Selling Organs for Transplantation

Selling Organs for Transplantation

Essay #1
By this date, we will have covered a significant number of moral problems. Choose one of the
essays that you feel you can best explain (you don’t have to agree with it). Obviously, do not use
the same essay that you wrote on for the mid-term. Then,
1) Summarize the author’s argument in a clear, precise way without minimizing it.
2) Explain why or why not the argument works (i.e. whether or not the argument is sound). You
will be graded on your ability to explain and then evaluate the argument based on careful
reasoning.
Some essays have one argument (e.g. the Davis essay on paying college athletes), some essays
have numerous arguments (e.g. the essays on legalization of drugs); only choose one issue for
your essay, as it is short. Imagine you are explaining the issue to a stranger from another culture
that doesn’t understand the controversy. This means you cannot resort to religion, faith, or
personal experiences to make your argument. You can only resort to reason.
Direct your response to the issue at hand; do not waste essay space on summary or exposition.
Show me what you have learned from our discussions and readings. Remember, I am not
grading you on your opinion: I am grading you on your ability to explain and analyze an
argument.
Your notes, textbook, and readings are all welcome sources. Be sure to cite quotes if used (and
use them sparingly). I highly recommend typing your response into a word processing program
and saving regularly before pasting it into Canvas.
If you cut and paste something that is not yours, I will figure it out. Plagiarism of any kind
results in an automatic zero.
Keep your responses between 500 words

Selling Organs for Transplantation
LEWIS BURROWS, M.D .
Abstract
The need for transplant organs has far outstripped the supply of available cadaveric organs. Hundreds
of people on waiting lists, who could be saved by transplantation, die each year. This severe shortage
has justified the extension of transplantation to the use of living donors, but there are still not enough
organs to meet the need. This paper discusses the justification for changing policies in order to encourage organ donation. It presents reasons for allowing payments to be made to families that donate
cadaveric organs. It also presents reasons for allowing payments to be made to living donors, and
guidelines for how an ideal policy could be structured.
Key Words: Selling, payment, organs, transplant, financial remuneration, presumed consent, altruism,
ethics.
LIVING DONOR ORGAN TRANSPLANTATION is the
only field of medicine in which two individuals
are intimately involved: the donor and the recipient. It is also the only field of medicine in
which altruistic giving of oneself is the basis of
the medical practice. I have been asked to address a very specific aspect of this process, that
is, living organ donation for financial remuneration. No other subject in the transplant experience is as controversial. Many of those involved in the field—surgeons, physicians, social scientists, ethicists, and theologians—have
expressed an opinion on this issue.
As a result of impressive gains in this field,
organ recipients now have a significant chance
for both long-term survival and a reasonable
quality of life. These successes have led nearly
80,000 individuals to opt for transplantation as
a form of therapy. Unfortunately, the number of
organs available has lagged far behind the demand. Every year thousands die while waiting
for the gift of life that an organ transplant could
provide.
In the case of cadaveric giving, the family
of the brain-dead person is asked to donate.
Address all correspondence to Lewis Burrows, M.D., 201 East
17th Street, Apt. 27H, New York, NY 10003; email: Rockylew@msn.com
Adapted from a presentation at the Issues in Medical Ethics
2001 Conference on “Medicine, Money, and Morals” at the
Mount Sinai School of Medicine, New York, NY on November 2,
2001, and updated as of Eebruary 2004.
There is a serious shortfall in cadaveric organ
donations, with only 40-60% of U.S. families
consenting to organ recovery. Countries that
have adopted the doctrine of “presumed consent” (such as Spain, Austria, and Belgium)
have a much higher rate of organ recovery. In
these countries, families can “opt out” of donation; if they do not, the organs of deceased family members can be used for transplantation. In
most of the rest of the world, families have to
“opt in” before organs can be used for transplantation. “Presumed consent” countries that
require “opting out” obtain more than 40 donations per million population, as contrasted with
half that amount elsewhere. The lower rate is
obviously not adequate for meeting current
needs.
The number and rate of donations have
reached a plateau and leveled off following the
enforcement of lower speed limits for automobiles and the introduction of seat belt laws. It is
said that donation is a middle class, suburban
phenomenon; those groups donate at a somewhat higher rate than others. Why is the rate of
donation lower among the poor and in the big
cities? We truly do not know. Education, family
cohesiveness, trust in medicine, and moral and
religious sensibility may all play important
roles.
