Barry Hoffmaster argues that the moral cost of commodifying kidneys for transplantation must be calculated before the health care costs can be considered.  

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In a 2011 Canadian survey  (published in 2012) on the acceptability of using money as an incentive to increase the number of kidneys for transplantation from live donors, Barnieh and colleagues learned that more than half of the respondents would be “willing to consider” donating a kidney to a relative or friend for $10,000. They then set out to determine whether offering a financial incentive of $10,000 would be cost-effective.

The follow-up study acknowledges that transplantation is superior to dialysis because it extends life, improves the quality of life, and is less expensive. The research uses QALYs, (quality-adjusted life years), to assess outcomes, and determines cost-effectiveness by calculating the QALYs gained over a lifetime and the incremental cost per QALY gained. On the assumption that paying all living donors $10,000 could increase donations by five percent, the authors conclude that such a payment would be cost-effective. Given that finding, increasing a program’s living-donor kidney transplants from 100 to 105 would cost $1,050,000 (paying all 105 donors $10,000), but that large additional expenditure would be cost-effective when compared with the existing system of organ donation.

What should be made of this claim about cost-effectiveness? Is it reliable, given that the calculations did not include the likely substantial administrative costs, and given that factoring in these costs might well threaten the cost-effectiveness of the proposed strategy? What about the economic realities? Even if the proposal is cost-effective, should it be adopted? Where would the revenue to pay all living donors come from? Would it be transferred from other health care budgets? Would the cost of health care increase? Cost-effectiveness does not mean cost savings, let alone that a cost-effective program is, all things considered, worth it.

There also are inherent moral concerns with the proposed strategy. The authors stipulate that the payment program must be run by a governmental agency. They reject the efficiency of the private sector for a very simple reason: they want to dispel the impression that paying “donors” creates a market for the buying and selling of kidneys. This also explains why the payment is fixed – they do not want to contend with market fluctuations or allow haggling about price. The authors explicitly oppose a market model, but defer ethical examination of their proposal without recognizing the moral nature of their covert assumption that, unlike buying and selling a kidney, offering a monetary incentive for a kidney is morally permissible.

Monetary payments can be made for various reasons: to reimburse, to compensate, to induce, or to buy. Reimbursement can be straightforward, as with travel expenses. Compensation is trickier, depending upon what is being compensated, and can become elusive (almost arbitrary) when it is for intangibles such as pain, suffering, and risk. Incentives are even dicier A financial incentive in the form of a monetary payment is not easy to distinguish from buying. For example, what is the difference between offering my son twenty dollars to rake the leaves and paying a lawn company to do the raking? It might cost less to have my son rake the leaves, but am I not buying a service either way? And doesn’t that become even more obvious if my son starts dickering about the amount? Recognizing the slippery line between inducing and buying, other proposals to increase organ donations by offering financial incentives have steadfastly avoided cash for organs – choosing instead to provide inducements such as partial coverage of funeral expenses.

The outright sale of human organs is illegal in almost every country (perhaps not in Iran), yet there is an extensive, readily accessible international black market that displays the familiar features of a market: money changes hands in return for a good; price depends upon supply and demand; and people, including brokers, make a profit. But markets are heterogeneous, multidimensional, and flexible. A market does not have to generate a profit. It can serve to lower a price, compensate for losses, and make an item more available. A market does not have to operate in the private sector of an economy.

A market is a socially institutionalized system of exchange. What the authors propose is a socially institutionalized system for procuring kidneys for transplantation from living persons in return for money. That system would be institutionalized in a public-sector agency created to enable the exchange of a kidney for a $10,000 payment.

A kidney market, however suppressed, is not morally innocuous, because it introduces the core concern of commodification. (Richard Titmus, The Gift Relationship, Vintage Books, 1971) Commodification occurs when something acquires a monetary value that degrades its inherent value. Some things, such as love, trust, and dignity, cannot be commodified. Other things, such as a gift to a loved one, can be commodified, but should not be. A market in kidneys, even when hidden, could devalue and dilute the altruism of truly donating kidneys, and the erosion of that altruism could threaten the already insufficient supply of kidneys for transplantation.

Calling a $10,000 payment to a live kidney “donor” an “incentive” is a stratagem, perhaps unintentional, for avoiding the moral repugnance and stigma associated with buying and selling human organs. Determining the moral permissibility of such a market exchange must come before, not after, determining the cost-effectiveness of such a payment.

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Barry Hoffmaster, Professor of Philosophy, University of Western Ontario