Sunday, January 17, 2010

Should We Pay For Organ Donation?



Could this man increase organ donation?



Choose the best answer.

To stimulate organ donation, we should provide organ donors with:
  • Cold, hard cash
  • Upgrades to business class on any flight within the continental United States for 1 year
  • College tuition discounts for up to 3 children
  • Income tax relief
  • First row Bruce Springsteen concert tickets
  • A certificate of appreciation
There is a reason that we don’t ask families of kidnapped victims what our policy should be with regard to hostage negotiations. Any family in this situation, including mine, would favor paying the ransom. While this would serve an individual family’s interest, it would conflict with the public’s interest as it would encourage more kidnappings. Thus, the greater good would be compromised.

Similarly, families seeking an organ for a loved one are not the proper source of policy recommendations for organ procurement. Understandably, they want an organ at any cost. Certainly, if my child needed a liver to survive, I would not want to hear that saving him would amount to an ethical crime against humanity. And, I might not care. For this reason, medical ethical policies should be carefully crafted by thoughtful and dispassionate individuals who can approach the issue from a broad societal perspective. Of course, those who have a personal stake in the game should have a voice at the table, but they should serve as an advisory and informational role. Their views should be considered, but not necessarily adopted. These are heartwrenching and controversial issues, particularly when an individual’s plea for life is deflected off an ethical firewall.

Is purchasing tissues and organs a worthy idea for society? Would it violate ethical standards against exploitation? Would it injure the ethical principle of justice?

Many argue that buying organs should be permitted, just as affluent folks can purchase cosmetic surgery, luxury cars or Caribbean vacations. If they can afford to purchase a kidney from a willing seller, they argue, why shouldn’t the transaction take place?

Organ shortages have resulted in a reconsideration of ethical procurement practices that were heretofore prohibited. Many fear that folks at the end of life are already viewed as organ donors in an effort to save others who are awaiting organ transplantation. One way to increase the donor pool with the stroke of a pen is simply to ‘modify’ the defintition of death. In the past, dead meant brain death. Nowadays, cardiac death, a new & improved definition of the end of life, has greatly increased organ donor supply. Is this definition-creep motivated by a desire to increase the donor reservoir? Is this the right thing to do? It takes little imagination to foresee how slippery and vertical this slope can become.

Sick and desperate people awaiting organs have rights too. We must be extremely cautious that our zeal to protect society’s rights is not outweighed by their right to life.

It is illegal to purchase organs in the United States, but other countries have different policies. The Wall Street Journal, John Goodman’s Health Policy Blog and NPR reported that Iran will pay citizens to donate and, as a result, they have no organ shortages. Singapore organ-seekers pay tens of thousands of dollars for an organ. Some nations, such as Sweden and Spain, presume consent to donate organs, unless the invidual has actively opted-out of the program. In the United States, there is no presumed consent. Israel, in response to a low organ donation rate, has just launched a program to reward willing donors by giving them priority should they ever need a transplant. I just learned about an organization here in the United States called LifeSharers, whose members pledge to donate organs and to give fellow members in need priority access of these organs. The organization charges no fee and currently has over 13,000 members.

Maurice Bernstein queried on his provocative Bioethics blog if it should be legal to procure organs from dead individuals without consent from the patient or family. There is a long thread of thoughtful comments from readers.

I think we should provide more incentives to donate, although I do not advocate buying and selling organs on the free market. This would lead directly to economic and physical exploitation of our most vulnerable people. I also vigorously oppose bending the definition of death for the purpose of saving others. One life is not worth more than another. Of course, it’s easier to make principled and categorical statements as a blogger. But, don’t ask me for my high and mighty opinion if my child is on the transplant list. I’d pay the ransom.

What are your thoughts to promote organ donation within the boundaries of medical ethics?

19 comments:

The Medical Contrarian said...

"I think we should provide more incentives to donate, although I do not advocate buying and selling organs on the free market. This would lead directly to economic and physician exploitation of our most vulnerable people."

How do you define exploitation?
Are you suggesting that there are large numbers of people who are not equipped to make judgments regarding their own bodies?
What criteria are used for those who donate their kidneys for non-monetary compensation and could not these same criteria be used for those who elect to make donations based upon monetary incentives?
Are you suggesting that those who decide to donate a kidney based upon money are being exploited by definition?

Michael Kirsch, M.D. said...

If organs are sold, then there is the strong potential for economic exploitation, as already exists in various parts of the world. Those who are poor, in debt or otherwise vulnerable could be preyed upon to sell an organ. This could also short circuit the system where organs are allocated according to medical need. Of course, if organs could be sold, there would be one clear winner - EBay!

M. Faasse (Chicago) said...

First of all, thanks for posting the link to the 2007 NEJM article on organ harvest after cardiac death. I've never been involved in a scenario like this, and it was eye-opening.

Secondly, are you aware of any recent public opinion polls on presumed consent/opt-out policies with regards to organ donation in the U.S.? I cannot find any - seems like this is important info to have.

Finally, to raise one point in response to The Medical Contrarian's post, the most insightful definition I've ever seen of exploitation is that it's when you "kill the chicken to get the eggs." Financial compensation for organ donation is more likely than other forms of compensation (e.g., love of family/friends, feeling good about yourself, etc.) to promote a prioritization of short-term gain, neglecting the long-term consequences.

tishrei said...

To be honest, I have never ever considered this issue. Human nature, unfortunately causes people to exploit each other -- those that can, do and those that are vulnerable will be exploited.

