In 1985 the federal government
explicitly nationalized all organs available for donation. Claiming such
organs belong to the public as a whole, the National Organ Transplant
Act made it a crime for individuals to buy or sell organs intended for
transplant. Instead of allowing any sort of market in organs to develop,
NOTA set up an organization called the United Network for Organ Sharing
to determine how scarce organs should be allocated to the many patients
in need of transplants.
Pennsylvania is proposing
to take a bold departure from this regimen next year when it will begin
offering $300 worth of assistance in the form of payment of funeral expenses
to those who donate organs. Whether or not the payment of funeral expenses
of organ donors violates the ban on selling organs is yet to be decided.
Under NOTA the state does usually pick up the donors’ surgical expenses,
and some medical ethicists argue that a $300 payment for funeral expenses,
which will be made directly to the funeral home rather than the family
of the donor, is similar to the current payment of surgical expenses.
It is good to see at least
one state finally moving in this direction, but it would be better for
all concerned if the U.S. Congress would simply overturn NOTA, revoke
UNOS’ monopoly on organ allocation and allow private institutions to handle
organ donation from beginning to end.
UNOS itself often seems to
be an obstacle to increasing organ donation. Although semi-independent,
UNOS regularly bends with the shifting political winds. A few years ago
it was revealed that blacks tended to receive far fewer organ transplants
than whites, largely because blacks donate far fewer organs than whites,
and tiny genetic differences are extremely important in determining the
likelihood of the rejection of an organ. UNOS promptly promised to incorporate
race as a factor in allocating organs, although that promise doesnÂ’t seen
to have done much to affect the rate of organ donation by African Americans.
Similarly, when it was recently
revealed that adults were more likely to receive organs donated from children
than were children in need of a transplant, UNOS promised to revises its
system to do away with this disparity. It arrived at this decision even
though this seeming disparity results from a rather sensible policy —
if a donated liver from a child becomes available in New York, UNOS will
give priority to recipients in New York rather than Los Angeles, even
if the New York recipient is an adults and the Los Angeles recipient is
a child. Since there are far more adults on the transplant waiting list
than children, adults end up receiving most of the organs donated by children.
UNOS is constantly changing
its allocation formulas to decide just how much an adult’s life is wroth
compare to a child’s or a black person’s life compared to a white person’s
or a person living in New Orleans Compared to someone living in New England.
As with all bureaucracy’s, UNOS’ performance is less than inspiring.
But could a private market
in organs really work? The objection most often raised to proposals to
privatize organ allocations is that it will disproportionately benefit
the rich. News flash: the rich already are disproportionately favored
by UNOS’ system and will be inevitably favored by any conceivable organ
donation system that doesn’t explicitly discriminate against them. Today,
for example, the wealthy are more likely to have their illnesses detected
earlier which makes them better candidates for organ transplants; the
wealthy can afford to fly to different regional organ transplant centers,
thereby increasing their odds of obtaining an organ; and, of course, the
wealthy are more likely to be able to afford the transplant operation
and the expensive cycle of drugs and post-operative medical treatment.
Not to mention the fact that
by world standards even those of modest incomes in the United States who
receive organ transplants are among the richest people in the world. A
critique that insists that justice is not served if the poor do not have
equal access to organs must answer why the truly destitute of Latin and
South America are regularly excluded from receiving organs donated from
the United States, even though there is no strictly medical reason they
could not be included in the pool of potential organ recipients. I suspect,
though, that most Americans regardless of financial means which recoil
at this idea.
The real issue is whether
or not the poor would be at more of a disadvantage under a market system
than they are under the current UNOS system or compared to what could
be expected from some realistic alternative to UNOS and the answer is
probably not. All potential organ recipients, rich or poor, are at a severe
disadvantage today in that the number of available organs is miniscule
compared tot he number of people needing transplants. There were about
64,000 people in need of transplants in the United States last year, but
less than 6,000 organ donors. UNOS has been given ample opportunity to
find ways to increase that level of organ donors over the past few decades
and proven quite incapable at the task.
Would a market system have
any better luck? Nobody really knows. Some ethicists argue that allowing
organs to be bought and sold would discourage people from making organs
available, but there is little evidence for this. Other parts of the body,
from women’s eggs to blood and even entire bodies are regularly, bought,
sold and rent for periods of time (in the case of people who earn money
for participating in pharmaceutical drug studies) without adversely affecting
their supply. Contrary to the claim by some ethicists, the stigma attached
to buying and selling of organs appears to be one artificially created
by the ban on such transactions by NOTA.
Many of the imagined horror
stories of the rich harvesting organs from the poor are unlikely to materialize
because it is unlikely that organs would command the sort of prices envisioned
by some ethicists. Although many people assume that organs would sell
for tens or even hundreds of thousands of dollars, the experience with
countries that have legalized organ sales such as India’s experiment with
the practice confirms that the price people are willing to pay for organs
is relatively low — in the few thousands of dollars. One of the dirty
little secrets that both opponents and supporters of organ transplant
sales rarely mention is that there are so many obstacles facing organ
donation from a purely medical point of view that it is questionable whether
purely economic transactions between organ buyers and sellers would add
more than marginally to the available supply of organs.
Rather the exciting possibility
from allowing a free market in organs is not that a few wealthy people
will buy organs from the poor, but that alternative institutions for obtaining
and allocating organs will emerge that find ways to increase the donor
pool. Maybe the $300 in funeral expenses Pennsylvania is offering won’t
be enough to encourage organ donation, but maybe $1,000 might tip the
scales. Maybe a private foundation made up of physicians and ethicists
might hit upon the right combination of incentives that increases donations
whole reassuring people about the sanctity of human life.
Part of the problem, however,
will be that the sort of polices that encourage organ donation may not
be the ones that are politically tolerable. As noted earlier, for a variety
of reasons African Americans are generally less likely to be organ donors
and transplant recipients. As numerous studies have shown, blacks are
also far more likely than whites to distrust the medical establishment
— often with good reason given incidents such as the Tuskeegee Syphilis
Experiment in which treatment for syphilis was intentionally withheld
from black men as part of a government-funded study. One can imagine a
private organ foundation dramatically increasing organ donation rates
among African Americans by pledging to give blacks first priority as organ
recipients. Such a system would certainly draw enormous criticism and
controversy.
There is no doubt that a transition
to a market system for organ donation wold create numerous ethical problems,
but they seem small compared to the current quandary — close to 100,000
people a year who die or receive substandard medical treatments because
of a lack of organs available for donation. The UNOS experiment has failed.
It’s time to look at the alternatives.