In light of the gap between organ need and
organ donation, we are beginning to consider
various forms of financial incentives to families
as a stimulant for donation (1, 2). I am not re-
© THE MOUNT SINAI JOURNAL OF MEDICINE Vol. 71 No. 4 September 2004 251
252 THE MOUNT SINAI JOURNAL OF MEDICINE September 2004
ferring to the token $399 that the state of Pennsylvania has offered for funeral expenses. That
amount would hardly pay for a plain pine coffin. Nor am I referring to the more than $10,000
state income tax credit that the Wisconsin senate approved in January 2004 (3). That incentive would he of little use to the poor. I am referring to a suhstantial amount, to he included
in the financial transactions that occur during
the transplant process.
Organ transplantation involves payments of
large sums of money. Huge sums go to the hospitals, the transplant surgeons, the physicians,
the ancillary staffs and the insurance companies. And most of the money actually goes to
the pharmaceutical industry. Many millions of
dollars flow into their coffers for the immunosuppressants, antihypertensives, antihiotics,
anticholesterols, antacids, and so on, that recipients routinely receive in the course of their
treatments. The only people who are not heing
remunerated are the families of the donors.
They alone are being asked to he altruistic.
Just try to do a transplant today on an uninsured patient. I can assure you, the patient will
not get through the front door. Medicaid will pay
for dialysis treatment of an uninsured alien. But
Medicaid will not pay for his or her transplant.
What would be the harm of providing a payment to the donating family of, let’s say,
$20,000? A liver transplant can cost upward of
$300,000, a heart transplant $200,000, and a
kidney transplant more than $100,000. In kidney transplantation, even the insurance company would benefit from the payment, since
they would no longer have to pay for dialysis
therapy.
The most controversial remuneration of all
is payment to a living donor who has no relationship to the recipient. Because of the organ
shortage, most centers in this country accept the
donations of living donors who are related, or
emotionally related (for example, a spouse or a
friend) as the source of transplant organs. In situations where there is an obvious relationship
between the donor and recipient, people find no
violation of ethical principles. In spite of the inherent risks of donating a kidney or a segment
of liver, and the pressures and emotions related
to the desire to save a loved one, these organ
donations are found acceptable.
But, what of the donor who has no obvious
relationship to the recipient? What should we
say of someone who only wants to donate an
organ to someone with the means to pay for it,
perhaps out of financial desperation? About
twenty years ago, a foreign-born nephrologist
at our institution offered me the opportunity to
perform more than two hundred kidney transplants each year. He proposed bringing donorrecipient pairs from his country to our hospital
for the surgery. I was to be paid a sizable sum.
The apparently wealthy recipients would pay all
the involved expenses, and each donor would
receive approximately $2,000 for his or her kidney. Apparently, $2,000 was then a substantial
sum for a poor person in his country. According
to my nephrologist friend, that amount of
money would change the donor’s life and the
standing of his family for generations. Yet even
aside from the legal considerations, I rejected
the offer outright, because it included no assurance of the donor receiving adequate long-term
aftercare. I also felt a sense of revulsion at the
idea of a poor, desperate individual peasant
being used in this manner by some wealthy
businessman or aristocrat.
Nowadays, this form of commercialism is
prevalent in the Third World, where either there
are no laws prohibiting these transactions or existing laws are not enforced. I shall not address
those practices. Instead I want to consider payment for organ donation in an ideal situation. I
want to consider the situation where the donor
and recipient are carefully selected and carefully matched, and where the operation is well
controlled. The donor would be offered longterm care, and the recipient would pay the
donor a significant sum. There would be no
“middle-men” or brokers involved, and the allocation process would be carefully controlled
by the national or regional organ allocation
mechanism. Under such circumstances, would
it be ethically acceptable for one individual to
use another for his own survival and wellbeing? Would the infliction of pain and suffering on one individual be justified by the benefit
to another individual? Should someone with the
financial wherewithal be allowed to purchase
transplant priority? Does allowing such financial transactions undermine what has been a
truly altruistic practice? Would payment to living donors inevitably undermine the public’s
faith in the process?
Let us examine the proposal in light of the
ethical principles involved, to see if they would
be violated. But first, I would like to rule out
several factors that would be inconsistent with
the organ exchange ideal that I imagine:
1. The donor comes from a country where
aftercare is deficient or unavailable. Such
a situation would subject the donor to an
Vol. 71 No, 4 SELLING ORGANS FOR TRANSPLANTATION-BURROWS 253
unacceptable risk of harm and would therefore exceed a reasonable balance of harms
and benefits.
