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The Consequences of Public Policy to Buy and Sell Organs for Transplantation

2004; Elsevier BV; Volume: 4; Issue: 2 Linguagem: Inglês

10.1046/j.1600-6143.2003.00370.x

1600-6143

Jeffrey Kahn, Francis L. Delmonico,

Organ Transplantation Techniques and Outcomes

There is an increasing interest in addressing the shortage of transplantable organs by using monetary payments to obtain them. Recent commentaries in the New York Times (1Kristof N . Psst! Sell Your Kidney ? New York Times November 12, 2002.Google Scholar) and from the Kennedy Institute of Ethics Journal (2Kennedy Institute of Ethics Journal , Vol. 13 Number 1 March 2003.Google Scholar) share a recurring message: ‘it may be time to turn to a market approach’. The source of these commentaries has been from those who do not have a direct care responsibility for transplant patients or organ donors. Their primary focus has been to propose financial incentives for deceased donation; they have not recommended buying organs from live kidney donors. Legislators, aware of these editorials, have sought direction from the transplant community (3Assessing Initiatives to Increase Organ Donations . The House Committee on Energy and Commerce: Subcommittee on Oversight and Investigations June 3, 2003 J. Greenwood, (PA) Chair.Google Scholar). As a result, economic analyses have been prepared that display a cost savings of successful transplantation and underscore more dramatically the need for organs (4Schnitzler M Matas A Paying for living donor (vendor) kidneys a cost effective analysis.Am J Transplant. 2003; 4: 216-221Google Scholar,5Robeznieks A . Putting a price on living organ donations. Interview with Gary Becker. American Medical News June 16 2003 , http://www.ama assn.org/amednews/2003/06/16/prsf0616.htmGoogle Scholar). As these analyses emerge, a consideration of financial incentives has become evident, no longer restricted to deceased donation. Furthermore, the authorship of these economic analyses is no longer limited to the public sector (4Schnitzler M Matas A Paying for living donor (vendor) kidneys a cost effective analysis.Am J Transplant. 2003; 4: 216-221Google Scholar). The consideration of payments for live vendors by physicians is placing the transplant community at an ethical and professional crossroad that is a departure from the standard of the past 50 years (6Delmonico FL Interview with Dr. Joseph Murray: a Nobel laureate and transplant pioneer reflects on the birth of clinical organ transplantation.Am J Transplant. 2002; 2: 803-806Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar), and necessitates a reply. In this continuing debate (with some purporting to show the economic value of payments) there are consequences to be measured by society, independent of increasing the supply of organs. Does an economic analysis of cost effectiveness make the buying and selling of organs by society ethically acceptable? Would such a market be acceptable health policy for government planners? We believe the answer to each of these questions is ‘no’. A discussion of the ethics of organ sales ought to precede any analysis of its economic or practical value. Ethical considerations cannot be bracketed for a subsequent assessment. The end of an increased supply of organs cannot justify using any means available—the means matter. Further, demonstration projects that claim evidence that payments ‘work’ may also ignore the important ethical question of the means used to achieve them. The social, ethical, and professional consequences of adopting a market approach by a focus on cost effectiveness are profound. A decision by legislators, policy makers, or the transplant community to proceed with payment for organ donation must consider these consequences before embarking upon even a pilot project. Proponents of organ sales suggest that it will be important for the government to exercise regulatory control, as the sole ‘buyer’ of organs. However, it is highly unlikely that our federal legislators will soon endorse such a government run system. The current efforts to draft legislation are far removed from live donor payments, and yet Congress has been unable to forge consensus. Pilot ‘demonstration projects’ of financial incentives (for only deceased donation) have not been widely endorsed because legislators are appropriately cautious of the social consequences of a perceived (simultaneous) sanction of payments to vendors. Legislative authorization could have a far reaching influence on international organ donation policies. It could open the door to a more widespread market in organs than currently exists (7Scheper Hughes N Keeping an eye on the global traffic in human organs.Lancet. 2003; 361: 1645-1648Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar). Further, some proponents of government regulation assume that government would be able to tightly control the market in organs. However, if the justification of a market in organs is to solve the organ shortage, then why should vendors be limited to a government regulated market? If a better price is available through internet bartering, why shouldn't vendors make their best (that is, most lucrative) deal outside of government regulation? Taken to its logical extreme, some individuals would become more valuable subdivided into sold body parts (left lobe of the liver, a lobe of the lung) than kept whole. In her ‘case for allowing kidney sales’, Radcliffe Richards proposes the use of organ sales as a remedy for the poor to lift themselves out of destitution, at least temporarily (8Radcliffe Richards J Daar A Guttmann R et al.The case for allowing kidney sales.Lancet. 1998; 351: 1950-1952Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar,9Radcliffe Richards J Nepharious goings on: kidney sales and moral arguments.J Med Philos. 