Kidney Market: We’re Not There Yet

Kidney Market: We’re Not There Yet

The importance of a solution to the lack of kidney donations cannot be overstated. While about 1% of the US population live with End Stage Renal Disease (ESRD), this population accounts for about 7% of the Medicare budget. There is an average yearly cost of about $89,000 for dialysis, almost completely covered by Medicare, private insurance, or Medicaid. The other option that patients with ESRD have is to receive a kidney transplant. A kidney transplant is substantially cheaper and has a greater five-year survival rate for transplant recipients [1]. You may look at the article from my partner in this point-counterpoint article if you need convincing on the difficult position that the United States is in when it comes to providing a high quality of life for those with End-Stage Renal Disease (ESRD).

While Conner defends the idea of creating a kidney market, I will defend that we keep kidney markets as they are now: illegal. Moral repugnance is often cited as the first reason against the use of kidney markets in the United States. The idea of commodifying our bodies, for whatever purpose, violates our socially accepted notions of value-systems. However, while I will be arguing against the creation of a legal organ market, I don’t believe that this reason alone is enough justification for illegalization of kidney markets. We should forbade markets of this nature because of the real damage that they can impose on our fellow citizens.

A 2016 study showed that US citizens are willing to accept higher levels of moral repugnance for more efficient systems. In other words, Americans are more willing to accept “morally repugnant” markets, such as kidney markets, when there is a high return, such as saved lives from an increase in kidney donors [2]. (From here on out, however, I will refer to the kidney “donor” in these markets as kidney “vendors.”) In fact, we’ve already legalized egg and sperm donation for sale in the United States. When I search egg donation on google, one of the top sites specifically says, “Virginia egg donors receive substantial compensation.”[3]. These markets are arguably more ethically problematic because they lead to the creation of life. This argument against kidney markets, while an important component, does not hold up when compared to current laws.

 

In 2010, the World Health Organization (WHO) released guiding principles on Human Cell, Tissue, and Organ Transplantation. Up until this point, I have not made a very strong case against kidney markets in the United States. I want to use some of the points from the WHO in order to make my next arguments. The WHO says that individuals donating should “be informed of the probable risks, benefits and consequences of donation in a complete and understandable fashion,” that “payment for […] organs is likely to take unfair advantage of the poorest and most vulnerable groups [and] undermines altruistic donation” and that “allocation of organs […] should be guided by clinical criteria and ethical norms, not financial or other considerations” [4].

 

Regardless of whether you are selling or donating your kidneys, there is a lack of data on the risks in the long-term. One potential risk is feeling a sense of regret after donating [5]. Hospitals are only required to follow donors for two years after their surgeries. There are some preliminary studies suggesting that risk of ESRD is higher for donors but still fairly small. However, most of these studies admit that their sample sizes are too small, making them less significant and untrustworthy [6]. People donating kidneys deserve the highest scientific standard and that is not what they currently have. Lack of data means that a patient will not be informed of probable risks “in a complete” fashion [4]. Accepting live donations is ethically problematic based on this information alone. If we are to accept kidney vendors, I feel that this adds undue influence. Until we have improved our data collection methods, selling kidneys is unfairly influencing people to act without adequate attention to consequences.

 

The second point I bring up from the WHO includes one of the most cited arguments in this debate: “payment for organs is likely to take unfair advantage of the poorest and most vulnerable groups.” Logically, it will not be those that are economically advantaged donating their kidneys for money. It is those that are more economically disadvantaged, and often more likely to have poor health outcomes, that would become organ vendors [7]. These groups would, thus, be under undue influence. A researcher at the Centre for Health, Ana Manzano, says that “the poorer the donor, the higher the possibility that he or she loses the functionality of the remaining kidney because of demanding work or inadequate health care” [8]. The health gap between socioeconomic classes would only continue to increase due to both economic and social influences that are too strong to be overpowered. Gary Becker, Nobel Laureate, and Julio Elias estimate that individuals would be paid about $15,000 for a kidney if a market is created [9]. This is much lower than the $45,000 that is estimated to be needed to eliminate the kidney waiting list [10]. If there was a poor health outcome in the future, $15,000 would not be enough to support vendors and it certainly will not bring vendors out of economic and social constraints. The benefits of influencing an economically disadvantaged individual to sell their kidneys does not outweigh the costs.

The WHO also points out that creating a market would undermine altruistic donation. Currently, altruistic donation accounts for 1/3 of all kidney donations. Before moving into the undermining of altruistic donation, we must talk about the issues with the system to begin with. As mentioned before, we do not have enough data to know the long term effects of kidney donation due to a lack of kidney donation registry. Death, pneumonia, and blood clots are the most frequently offered consequences of donation. Many donors are often unprepared for the financial and emotional consequences of lifelong health problems because the system is currently focused on the health outcomes of the kidney recipient [11]. I suggest that we work on bettering this system first before moving into expansion into a market. If we don’t have this system figured out as is, we are not likely to succeed with a market that attracts vendors from a group that is more likely to have poor health outcomes. The WHO is right in that creating a market would undermine altruistic donation but live donation is already a sticky field. I say that we figure out how to treat living donors properly first through our current system before jumping into a system that is mostly based on living donation.

        Kidneys should be received based on clinical and ethical criteria, not financial ones. If a market was created in the United States, the economically advantaged would have the highest access to it for both social and economic reasons. This adds another level of discrimination against economically disadvantaged groups. The argument to counter this is to say that because the government would be saving so much on dialysis, they should be the ones to pay in order to avoid this. I will use Iran’s kidney market as an example of why this is not probable. Iran started off covering the costs of a kidney donation. The government paid the donor equivalent to about $15,000 US dollars. Within a few years, however, this system broke down and it became the patient making about 90% of the payment. Vendors in this Iranian market also appear to have a lot of shame about donating. While incorrect due to screening, many Iranians assume that vendors are drug addicts needing a fix [12]. This is likely to be duplicated in the US and may be a source of regret for vendors here as well. To be quite honest, my biggest fear with this kind of market in the United States is that our healthcare is already comprised of many for-profit businesses, including insurance and pharmaceutical companies as well as many hospitals. With a capitalist economy like ours, it is unlikely that kidney allocation would be based solely on clinical and ethical criteria.  

My solution to the kidney shortage is much less ethically problematic. The United States currently has an “Opt-In” system for organ donation. When an individual goes to the DMV to receive or renew their license, there is an option to list yourself as an organ donor. You must “Opt-In” to it. In my own experience, it is something that the DMV does a poor job of advertising. When I recently went to get a Virginia license, I asked the employee on three separate occasions to list me as an organ donor. Each time, it was only because I brought up the issue; I was not directly asked but had to ask for myself. If I had not read the final paper carefully, I would not have noticed that the employee had forgotten to list me as an organ donor. I would have walked out very disappointed. This “Opt-In” system in the United States is very obviously failing us.

In a study completed at Cornell University, researchers found that participants in “Opt-In” and “Opt-Out” countries had very different views on what it meant to be listed as an organ donor when you die. “Opt-Out” countries thought of this listing as trivial and inconsequential – in other words, it is strange to not donate your organs. “Opt-In” countries, such as the US, viewed it as extraordinary altruism or equal to donating half of your life savings [13]. This difference in views of organ donation causes a steep difference in numbers of kidneys transplanted. Fewer than 15% of people donate their organs at death in “Opt-In” countries compared to more than 90% in “Opt-Out” systems [14].

Opt-Out systems have a definite increase in total numbers of kidneys transplanted [15]. If we want to reduce the kidney waitlist, it seems only logical to change our system to reflect this value. Also, donations from deceased donors provide two kidneys, not just one. A representative survey conducted by the United Network for Organ Sharing found that while 79% of responders were in favor of organ donation, only 36% said to be potential donors [16]. To me this indicates a gross issue in the way we present the option of whether or not to be an organ donor. As a last point in favor of “Opt-Out” systems, I would like to point out that when a patient passes away, it is uncomfortable for a patient’s family and the medical team if a member of the team asks for the family to donate the deceased’s organs. While I hope this does not come off as insensitive, this awkwardness and tension leads to a lot of missed opportunities: the potential to save 8 lives to be exact [17]. The culture around donating organs at the end of life needs to be changed, managed, and marketed differently. 

I am not completely disregarding the kidney market as an option for the future, however, I believe that there are many steps that need to be taken before it can occur. We need more data on long-term effects in donors. We need to make sure that those giving kidneys be treated as well as kidney recipients. This treatment should start with the ones that are currently donating. And lastly, we need to focus on changing our system to be an “Opt-Out” system that is managed correctly. If these changes are made and we still have a long waiting list, then a market may be a viable option. For now though, the thought of a kidney market is a hasty and potentially dangerous decision.

 

References.

  1. "Statistics." Statistics | The Kidney Project | UCSF. Accessed November 05, 2017. https://pharm.ucsf.edu/kidney/need/statistics.

  2. "Understanding moral repugnance: The case of the kidney market." Understanding moral repugnance: The case of the kidney market | VOX, CEPR's Policy Portal. Accessed November 05, 2017. http://voxeu.org/article/understanding-moral-repugnance-case-kidney-market.

  3. "Egg Donation: Richmond, Virginia." Virginia Egg Donation: Virginia Egg Donors & Frozen Egg Bank Program. Accessed November 05, 2017. https://www.eggdonoramerica.com/contact-us/local-resources/virginia.

  4. WHO. "WHO GUIDING PRINCIPLES ON HUMAN CELL, TISSUE AND ORGAN TRANSPLANTATION." Http://www.who.int. http://www.who.int/transplantation/Guiding_PrinciplesTransplantation_WHA63.22en.pdf?ua=1.

  5. Poulson, Michael. "At 18 years old, he donated a kidney. Now, he regrets it." The Washington Post. October 02, 2016. Accessed November 05, 2017. https://www.washingtonpost.com/national/health-science/at-18-years-old-he-donated-a-kidney-now-he-regrets-it/2016/09/30/cc9407d8-5ff9-11e6-8e45-477372e89d78_story.html?utm_term=.f74ea3d8c2d1.

  6. Lam, N. N., K. L. Lentine, A. S. Levey, B. L. Kasiske, and A. X. Garg. "Long-term medical risks to the living kidney donor." Nature reviews. Nephrology. July 2015. Accessed November 05, 2017. https://www.ncbi.nlm.nih.gov/pubmed/25941060.

  7. Swain, Geoffrey R. "How does economic and social disadvantage affect health?" Winter 2016-2017. https://www.irp.wisc.edu/publications/focus/pdfs/foc331a.pdf.

  8. Muzi, Francesco Alesi and Luca. "Kidneys for sale: Iran's trade in organs." The Observer. May 10, 2015. Accessed November 05, 2017. https://www.theguardian.com/society/2015/may/10/kidneys-for-sale-organ-donation-iran.

  9. Becker, Gary S., and Julio J. Elias. "Cash for Kidneys: The Case for a Market for Organs." The Wall Street Journal. January 18, 2014. Accessed November 05, 2017. https://www.wsj.com/articles/cash-for-kidneys-the-case-for-a-market-for-organs-1389992925.

  10. Held, P. J., F. McCormick, A. Ojo, and J. P. Roberts. "A Cost‐Benefit Analysis of Government Compensation of Kidney Donors." American Journal of Transplantation. October 16, 2015. Accessed November 05, 2017. http://onlinelibrary.wiley.com/doi/10.1111/ajt.13490/full.

  11. Cuda-Kroen, Gretchen. "Organ Donation Has Consequences Some Donors Aren't Prepared For." NPR. July 02, 2012. Accessed November 05, 2017. http://www.npr.org/sections/health-shots/2012/07/02/155979681/organ-donation-has-consequences-some-donors-arent-prepared-for.

  12. "Tina Rosenberg on the Kidney Market in Iran." EconTalk | Library of Economics and Liberty. Accessed November 05, 2017. http://www.econtalk.org/archives/2015/09/tina_rosenberg.html.

  13. Box. Accessed November 05, 2017. https://stanford.app.box.com/s/yohfziywajw3nmwxo7d3ammndihibe7g.

  14. ""Opt Out" Policies Increase Organ Donation." SPARQ. Accessed November 05, 2017. https://sparq.stanford.edu/solutions/opt-out-policies-increase-organ-donation.

  15. Shepherd, Lee, Ronan E. O’Carroll, and Eamonn Ferguson. "An international comparison of deceased and living organ donation/transplant rates in opt-in and opt-out systems: a panel study." BMC Medicine. September 24, 2014. Accessed November 05, 2017. https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0131-4.

  16. Kittur, Dilip S., M. Michele Hogan, Vinod K. Thukral, Lin Johnson McGaw, and J. Wesley Alexander. "Incentives for Organ Donation? ." DigitalGeorgetown Home. December 07, 1991. Accessed November 05, 2017. https://repository.library.georgetown.edu/handle/10822/735692.

  17. "LiveOnNY." New York Organ Donor Network. Accessed November 05, 2017. http://www.liveonny.org/about-donation/quick-facts-about-donation/.

Why We Need a Market for Kidneys

Why We Need a Market for Kidneys

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