How much is your life worth? If you suffer a heart attack, get bypass surgery, and stay in the hospital for several weeks, you're looking at about $100,000. If you need insulin to keep from lapsing into a diabetic coma, it costs several hundred a year. We pay for the treatments that save our lives -- and, in a sense, that it what our lives are worth (to someone with an invoice). This practice is as old as medicine itself.
What about organs? Eighteen people die every day because they can't survive the wait for a kidney, liver, heart, or lung. Kidneys are in greatest need; the national waiting list is about 96,000 deep. And in major cities, the wait is over ten years of misery on dialysis -- if one can survive that long.
Recently, Lianne Barnieh, and Braden Manns, of the University of Calgary, in Canada, and their colleagues estimated that if living kidney donors were paid $10,000, transplants would increase by at least 5 percent. Their results appear in the Clinical Journal of the American Society of Nephrology. The authors argue that payment would also save money and improve patient outcomes. With public payments for dialysis in the U.S. roughly $ 30 billion per year, getting more people transplanted and thereby untether them from dialysis machines, would be an enormous boon to the health budget.
But the human impact is even greater. When I needed a new kidney several years ago, it was a difficult process -- hellish, really -- to find a donor. Living in Washington D.C. meant that I would languish on dialysis for at least five years waiting for a cadaver donor from the waiting list if I could not find a friend willing to give me a body part.
Thank God I did. In March of 2006, I became a beneficiary of someone's enormous generosity. This friend performed an act of unrivaled compassion towards me -- and yet, when it was over, I was less moved by the power of altruism than I was by its inability to save so many others. So, I became impassioned advocate for changing the law so that people who are willing to save the life of a stranger can accept a reward for doing so.
Altruism makes wonderful private policy, but as public policy it is a qualified failure. Our current system, in place since 1984, runs on voluntary donation and, as a result, presides over the needless deaths of about 7,000 people each year.
The scope of this heartbreak is powerfully portrayed in a new HBO documentary airing Monday, Nov 4 called Tales from the Organ Trade.(Disclosure: I was an unpaid adviser.) The brilliance of Ric Bienstock's film is its neutrality. Traveling to dark places in South East Asia and Eastern Europe to interview kidney buyers, brokers, sellers, and surgeons Bienstock captures the kind of symmetric desperation -- the fatally ill and the painfully impoverished --that fuels the organ trade.
Not every donor is a victim, to be sure. It's more complicated than garish pictures of young slum-dwelling men lifting their shirts to display their scars ("kidney porn," as a colleague calls it). As the film shows, some donors and their families are very grateful for the chance to benefit while helping a stranger. Yet there are enough shady dealings, lousy informed consent practices, and poor health outcomes to cry out for regulation of such transactions -- or for banning them, as the World Health Organization (WHO) is trying to do.
The problem with bans, of course, is that they are flouted. And everyone suffers more. Prohibition simply drives corruption rings further underground, thereby increasing the risks to recipients and donors or causing markets to blossom elsewhere around the globe. Sadly, as the film shows, the WHO can't grasp the futility of its well-meaning efforts to stamp out trafficking.
The alternative is obvious: we need to enable more patients in wealthy countries to obtain transplants at home by empowering their governments, under strict regulation, to offer incentives to prospective donors. How? By implementing pilot projects that circumvents donor exploitation. If in-kind rewards were offered to donors, such as a contribution to a retirement fund, an income tax credit, or tuition vouchers for their children--rather than lump-sum cash payments--the program would not attract desperate people who might otherwise rush to donate for a large sum of instant cash.
(For the record, $10,000 in value seems low to me, and a 5 percent jump in donations is not enough of an increase. But in the end, determining whether there are enough individuals who are motivated to save a life and the magnitude of reward that would attract them is an empirical matter.)
Such an incentive program would carefully screen would-be donors for physical and emotional health, as is currently done for all volunteer living kidney donors everywhere. A months-long waiting period would ensure that donors are not acting impulsively or with less than fully informed consent. Finally, all donors would be guaranteed follow-up medical care for any complications.
Notably, the incentives would be provided by a third-party such as a governmental entity, charity or insurer; not by individual patients. Thus, organs procured in this manner would be distributed to the next needy patient in line -- with no special advantage to the well-off. Third world localities, where dialysis does not exist for anyone but the very wealthy, could conduct similar programs.
Not only would more lives be saved through legal means of donor rewards, but it would also result in fewer people from rich countries paying kidney brokers to haunt the back alleys of China, Pakistan, Egypt, Colombia and Eastern Europe in search of hapless donors.
These are my views. I am grabbing the opportunity presented by this television special to promote them. But Tales from the Organ Trade is not pushing a policy prescription. It is descriptive yet moving, following four people from Toronto who need kidneys and talk from the heart. The film is as scrupulously evenhanded in depicting their agony as it is in presenting the often dangerous conditions under which the black market operates.
Ric once told me that was neither leaning towards or against compensating kidney donors when she started -- if anything, perhaps, she thought it was creepy. To be sure, most people have not given the topic much thought either but anyone who is open-minded will find themselves compelled by Tales from the Organ Trade to weigh the tragic choices faced by people who are only trying to save their own lives. At that point, it becomes a moral imperative to contemplate ethical solutions.
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Sally Satel is a resident scholar at the American Enterprise Institute and editor of When Altruism Isn't Enough: The Case for Compensating Kidney Donors.