Selling Your Kidney

If organ sales are legal, does that mean that creditors can treat body parts as assets and come after them?

Libertarians are very likely to assume nice uniform spherical everythings, especially uniform spherical legal systems. Most developing nations are unlikely to have much of a legal system, much less the kind of wonderful system that libertarians assume. (Heck, our legal system has problems aplenty.) Any system of pay kidney donation is likely to assume a lot of enforcement and regulation:
. The donor's other kidney must be in good shape. (Heck, does the donor have another kidney?)
. The recipient must really need the kidney.
. Most of the money must really go to the donor, without the usual 95% middleman cut.
. Informed consent.
. No Chinese donor specials: executed criminals as donors. (The incentives get a bit baroque.)
. Will the donor be promised to be on the top of the list for free, if the donor needs a kidney? If so, is this promise enforceable?
. etc., etc.

I am reading The Repossession Mambo, a novel about a future where mechanical artificial organs (artiforgs) are mass produced, and then financed by a Credit Union, secured with a lien on the "collateral.".

They are very expensive, and when the borrower can't keep up with the steep payments (sometimes several steep payments, if they have more than one artiforg) the the "Union" repos the collateral, which is then sold to another purchaser.

The shape of things to come.

There is a simple alternative to buying a kidney from the poor: If you need a kidney, and you find someone willing to donate one to the general pool of those who need kidneys (where "willing to" means "actual does"), then you automatically go to the very top of the list in that pool.

Right now, it's not enough to find someone willing to donate a kidney - it has to be a *match*. That's why (now) either you keep looking (asking friends, hoping for the kindness of strangers, whatever), or you have to hope that some sort of chain match can be constructed, which is rare because it's a lot of work: see, for example, http://wjz.com/health/kidney.transplant.2.1103495.html

In short, the problem isn't with the lack of donors - it's with the current system requiring that you personally must find a *matching* donor.

My response:

1. One big issue with organ donation for money is the absence of insurance for the donor should the donation result in disability. It seems to me that this, at least, is one difference between police and firefighters: they are specifically compensated for their labor and also for the risk of early death or disability through benefits paid to them and their dependents. Even $100,000 won't compensate you if you need a lot of medical care arising out of a donation procedure.

2. The sale of organs could be made less exploitive through a variety of techniques, including mandated insurance or liability for adverse consequences to the donor, psychological counseling, informed consent of the donor and the donor's spouse, must be done by individuals who are certified to do it, cannot be done if the donor has certain medical conditions, only on legal residents of U.S., etc.

3. I don't know about number 3. It depends on how difficult the recovery is and your underlying health status. The problem with arguments like this is that when you make something common you often raise the risks of doing it -- after all, most kidney donors are dead, so we really don't know how safe it is for people who are living. If there are 10,000 every year and the number actually increases to 80,000, that's a whole lot more people undergoing the procedure and a whole lot more doctors doing it, and a whole lot more horror stories about voluntary living donors losing their health or their life.

We do pay healthy people for the medical use of their bodies. Medical studies and surrogate pregnancy, for example, and they certainly have risks and complications. The difference being that organ donation is an irrevocable choice.

The NIH gives the incidence of chronic kidney disease in people over 20 in the US at 11.5%. Most of it due to diabetes and hypertension.

http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/

A German study of 160 transplants give a complication rate of 25.6% (21.9% minor, 3.8% major) with no mortality. Kidney function remained stable for all donors during the follow-up period (mean duration 3 years).

http://ndt.oxfordjournals.org/cgi/content/full/18/12/2648

To the extent that we've got rabbis making $150k profit on a kidney they paid $10k for and the fact that medical tourism isn't going away, it's difficult to deny the benefits of a regulated market.

I doubt libertarians would be too enthused by the single payer model I'd envision: The government is the only legal buyer and seller, $100k to the donor and a $60k markup to insurance companies, discounts for hardship cases.

Of course some portion of the donors would eventually need a kidney transplant themselves and certainly at a higher rate than the general population given that they only have one kidney and will be from a lower socioeconomic group. But they would find it a lot easier to get a replacement.

Globally, this would most likely develop like international adoptions did - a free for all for while, then increasing regulation. It will probably happen faster since the profit opportunities on organ donation would be higher for the government than it is for adoption and they have the adoption experience. That doesn't mean they won't be corrupt or exploit their citizens, but we seem more tolerant of sovereign exploitation than the free market version.