I hope that we never get to the point where people can sell off body parts. There are some things that just seem so unethical -- this is one of them -- I can't articulate why. It just seems so very wrong. Maybe after I've thought about it, I would be able to articulate why it never should be legalized that people can sell of parts of their bodies to be placed in someone else's body. I would rather give away an organ that I did not need than to sell it to the highest bidder.

nutrprofe said...

Organ donor designation is currently left to the Bureau of Motor Vehicles. Their employees are not effective ambassadors for organ donation. Maybe people should be required to listen to a 2-minute video about organ donation before deciding whether to be organ donors.

Certainly, we should require anyone who gets a motorcycle license to sign up as organ donors. Society pays the price when motorcyclists become disabled; society should benefit if they die prematurely from their dangerous hobby.

tishrei said...

OY!

megan said...
This comment has been removed by a blog administrator.
Evinx said...

I am all for having a market system for organ donations. Anything else induces corruption, shortages, and gray markets, which is what we have now.

Why is it OK to daisy chain organ donations (I give you my kidney, and you give my friend yours, etc). That is perfectly OK? It is simply a form a barter.

Money is merely a medium of exchange, nothing more. It faciliates transactions and having a market for organs allows for the allocation of a scarce resource without mandates, trickery (opting-out), and non-monetary bribes (or under the table bribes a la the rabbis in NJ).

If you do not like having a market for organs, then you need to come up with a system to allocate a very scarce resource. No one has a work-able system yet. Fiat does not work. Altruistic appeals do not work.

Michael Kirsch, M.D. said...

Evinx, welcome back. Would you be concerned that organs for sale would exploit our most vulnerable citizens and residents? I do not support selling them on the open market, as we do for appliances and various commodities. In my view, it would guarantee exploitation and abuse.

Evinx said...

Dr Kirsch,

As a gastroenterologist, you know full well there are risks associated with say a colonoscopy. Maybe a perforated colon, maybe anesthesia complications, etc. Yet, we do not say no to this medical procedure. The good outweighs the few negative outcomes. At the same time, we keep trying to reduce and eliminate these negative outcomes.

Same thing with a marketplace for organs. We can build in safeguards; yet, they will not be perfect. Of course, we do not want to take advantage of the the mentally incapacitated or children, and so on.

We do know that free markets prevent shortages and gray markets. Let's face it - if Bill Gates needs a kidney, he can (if he so chooses) avoid the lines. Maybe he will donate a medical wing to a hospital, maybe he will donate $50 million to fund some research. Maybe a physician can get one out of "professional courtesy." Who knows for sure?

I agree with your concerns; but, that does not mean we avoid all the good that can result. Pefection does not exist but I believe a free market for organs can do far more good than harm - plus it will encourage more research (the capitalistic result of high organ prices - at least at the start)which will ultimately tend to drive pricing down.

Mr Spock of Starship Enterprise said, "the good of the many outweigh the good of the few." He was supremely logical.Don't you agree?

Michael Kirsch, M.D. said...

In my view, the potential for unethical abuse from selling organs on the open market outweighs the benefits to organ recipients. Live long and prosper!

Egg Donors said...

Great Post.....

I found your site on stumbleupon and read a few of your other posts. Keep up the good work. I just added your RSS feed to my Google News Reader. Looking forward to reading more from you down the road!

Thanks for sharing....

Anonymous said...

Lieb,J."Stimulating immune function to kill viruses." (2009) Amazon(and bacteria, parasites, and fungi). Predated by nine reviews, the first published in 1981.
Lieb,J."Killimg Cancer."(2010) Amazon (in press). Not hyperbole: antidepressants are powerfully cytotoxic, and cytostatic). First suppressed by FDA,CDC,NIAID,WHO, UNAIDS, GLOBAL, CIDRAP, 60+ medical schools
Second suppressed by FDA, CDC, NCI, ACS, KOMEN, AVON, ASCO, AACR, NEJM, JAMA, LANCET, BMJ. Seems that many docs need a comprehensive ethicsoscopy

Ipecac said...

I think that if you create an open market for organs, the (theoretical) increase in supply still wouldn't meet the demand and you'd end up with only the rich getting organs while everyone else wouldn't. At least there's a possibility of fairness in the current system.

I totally agree that organ donation should be encouraged as much as possible. As a matter of supply and demand, if everyone who died donated, would that fully meet the demand? If so, then it's even more tragic that more people don't donate.

Michael Kirsch, M.D. said...

Would you support a system that presumes consent from the deceased? Keep in mind, that for successful organ procurement, plans have to made in advance of death. Thanks for you comment.

Ipecac said...

Boy, "presumed consent" touches on so many issues.

Off the top of my head, I'd say that I'd be in favor of it. The dead don't need the organs while the living do. Presumed consent would vastly increase the supply of viable organs.

But then, it's easy for me to endorse since I'm already a registered donor; I'm okay with the idea of someone using mine.

Michael Kirsch, M.D. said...

Israel just instituted a policy where if an individual volunteers to be an organ donor, then he and his family will have a higher priority status should any of them need organs.
Good idea?

Michael Kirsch, M.D. said...

Current issue of Annals of Internal Medicine supports paying for kidney donations. While the authors admit their study has limitations, it deserves to be part of the conversation. http://bit.ly/bkfCbS

Michael Kirsch, M.D. said...

For those interested, here's a short USA Today editorial advocating presumed consent. http://bit.ly/ccv69y

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