You Can’t Unring a Bell

Aviva Goldberg suggests that while payment may increase the number of living kidney providers, this benefit may not outweigh the risks associated with commodification of the human body.

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In a recent article – “The Cost-effectiveness of using payment to increase living donor kidneys for transplantation” – Lianne Barnieh and colleagues cite the following disheartening facts: kidney donation rates have remained stagnant for the last decade, and waitlisted patients continue to die.  These facts, they suggest, are reason enough to explore strategies to increase the number of kidneys available for transplantation, including the option of paying for organs.  The authors conclude that paying $10,000 per kidney could generate cost-savings for the health care system, even if this only increased the number of available kidneys by five percent. So, is it time for us to initiate a clinical trial of a regulated market in organs for transplantation?

Organ markets strike many as repugnant, but it’s not clear that we should reject this strategy out of hand. Nobel Laureate Alvin Roth, an economist, points out that markets once considered repugnant, like the market for life insurance, become acceptable with time. He also notes that paired kidney exchanges (where a kidney that is incompatible with the donor’s intended recipient is swapped for that of another donor who is similarly situated) is also a kind of organ market, but one that is generally considered ethically acceptable. As well, earlier research by Barnieh and colleagues suggests that many Canadians consider regulated financial incentives for living and deceased donation ethically acceptable.

Nicholas Green Memorial Bell Tower

Nicholas Green Memorial Bell Tower

Whether payment for kidneys is ethically acceptable depends, to some degree, on how organ sellers are treated before and after surgery.  It also depends on who is responsible for making the payments. Those who would promote a clinical trial of a regulated market in organ sales, stress that good medical follow-up of sellers is essential, along with a single payer system where the government pays a fixed rate for organs. In this case, Canada, with our socialized health care system, seems like the ideal place for a clinical trial of a regulated market in solid organs.

Such a trial would necessarily have far reaching effects.  For example, it would change transplantation from a gift model to a trade model. Transplant health care providers would be brokers of financial transactions instead of facilitators for the “gift of life”.  In turn, this could affect the way the public views transplantation, potentially resulting in decreased altruistic donation rates from both deceased and living donors.  While Barnieh and colleagues’ earlier research suggests that the public may support organ sales, there is a big difference between what people say in answering a survey and how they react in the real world.

Creating a regulated market in human organs means that we are comfortable, as a society, sanctioning payment for goods (organs) that are part of our bodies. It means that we are accepting the idea that we are similar, at least in some ways, to other things that we buy and sell in the marketplace. And yet, we have rejected the commodification of the body by outlawing slavery, criminalizing prostitution, and banning egg and sperm sales in Canada.

Clark Wolf warns that “since people are literally dying every day because of the lack of transplant organs, the commodification argument must be supported with the strongest underlying reasons.” But just as the commodification argument, on its own, should not trump all arguments in support of organ sales, the fact that the current transplant system underserves those on the waiting list does not, on its own, justify creating a market for organs.  There are many ways to increase the number of organs available for transplantation that are, and will remain, ethically unacceptable.  We could arrest people on spurious charges and execute them so we could get their organs (as appears to be happening in China). We could go to developing nations and pay people paltry sums to give up their organs (as is denounced by the Declaration of Istanbul). Or, we could lure people into hotel rooms and steal their organs (as depicted in the thought provoking film Dirty Pretty Things).  In Canada, we don’t endorse  these strategies because we recognize that the desire to save the lives of those who are suffering from end-stage organ diseases must be tempered with the responsibilities that we have to those who may be coerced or unlawfully forced to give up their organs.

Barnieh and colleagues have done an admirable job of trying to “take a step back and remove some of the heatedness” around the debate on organ sales.   But this debate is necessarily one of passion, since it pits the science of cost-effectiveness against the ethics of commodification. A paper that suggests organ sales could work and that recommends a study of the feasibility of paying living “donors” is inevitably going to enflame those who oppose the practice, and who worry about the unintended consequences that may result.

You can’t unring a bell. Even if paying for organs may be cost-effective, this strategy to increase the number of organs available for transplantation may be best left to theory rather than practice.
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Aviva Goldberg is a pediatric nephrologist and an Assistant Professor in the Department of Pediatrics and Child Health, Faculty of Medicine, University of Manitoba.

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