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Redesigning the Organ Donation Market
There is no market for organs, so my title itself is misleading. US Code, Title 42, Chapter 6A, Subchapter II, Part H, Section 274e states:
It shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce. The preceding sentence does not apply with respect to human organ paired donation.
Persons violating this law “shall be fined not more than $50,000 or imprisoned not more than five years, or both.”
So, in order for market forces to be introduced into the organ donation market, the law would have to be changed. The bit above regarding paired human organ donation is discussed in this fascinating episode of Freakonomics radio about systems of exchange where money isn’t allowed to trade hands… for instance, in organ donation. So the question becomes: How can we go about doing that?
The first thing we need to tackle is why this law exists in the first place. Ever since organ transplantation became a viable technology there have been people who have been opposed to it for a variety of reasons, starting with religious/spiritual objections, all the way down to the “ick” factor. This in turn has led Congress to pass this law in order to allay people’s fears that the poor could be exploited or that predatory doctors with rich benefactors in need of an organ would prowl the various sick wards of a hospital in search of desperate people in need of a quick buck.
In fact, the “predatory doctor” fear is one of the greatest concerns cited by people when asked why they won’t sign an organ donation card. To be fair, it is a fairly horrific thing to contemplate (as the plot of several horror films attests) a doctor assessing your body as a butcher might a hog. So, there is a well-established cultural taboo backing this prohibition. We don’t allow people to treat their organs as being “fungible” in the same way that money is.
The trouble comes when considering the unintended negative consequences of the ban. As a result of the fact that money can’t lubricate these sorts of transactions the market is “sticky” — there aren’t enough organs to go around because normal people don’t want to give up a perfectly healthy kidney in exchange for the satisfaction of a job well done and a not-inconsiderable amount of post-operative pain. However, the real unintended consequence comes in terms of lives lost and dollars spent.
Medicare spent $57.5 billion dollars on kidney dialysis in 2009 – an average cost per patient of $72,000 per year. 13 people die every day awaiting a kidney which never arrives. These are real costs – and ones we should be sensitive to.
By comparison, a kidney transplant costs Medicare about $106,000 for the first year and about $17,000 in maintenance each year thereafter. Keep in mind these were 2009 dollars and the costs are surely higher today. While it doesn’t take a genius to see that public health dollars would be better spent on transplants than dialysis, particularly considering the medium to long term, that also ignores the vast improvement in the quality of life which the recipients get from not having to live their lives around dialysis centers.
So how do we get from here to there? First we have to overcome people’s justifiable fears of exploitation. The paired-donation concept goes part of the way towards accomplishing this by allowing a person in need of a kidney to access a much broader range of potential donors, as a person who isn’t them can donate an organ in their name to a third party in exchange for a matching organ of their own. It’s totally voluntary. But this still limits the universe of potential donors to the family and (deeply committed) friends of those who need a kidney themselves. In order to better satisfy this need a broader net needs to be cast.
To that extent, I would propose that the current prohibition be lifted, and replaced with a system that works like this:
The only thing that the government needs to do is administer a database that matches donors to recipients on the basis of the relevant criteria — genetic and blood type compatibility. This will have the effect of making such organs more “fungible” and removing the appearance of favoritism.
So how would it work?
Healthcare providers would insert the recipient patient data into the database and it assigns them an alias, stripping the patient of all identifying marks to outside observers. The recipient, or their insurer pays a fee into the donation pool. The purpose of this fee is to reimburse potential recipients for their organ and to defray the cost of the procedures. The amount of reimbursement available would be the residual amount in the pool after recovering transplant costs.
Organ matching companies would similarly insert potential donors into the system on the basis of their blood and genetic factors. Their identity is aliased as well so that the system can’t be gamed by those seeking to broker an outcome – the technical details could include each company seeing a unique set of aliases for potential donors so that each company seeking to access the database won’t be able to distinguish one potential recipient from another. The database could also be designed to prioritize recipients on any number of criteria, from “length of time in the pool” to “severity of need.”
Certain rules, such as strict non-communication between donor-seeking and recipient seeking firms would have to be maintained, in addition to non-communication between the database operators and the donor/recipient. This would have the effect of making such organs as fungible as the dollars we are seeking to substitute them for.
But how do we set the fee for entering the pool? That too is simple: the insurance companies or the individuals involved will essentially have to bid on what they believe the appropriate price for donor remuneration and transplant costs will be. The relative motivation of the individuals and organizations involved will adjust the prevailing price for pool entry and thus, the amount of remuneration donors will receive. If the prices are too low, there won’t be enough donors and pool entry fees and donor payments will consequently increase as the motivation of the individuals seeking an organ goes up.
