exploited by taking the opportunity and decision away from them?"

But the bias, in and of itself, "raises concerns about justice," says David Magnus, a professor of medicine at Stanford University and a co-author of the study's editorial.

An imbalance of the poor disproportionately providing organs to the rich has caused problems in other countries that have tried organ markets such as Iran and the Philippines, he says.

Another concern about offering compensation is that it would decrease the amount of people willing to donate for free. The study, however, and a growing body of research on the subject, suggests otherwise, Halpern says.

Researchers compared the responses of those who were given the money option up front with those that were given altruistic-only scenarios to start and found that the "specter of payment did not affect whether they responded 'yes' to doing it for free."

What this data cannot predict, however, is what percentage of people would actually donate, Halpern warns.

"The study has been misinterpreted by some," he says. "They'll cite that 30 percent of people are willing to donate an organ to a stranger, but the study was not designed to gauge this. The study offers a number for this, but I don't believe that number."

Instead, he warns, the study can suggest how changes in incentive structures change an individual's decision to donate. But at the end of the day, these were hypothetical questions.

Selling Our Bodies

The equality or success of the incentive aside, the question to ask in this debate may be: As a nation, are we OK with the idea of making a profit off of our organs?

Up until 2008, the letter of the law was that no compensation whatsoever -- short of the joy of giving -- could be given in exchange for organs, according to the National Organ Transplant Act of 1984.

But the Charlie Norwood amendment, passed two years ago, provided a tiny window in the legislation that allowed for paired organ donation.

That is a system whereby an organ swap, sometimes with up to 26 people involved, takes people who would give a kidney to their loved ones but are not matches for them and allows them to give their organs to strangers in return for the organ of other strangers who match their loved ones. Thirteen patients in the Washington, D.C. area were given a new lease on life last Christmas by just such a swap.

But is there a difference between payment in kind and payment in cash? This organ quid pro quo was passed by Congress with overwhelming approval, but other forms of compensation are seen as unethical, Harlan Abraham, lawyer and co-author of "On the List: Fixing America's Failing Organ Transplant System", points out.

Isn't a wife who donates a kidney for her husband, on whom she relies for income, also donating for compensation in a way? Cronin asks.

Halpern goes even further, arguing that while kidney donation is an extremely low-risk transaction, another form of selling the body, prostitution, brings great risk to the seller. Even readily acceptable trades such as stunt doubling and playing for the NFL are ways of selling the body by incurring bodily risks, he says.

So where do should the line be drawn when it comes to putting bodies on the market?

That is an unanswerable question, Abraham says.

"If only religion ruled the day, we'd get one answer," he says. "And if only politics ruled the day, we'd get another. And if only economics ruled, we'd get yet another.

"Eighteen people will die today on an organ donation wait list, and 18 tomorrow," he adds. "Right now, there is a disincentive to donate because health insurance doesn't always cover post surgery."

Changing Face of Organ Donation

But, Abraham argued, an organ market is not the way to meet the need.

He prefers non-monetary compensation, such as 20 years of health care or life insurance, or even tax credits, as a way to "give donors an incentive that isn't bargaining for their flesh."

"There is a reason that selling organs is illegal in almost every country of the world," he says. "I believe it's unethical."

But Halpern sees no ethical difference between this kind of compensation and money in your pocket, and he argues that swapping systems and tax breaks will not be nearly as effective.

"Small payments won't do it; we know the magnitude of the payment is intrinsically related to its effectiveness," he says.

So should the guiding hand of the marketplace be brought to bear on whether or not Americans sell their organs?

An experiment in this approach, at least, is long overdue, Cronin says.

"If we test this ... in a small, highly monitored, government regulated, geographically limited way, ... and the outcomes are poor, I'll be at the head of the line to end the program," says Halpern. "My concern is that we not leap to the theoretical conclusion that using itwon't work."