Published On January 15, 2007
EVERY DAY, AS SOME 17 AMERICANS DIE WAITING for donor organs—mainly kidneys—more and more terminally ill patients are turning to the black market. Now Amy Friedman, a transplant surgeon at the Yale University School of Medicine, and her father, Eli Friedman, a kidney disease pioneer who created the first dialysis center in New York City, have proposed a solution to make up for the organ shortfall, a solution that’s currently illegal: paying living donors. Here, Amy Friedman answers the practical and ethical questions.
Q: Is money the only solution to the organ shortage?
A: The best solution is for the public to donate organs. But it’s just not happening. Public relations campaigns and drivers’ license designations haven’t increased postmortem donations. And, thankfully, helmet laws, falling crime rates and medical advances have decreased the number of donations. Right now, the largest source of organs is of less-than-ideal quality, such as deceased people as old as 65.
Q: How much better are live organs rather than postmortem ones?
A: Live organs offer a much better chance of survival and longer functionality because we use only healthy live donor kidneys. They’re also transplanted directly from person to person, so, unlike postmortem organs, they’re never away from a blood supply for a long time.
Q: What dangers does a black market pose, besides being illegal?
A: It is not known who, if anyone, reviews donors’ medical conditions to make sure they won’t be harmed by loss of an organ. The organs may be inadequately screened for infectious diseases or cancer; they may be poorly matched to the recipients; and they may be handled by unregulated or inferior surgeons.
Q: In the February 2006 issue of Kidney International, you and your father proposed legalizing the purchase of kidneys.
A: Our case hinges on the proposition that people are entitled to control their bodies, even to the point of risking life. The military is a prime example. You enlist with the clear understanding that you’re risking your life in return for money—and if you die, your family gets a death benefit. That is not ethically distinct from what we’re proposing. Neither is a woman’s choice to sell her eggs.
Q: What about other organs?
A: In the future, we could see paying live donors for segments of liver or lung, and potentially intestine. But the risks are higher.
Q: How would you compensate postmortem donors?
A: Some have proposed paying funeral costs when they die rather than giving cash. You wouldn’t want money motivating people to contribute to a family member’s death.
Q: What would a live kidney cost?
A: Some economists have established a “market price” of $45,000.
Q: Who would pay?
A: Medicare, Medicaid and private insurers. And a third-party payment system would introduce a tremendous equity in today’s black market or legal allocation system.
Q: Would legalizing payment for organs create a system in which the poor sell their organs and shoulder most of the risk?
A: Probably, but our society has already accepted that idea: It’s primarily poor Americans who risk their lives in the military and poor college-age women who sell their eggs and face infrequent but serious health risks.
Q: If a kidney costs $45,000, but people still have to go through an allocation system, what’s to stop them from paying $100,000 to get around it?
A: They’d have to find a center to transplant it. With this federal system, it would be illegal for a surgeon to do that. Where it gets stickier is when someone with an illegally transplanted organ needs follow-up care. We’re ethically responsible for treating them. Are we encouraging the black market by doing that? Maybe. But what else are we going to do?
Q: Have any of your patients gotten black market organs?
A: Yes. I can’t say I blame them. Waiting for a legal organ often ends in death.
Q: Should people make a profit from their organs?
A: When someone donates an organ, everyone benefits financially except the donor. The recipient gets to live and go back to work and make money; the transplant surgeon, anesthesiologist and hospital administrators get paid. Even Americans save money since we pay for the Medicare that covers kidney failure treatments that patients will no longer need after transplants. Isn’t it hypocritical that everybody except the donor receives tangible benefits?
Q: How soon will this change?
A: Changing the situation would involve legislation. But the issue is quite a hot potato—I don’t see any politician touching it any time soon.
Q: How did you end up working on this with your father?
A: My mother had a kidney transplant in 1980. We experienced the desperation of waiting for an organ and the incredible impact of getting one.