For example, say there are 20 people who have each paid $100,000 in the pool awaiting a kidney. Let’s say this leaves $20,000 per potential donor as a fee but there are no donors at that price – now a wealthy person comes along and desperately needs a kidney. The wealthy person donates $1,000,000 to the pool, increasing the potential payout to each donor significantly and suddenly, more people find that they are willing to part with a spare organ for, say $70,000 as opposed to $20,000.
In this scenario, rather than the wealth of some individuals representing a perverse incentive for the system to favor them, the largesse of the wealthy actually ends up favoring all potential recipients to some extent because their addition to the pool of available funds will have the effect of dramatically increasing the number of organs available.
Of course, additional rules such as the age of potential donors, their citizenship status and other factors would need to be considered, but in the aggregate, I feel as if this system would have the effect of improving the lot of people suffering with various chronic conditions. By divorcing the identity of both donor and recipient and inviting neutral third parties to match them we would allow the market to function and hopefully save a great deal of money and suffering in the process.
Published in General
There is no organ shortage. There is only a shortage of free organs. Why we let people die, because we don’t want to let people decide what to do with their body is beyond me. Everyone else involved in the operation makes money except the organ and blood donors, yet without them the operation doesn’t happen. It is nuts.
That is also correct. We tend to bury a lot of viable organs, but the issue with that is that people don’t like the idea of being cut up after their death. They also don’t want to be hovered over by doctors awaiting their death or family members who might have a financial interest in their demise being unable to wait to pull the plug on them.
People are obviously free to donate their body parts after their death and do so frequently, but getting some people at the margin to donate them before they’re “done” with them is tougher, but it avoids some of those messy end-of-life issues.
The people that enable the continuation of the organ market ban are culpable in the deaths of those who would otherwise survive. It upsets me so much thinking about it.
Great stuff, Maj.
I would be an organ donor, but my husband has said the family of the donor has to pay for keeping the donor on life-support until they are ready for harvesting.
Is this true? And if so, would this be prohibitive in having more donors?
I understand that there are organizations doing much of the matching work you describe, such that “chain donation” is a growing part of the transplant scene. Adding intermediaries makes the most of the possible combinations under the existing restrictions.
I would imagine this is probably true – once you’re “brain dead” and removal of artificial life support would cause your natural demise due to lack of brain stem activity it may be that the recipients aren’t prepped and ready to accept your organs.
This is especially relevant in the case of heart or lung transplants where you can’t survive without them, and recipients matching you might not be in the queue when you die and the organs don’t live outside of a body indefinitely.
Sally Satel, at AEI, is a kidney recipient. She has a different idea for compensation, which would come from govenrment in the form of incentives:
https://www.aei.org/press/when-altruism-isnt-enough/
This is correct. By allowing a third party (say your wife or husband) to donate an organ for you it can set off a chain of donations around the country due to other people having third parties willing to donate for them as well.
That greatly eases transaction costs, but in reality it only scratches the surface of the need because the number of people needing organs is growing far faster than the number of donors.
Ultimately, the hope is that such donations won’t be necessary because we’ll be growing genetically identical replacement organs in animals in the future, but in the meantime economics could help to fill the gap.
I suggest giving everyone who signs an organ donor card when getting his driver’s license free licenses for life. In this way, he is paid while alive for giving up his organs when he’s dead.
If I were made that offer I’d sign. Would you?
They’d have to pay me in addition to that! What are you going to spend on your driver’s licenses throughout your life? $200? What if you move to a different state?
EDIT: I also think that isn’t an ironclad contract either. Your family has some say over it as well if I’m not mistaken. A little check mark on your license doesn’t have much weight in comparison to things like wills and spouses.
You could throw in free registrations, too. I think on the margin it wouldn’t take that much, especially for younger people, to get them to agree. I’m not saying it solves the problem entirely, but it would help.
The main point of this suggestion is to find a way to move the payment for the organs from the after-death time frame when the money is of no value to the donor, to the still-alive time frame. The amount is a trivial question.
This issue can be resolved by a change in the law, a law that would have to be changed in any case.
In a state like Colorado where you have the Taxpayers Bill of Rights (TABOR) a great deal of new revenue that the State has had to obtain comes in the form of fees – particularly for vehicle registration. I imagine you might get some people signing up if they knocked $25 off their registration… but almost a third of people do so already, so you are just going to be bleeding revenue for minimal gain.
Indeed.
There is one place on the planet that doesn’t suffer from a lack of kidneys – Iran, which allows for the sale of organs in a government regulated market.
Oh irony! I think you can purchase the kidneys of executed prisoners in China as well… Ideas aren’t responsible for the people who believe them. :)
Surely, individuals have the right to act according to their own moral/ethical values without being held ‘culpable’ for the unrelated death of a complete stranger somewhere else.
