Kidney donations, payments, and the poor
Like most other countries, the United States does not allow people to sell their kidneys to make ends meet. There are also international laws and norms that prohibit commercial markets in human organs. For example, the Declaration of Istanbul on Organ Trafficking and Transplant Tourism as well as a rare joint statement from the United Nations and the Council of Europe both recently advocated for a complete abolition of organ markets. Furthermore, speakers at an international conference last month emphasized that the trafficking of organs from poor to rich countries remains a serious problem.
But there is increasing discussion of loosening the payment prohibition for live organ donations, particularly for kidneys. The issue is serious: Thousands of Americans die waiting for kidneys. How can we make more kidneys available for transplant? (On a personal note, my baby has only one kidney, and it has failed once already. Neither my wife nor I could be donors.)
Modest proposals would use non-financial incentives, such as linking a person's willingness to donate (or actual donation) with his and his direct relative's position on the waiting list to receive an organ. For example, a new law in Israel enacts this approach. Some advocates call for a flat payment from the government or tax credit for giving a kidney to a stranger. A few even praise an open, but regulated, market.
A supporter of a flat payment system recently sought to address concerns, including that it would unduly induce economically vulnerable people, by conducting a survey that asked people whether various sums of money would persuade them to provide one of their kidneys for transplant. The lead author of the report, Scott Halpern of the University of Pennsylvania's Center for Bioethics, concluded that there is no empirical evidence supporting these concerns.
This study, however, has significant flaws.
First, all surveys of altruistic behavior are subject to “social
desirability bias,” which means that respondents portray their real
and hypothetical actions in a more positive light than reality. This is not a marginal effect. In the survey, about 20% of respondents said they would donate a kidney to a stranger on a waiting list without payment. Yet in a given year, only 0.002% of Americans engage in live kidney donation, and the overwhelming majority of these are given to a family member or friend. In fact, if this rate increased to just 0.03%, there would be no waiting list for kidneys. In a survey like this, the large magnitude of this social desirability bias may mask in a survey who would and would not actually give a kidney when offered cash.
Second, the research team surveyed people on the Philadelphia regional commuter trains. This is not a random sample and likely has biases:
Lainie Ross, associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, says she feels the findings are flawed because interviews were done with participants waiting for a commuter train and thus left out poorer people who don't have jobs. "The buying and selling of organs will be exploitative because we will end up buying organs from very poor people," Ross says.
Halpern et al acknowledge that their respondents were disproportionately highly educated, but discount this as a problem since they found that education level did not correlate with responses.
Finally, the authors' data (see the figure below) do not necessarily indicate that there isn't a problem. Poor people surveyed were more likely to say they’d provide a kidney at all three payment levels, including no payment at all. The researchers conclude that the payments are not an inducement. Maybe so. They write:
Thus, our results do not corroborate concerns about the ethics of payment per se, but rather they suggest that poorer persons may contribute disproportionately to the supply of organs with or without payment. Reasons for these behaviors, perhaps including differences in the opportunity costs of donating among richer and poorer patients, merit future study.
Regardless, the poor would disproportionately provide kidneys under a system with payments.
Of course, paying for organs can have implication beyond increasing their availability for transplant. Alex Capron of the University of Southern California reacted to the study by saying, "Once you make the kidney into a commodity, people are going to treat the
human beings like a commodity."
How to increase the number of organs for transplant is a matter of life and death for thousands of people. Future study is indeed merited, and hopefully will not rely on a few dozen people on a single transit system.
Previously on Biopolitical Times:
