Paying for Kidneys

By Sally Satel
Monday, April 30, 2007

It is a sad time for the 96,000 patients waiting for kidneys, livers, hearts and lungs: The chasm between supply and demand grows wider each year. By this time tomorrow, 18 people in need of an organ will be dead because they did not get one soon enough.

Kidneys are in highest demand; currently, 71,000 people need a renal transplant. They will spend, on average, five years on dialysis while waiting for an organ from a deceased donor. At least half will die or become too sick to undergo a transplant before their name is called.

In desperation, many of these individuals advertise in print or online for good Samaritan kidney and liver donors. Some even go overseas to participate in a thriving -- and shady -- black market in body parts.

To be fair, medical professionals, policymakers and transplant bureaucrats have not been idle. They are working to expand the number of organs available from deceased donors and to improve methods of distributing this scarce resource most efficiently. These efforts will help but won't come close to meeting demand; last year there were about 10,600 cadaver kidneys and 6,400 from living donors for roughly 70,000 potential recipients.

This month, The Post reported that eight state legislatures have enacted or passed a model law that clarifies matters of donor consent (the measure is pending in 17 more states plus the District of Columbia). One especially thorny circumstance concerns the question of unconscious patients who, in life, signed an organ donor card but also specified in a living will that they do not wish to be put on life support if they stood little chance of breathing on their own.

Fulfillment of their desire to donate might require them being kept on a ventilator for several hours to maintain organ viability until a transplant can take place. Some bioethicists say a person's instructions for end-of-life care should always take precedence over his or her desire to bequeath organs. I am doubtful that a few extra hours on a machine to salvage organs would violate these patients' wishes. In any event, families can be asked to judge their loved one's intent until living wills are updated to include a donation provision.

Transplant policy also made news last winter. The United Network for Organ Sharing (UNOS), the nonprofit entity overseen by the Department of Health and Human Services that maintains the national waiting list and allocates cadaver organs, held a public meeting to propose that younger adults get priority for kidneys. Currently all adults, regardless of age, receive well-matched kidneys on a first-come, first-served basis.

But UNOS is understandably troubled when a young kidney, able to prolong by decades the life of, say, a 40-year-old, instead goes to a 70-year-old who dies a few years later, taking the organ with him (the chance that such an organ could be retransplanted is slim). At the UNOS meeting, which I attended, reaction to the proposal was mixed. "Who's to say an older person's five years of life are any less important than a younger person's nine years?" one of the many skeptical attendees asked. "That's playing God."

No, it's playing man -- the all-too-human business of deliberating strenuously and in good faith about what is right. Should the utilitarian imperative of enhancing survival across all transplant candidates take precedence over fairness to individuals? This is the tragic choice that comes with medical rationing.

Lamentably, too many transplant professionals are resigned to rationing. The alternative is to create a larger supply of organs -- and the most likely way to achieve it is through a safe, regulated system in which donors can receive compensation for their organs. The idea of rewarding living donors for a kidney, or their estates if they give an organ after death, has long been taboo. Yet as thousands die every year the idea is being taken more seriously -- and it should be.

A growing number of physicians, legal scholars and ethicists are urging pilot studies of a regulated system with strong donor protections. This would require Congress to amend the 1984 National Organ Transplant Act so people who give organs could receive "valuable consideration." Such consideration could take many forms, perhaps something as simple as offering them lifelong Medicare coverage. This could also serve as a compelling incentive to other prospective donors. Or Congress could grant waivers so that states can implement their own creative incentive ideas, perhaps using tax credits or tuition vouchers.

We need to move beyond the idea that organs must be relinquished as gifts. The altruistic motive is deeply noble and loving. But relying upon it as the sole legitimate reason for giving an organ is causing too many unnecessary deaths.

The writer is a resident scholar at the American Enterprise Institute. Last year she received a kidney from a friend.

© 2007 The Washington Post Company