1996; 21: 375-416Crossref PubMed Scopus (103) Google Scholar). Support for this argument has recently come from Robert Veatch: ‘if we are a society that deliberately and systematically turns its back on the poor, we must confess our indifference to the poor, and lift the prohibition on the one means they have to address their problems themselves’ (10Veatch R . Kennedy Institute of Ethics Journal , Vol. 13 Number 1 March 2003; 19–36.Google Scholar). Our view is that policies that allow the selling of organs represent a failure themselves. They signal a willingness to accept a policy environment that would make exploitation of the worst off a societal endorsed rule rather than the exception to be prevented. Moreover, government sanction of organ sales would represent an undermining of a moral foundation of our society that views government as having responsibility to provide for the poor. In support of organ sales, Veatch defends the libertarian influenced view that since our society has foreclosed other opportunities for the desperate to address their needs, ‘we must at least get out of the way and let them address the problem themselves in the best way that they can’ (10Veatch R . Kennedy Institute of Ethics Journal , Vol. 13 Number 1 March 2003; 19–36.Google Scholar). But this conclusion can only lead to a situation of increased exploitation, by creating incentives to withhold alternatives for helping the least well off, since then the motivation by the desperate to sell organs will be at its greatest (11Kahn J . Kennedy Institute of Ethics Journal , Vol. 13 Number 1 March 2003; 45–50.Google Scholar). In the face of seeming indifference to the plight of the poor, is it the correct or defensible policy decision to turn our collective backs on the poor entirely and allow for organ selling? Using the argument made by Veatch and Radcliffe Richard's, why not defend a public policy of other forms of selling one's body via government regulation? Recent reports from India reveal selling organs makes the vast majority of donors worse off than they were before their nephrectomy—medically, socially, and even financially (12Goyal M Mehta R Schneiderman LJ Sehgal AR Economic and health consequences of selling a kidney in India.JAMA. 2002; 288: 1589-1593Crossref PubMed Scopus (293) Google Scholar). An unfettered system of organ sales in the Americas would be ripe for the same kinds of exploitation as reported from India. Further, do American surgeons want to be the principal enablers of such a practice, and could they find themselves compelled by competition with other centers to take part in a practice they find unethical? A program of organ selling creates an inherent conflict for the physician's relationship with a patient. In that professional relationship, patients are not clients, consumers, nor commodities (13Delmonico FL Surman O Is this living donor your patient.Transplantation. 2003; 76: 1257-1260Crossref PubMed Scopus (30) Google Scholar). When the relationship is so altered that patients become vendors, the medical decision and willingness to perform a procedure may be forced on the physician – not based on the best care for the ‘patient’– but rather by the financial desires of the would be vendor. One could anticipate litigation from a potential vendor following a physician's refusal to perform an organ removal. The physician could be confronted by a vendor who has been ‘denied’ a payment for the sale of a kidney, especially if the payment were to be in the range of $100 000 or more! Any attempt to assign a monetary value to the human body or its body parts, even in the hope of increasing organ supply, diminishes human dignity and devalues the very human life physicians have nobly dedicated their careers to saving. In its commodification of organs, this approach threatens core values of the profession of medicine, turning physicians into ‘market providers’ for ‘consumers and clients’. Among the important roles of the profession that must not be lost are clear limits to engaging in or facilitating overly risky actions in the medical context, no matter how informed and willing patients may be or how great the financial gains to be made (13Delmonico FL Surman O Is this living donor your patient.Transplantation. 2003; 76: 1257-1260Crossref PubMed Scopus (30) Google Scholar). The disincentives and obstacles for live and deceased organ donation must be minimized (14Delmonico FL Arnold R Scheper Hughes N Siminoff LA Kahn J Youngner SJ Ethical incentives not payment for organ donation.N Engl J Med. 2002; 346: 2002-2005Crossref PubMed Scopus (191) Google Scholar). We commend the approach of Robert Metzger of the United Network for Organ Sharing (UNOS) in concert with the Association of Organ Procurement Organizations (AOPO) and the American Society of Transplant Surgeons to honor the potential organ donor's wishes. The decedent's self determination to donate should not be overruled. This approach of honoring the donor's wishes was the principle behind the Uniform Anatomical Gift Act (UAGA) promulgated in every state many years ago and recently endorsed again by the Secretary of Health and Human Services Advisory Committee on Transplantation. Thus, all of the transplant community should seize this national momentum to embrace the renewed social responsibility regarding organ donation embodied in donor authorization initiatives. There is a limit to the potential of deceased organ donation as evidenced by the recent AOPO report in the New England Journal of Medicine (14Delmonico FL Arnold R Scheper Hughes N Siminoff LA Kahn J Youngner SJ Ethical incentives not payment for organ donation.N Engl J Med. 2002; 346: 2002-2005Crossref PubMed Scopus (191) Google Scholar). Thus, proposals currently being considered by UNOS for live donors that would continue compensation for wages otherwise lost during the medical leave (up to 30 days following hospitalization) should be promoted. The difference between this approach and outright organ sales is that monetary enrichment is not the motivation for donation. However, at the same time, neither is the donor financially responsible for doing the good deed of donation. A reimbursement of expenses or a continuation of salary by an employer is an ethically acceptable approach, removing a disincentive for living donors. Finally, live donors should have some insurance against potential disability (or death) as a result of the donation procedure. The profession of medicine, the transplant community, and those involved in public policy have a responsibility to oppose the buying and selling of organs. It is an unethical approach to shift the tragedy from those waiting for organs to those exploited into selling them.