Given that 2.5M people die every year in the US, wouldn't it be better to find a way to increase the donation rate by 1.5%? It must be more difficult than I imagine...

I have delved into this issue and firmly side with organ sellers. I am actually going to hammer you with logic though so sit tight.

First: entering a generally risky profession is different than being coerced to do a specific act because you're feeling specifically desperate at a specific time. At least, it feels quite different to me. The other two arguments, baldly utilitarian though they are, strike me as more persuasive.
No one is coerced. A hospital will not be taking a kidney (and let's be clear hospitals and not donation companies should be the buyers here) without the person's voluntary decision. An appropriate regulatory scheme here would ensure the person is taking the risk voluntarily.

Second: Would this would be a global market? My discomfort with the idea is doubled or tripled at the idea of luring the poor in Bangladesh or Liberia into donating kidneys. Am I right to feel this way?
No. As far as I've worked it out it's a national regime (i.e. hospitals agree to treat any kidney complications in the future). But even if it wasn't in the first place, they get money for a far better life than they would have had otherwise. It's a good risk.

Third: I'll admit that my moral sense is affected by how much a kidney is worth. (I'm taking Somin's word for the fact that the risk involved is actually fairly small.) If the going price were $10,000, that seems like a bad deal. If it were $100,000 — well, that really could make a difference to a poor family. Hmmm. It can actually cost up to 85,000. See this article: http://www.wired.com/medtech/health/news/2007/05/india_transplants_prices

Fourth: This one is by far my most important objection: right now both the law and the taboo against selling organs applies to all organs. But if we make an exception for kidneys, does that weaken the taboo and make it more likely that markets will develop in other organs? Obviously it wouldn't for donations that would kill you, but how about corneas? You've got two of 'em, after all. Or maybe a piece of one lung? Or a chunk of something else. And then another chunk. Would venture capitalists start insisting on organ donations from entrepreneurs to prove their seriousness before they put up money of their own? Could a bank ask a bankruptcy judge to demand a kidney donation in order to pay off a loan?
Regulatory restraints would prevent this from running amok, but as long as you've got a spare it won't matter. It is also likely that due to medical ethics, organ donation would have to be purely voluntary and not as collateral. You might sell a kidney to help pay a loan, but a judge could not order you to sell a kidney. Not voluntary.

I am completley in favor of selling with appropriate legislation to ensure the hospital will care for the person in terms of kidney problems in the future and to ensure voluntariness.

I heard a podcast by Barry Nalebuff (http://www.whynot.net/), who briefly addressed the problem of scarce organ donations. He said that our system of requiring potential donors to 'opt-in' to the donor pool reduces the number of donors because of inertia. People generally do not want to decide to check the organ donor box on their drivers license paperwork.

On the other hand, he said that in Europe, organ donation is the default condition. Theirs is an 'opt-out' system, where anyone may check the box asking not to be included in the donor pool. Nobody is forced to be an organ donor, but inertia works the other way around, making a larger percentage of the population part of the pool of donors. Nalebuff claims that European countries do not suffer from the same shortage of organs for transplant that we have here in the U.S.

As for paying people for their organs: An article in the NY Times or WA Post described how poor people in (India? Turkey?) sell a kidney for some modest cash return (thousands or tens of thousands of dollars). This amount of money can have a huge impact on them, if it is carefully applied. Unfortunately, the money is often never delivered, or is used up in additional 'fees' paid to the organ broker. What is left is not enough to make a permanent difference in the seller's life.

The disparity of power, influence and education between the organ seller and the broker almost guarantees exploitation.

Came here to mention Larry Niven.

Now I need to mention the obverse, I will freely give people a piece of my mind.

I recommend this post by Matt Steinglass on the subject, especially the last two paragraphs:

http://mattsteinglass.wordpress.com/2009/07/24/paying-for-kidneys/

As the death toll from the organ shortage mounts, public opinion will eventually support an organ market. Changes in public policy will then follow.

In the mean time, there is an already-legal way to put a big dent in the organ shortage -- allocate donated organs first to people who have agreed to donate their own organs when they die. UNOS, which manages the national organ allocation system, has the power to make this simple policy change. No legislative action is required.

Americans who want to donate their organs to other registered organ donors don't have to wait for UNOS to act. They can join LifeSharers, a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. Non-donors should go to the back of the waiting list as long as there is a shortage of organs.

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