Or does that logic only pertain to election consequences?
I’m closer to Mike on this one. This is a case where prohibition has a direct, negative impact upon people’s lives. Permanent, negative consequences including death.
The law would certainly never be rewritten to require organ donation, so peoples’ personal ethical objection to the practice would be upheld, but other people who are literally dying today because of this ban could be allowed to live.
You are an optimist. I could easily see a step in that direction, making people who do not sign up as organ donors ineligible to receive an organ donation. (I might even support such a step.) It is not that hard to believe that a government that mandates helmets and seat belts for your own good would then require participation in the organ-donation community — for your own good, as well as others’.
But the underlying logic of “culpability” is what interests me. Are we to be held (somewhat, at least) responsible for all (serious) consequences that could arguably have been mitigated by an action that we did not take? If you accept that, how can you argue against gun control?
Two good authors have weighed in on this subject. I first recommend to my fellow Ricochetty The Jigsaw Man by Larry Niven. I also recommend the work of Lois McMaster Bujold’s Miles Vorkosigan saga especially the storys that take place around Jackson’s Hole.
Let’s hope that stem cell research some day allows us to grow new organs.
If you support bans on an organ market, you are literally standing in between someone who wants to give an organ and someone who wants to accept an organ, simply because there’s a side payment.
You’re unnecessarily increasing the cost of someone who wants to give an organ by not letting them also accept money. So, you are causing a match to not be made because you don’t like the idea that that someone else is allowed to violate your morals.
And of course it would be horrible for the government to force anyone to donate against their will, but the specter of that evil doesn’t argue for the necessity of the status quo.
Because buying and selling of guns should also be a free market! It’s entirely consistent!
If you mean allowing guns can lead to someone ending someone else’s life, you’ll have to help me out a little to show you how it’s not the same thing.
Organ market bans stops someone who would otherwise save someone’s life.
Gun bans stop someone from saving their own life. You’re not responsible for other people who hurt others. You are responcible for stopping someone else from helping others.
We may be talking past each other. I am not arguing for the ban on an organ market. I am reacting to your statement above about culpability. If one who disagrees with you on the likely effects of a program is culpable for indirect consequences, then you must accept culpability for consequences of the opposite course. (Decriminalizing drugs, for example, may reduce organized crime but increase incidence of addiction.) A free market in organ donation would be easy for some to exploit (ala Gosnell). So we must regulate it strictly. Government agencies will certainly ensure everything will go perfectly.
Do you really think that increasing the cost of something ‘unnecessarily’ (Who decides that?) is equivalent to ‘literally’ standing in between two parties in a transaction?
Yes. “Unnecessarily” is to differentiate government costs from other “natural” costs that price things in the market. The government is literally standing between the two parties, not allowing them to make the transaction. I’d be willing to give voters much less culpability than the people in government who actually causes the injustice, but asking for it isn’t without blame.
I question your assertion that the deaths are an “indirect” consequence. It follows obviously and immediately from denying people the ability to come to their own terms on their organs, whether or not they want those consequences. That’s basically the only reason people are in need of organs.
I would say that the ‘direct’ cause of death would be, say, kidney failure. I would consider ‘failure to prevent’ as ‘indirect’ at most. Refusing to rescue someone in immediate peril such as not throwing a rope to a drowning man gets close, but I would still say the direct cause was drowning and the proximate cause might be the swimmer’s carelessness. The more people/agencies involved, the less direct it gets.
To work off your analogy here I would say the government is a person standing directly athwart a third party trying to throw a drowning man a rope.
Not to be snarky, but they are standing athwart a third party trying to sell a drowning man a rope.
Not to say I’m against your line of thought.
Still indirect. Indirect does not mean without fault.
Returning to the original issue: If one were to have reason to believe that an expanded organ market (I have the urge here to assert that I am not opposed to such.) would create an environment that would result in more deaths than it would save (Extrapolate from assisted suicide and abortion trends.) then he would claim that those who vote to allow such a market were responsible for these (to him) inevitable deaths.
That’s why I don’t think it is valid to claim direct causality when debating consequences of government policies.
So, your claim is that if the facts of the world were opposite what they are, then it’s possible the correct action would be different…
…
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Maybe… but that would likely only be true if the number of deaths in a free market far exceeded the number of deaths in the absence of a market.
You need a very good reason to be allowed to stop someone from doing something they want to do. Even if there were 5% more deaths in a free market, I doubt that would make it morally permissible to stop it.
But we don’t live in anything like that world. There would be (at least) thousands more people saved per year in a free market.
Well, being allowed to sell a drowning man a rope. If that’s the only rope the drowning man has available to him, I doubt he would recoil.
I totally agree with that.