2. Third-party brokers, profiteers, or entrepreneurs are involved in the transaction.
Removing any portion of the transplant
process from the oversight of medical professionals would remove it from the fiduciary relationship that assures that the
donor’s life and health would be safeguarded. And commercialism introduces
possibilities of exploitation and conflict of
interest.
3. The donor does not truly understand the
nature of the donation and the potential
risks involved. Evaluation of the donor by
an impartial psychiatrist would be a crucial
element in assuring that the donor is making
an informed choice that reflects personal
values and priorities.
4. There are bidding wars for organs. The
assurance of donor and recipient safety must
be a crucial feature of living donor transplantation. Organ auctions could compromise long-term safety or lead to unexpected
and untoward outcomes of living donor
transplantation. Auctions can only assure
price compatibility between buyer and
seller. While the selling price should be set
high enough to elicit donors, the larger
process must take into account the costs of
long-term care and emergencies such as primary non-function of the transplanted organ,
or organ rejection. Because the transplantation community has the ultimate responsibility for the careful management of these situations, the transplant community must have
oversight of any financial exchange.
I would like to summarize the considerations that incline me to accept payment to organ
donors in the ideal situation.
1. Autonomy. Certainly the donor and the recipient have the right to proceed if those involved in their care are assured that they
have freely accepted the transaction with a
complete understanding of the risks and
benefits involved.
2. Beneficence. Both the donor and the recipient stand to gain from their contract, as
does everyone else on the waiting list below
the recipient. All of the others waiting for a
cadaveric organ will benefit by moving up a
notch in the process.
3. The “do no harm” principle (primum
nolle nocere). There is obviously some
harm done to the donor in the surgery involved in organ donation. There is also the
immediate exposure to surgical risks, and
the certain disfigurement and loss of an
organ. Also there are possible long-term
consequences of organ loss. These risks of
harm are so well defined in the kidney
transplant experience that donors can be assured that the risks, both long- and shortterm, are minimal. The risks associated with
the liver, lung and pancreas donation
process are not as well defined. Perhaps this
element of uncertainty justifies a moratorium on these donations until the risks can
be carefully assessed in well-controlled
clinical studies.
4. Justice. I am less confident about whether
an ideal organ payment system will conform to the basic principle of fair and equitable distribution of benefits and burdens.
The main benefit of payments for organ
procurement would go to relatively privileged individuals. They would get transplant organs more readily than others, in addition to all the other privileges that accrue
to the wealthy (e.g., better homes, health
care, service, etc.). Yet no one else would be
harmed by the paid organ donation, unless
there is a general loss of faith in the donation process, with a fall in the rate of altruistic giving. This is an empirical question
that can only be answered by a trial.
It is clear that I have changed my position
somewhat, on this form of donation. I have accepted the libertarian thesis that selling one’s
organs does not necessarily violate the right of
self-determination, and should fall within the
protected privacy of free individuals on the
basis of the principle of autonomy. I have also
been persuaded by pragmatic and utilitarian
considerations — the current system is failing,
and the benefits for all recipients of an increase
in available organs outweigh most objections.
Of course, I would insist on controls. The
donor must be healthy, both physically and
mentally, as determined by competent physicians and psychiatrists who are not directly involved in the transplant process. We must be assured that the donor fully understands the risks
254 THE MOUNT SINAI JOURNAL OF MEDICINE September 2004
involved and must sign a statement demonstrating true informed consent. Paid donors must be
guaranteed long-term medical care and life insurance for themselves and their families in the
event that complications occur. The transplant
should be controlled by medical professionals
and medical agencies that are intimately involved in transplantation and that can administer the process with due care and impartiality.
I offer a final personal note. I am not entirely pleased that I have had to reach this decision. I would certainly prefer that an ample
source of cadaveric organs be available to those
in need. Available organs would allow us to
avoid the dilemmas of living organ donors and
paid donations. But for the time being, while
my patients are dying for want of an organ, I
tiave accepted this libertarian, utilitarian approach. We do not live in ivory towers. In life,
we have to make hard decisions and accept the
consequences when all of our options have serious flaws.
References
1. Arnold R, Bartlett S, Bernat J, et al. Financial incentives for
cadaver organ donation: an ethical reappraisal. Transplantation 2002; 73(8):1361-1367.
2. Delmonico FL, Arnold R, Scheper-Hughes N, et al. Ethical
incentives—not payment—for organ donation. N EngI J Med
2002; 346(25):2002-2005.
3. Napolitano J. Wisconsin senate approves tax deduction for
organ donors. N Y Times 2004 Jan 23; A: 12.