Organ Donors for Compensation

by on December 8, 2011 at 7:03 am in Economics, Law, Medicine | Permalink

Today Alexander Berger will donate a kidney:

NYTimes: On Thursday, I will donate one of my kidneys to someone I’ve never met. Most people think this sounds like an over-the-top personal sacrifice. But the procedure is safe and relatively painless. I will spend three days in the hospital and return to work within a month. I am 21, but even for someone decades older, the risk of death during surgery is about 1 in 3,000. My remaining kidney will grow to take up the slack of the one that has been removed, so I’ll be able do everything I can do now. And I’ll have given someone, on average, 10 more years of life, years free of the painful and debilitating burden of dialysis.

Alexander doesn’t want any praise or talk of “heroic sacrifice,” that is part of the problem. He wants to normalize donation and he argues for compensation in a regulated market.

The people waiting for kidneys aren’t dying because of kidney failure; they’re dying because of our failure — without Congress’s misguided effort to ban organ sales, they would have been able to get the kidneys they desperately needed.

…There’s no reason that paying for a kidney should be seen as predatory. Last week, the Ninth Circuit Court of Appeals issued a ruling legalizing compensation for bone marrow donors; we already allow paid plasma, sperm and egg donation, as well as payment for surrogate mothers. Contrary to early fears that paid surrogacy would exploit young, poor minority women, most surrogate mothers are married, middle class and white; the evidence suggests that, far from trying to “cash in,” they take pride in performing a service that brings others great happiness. And we regularly pay people to take socially beneficial but physically dangerous jobs — soldiers, police officers and firefighters all earn a living serving society while risking their lives — without worrying that they are taken advantage of. Compensated kidney donors should be no different.

Here are further MR posts on organ donation and here is Jon Diesel on Do Economists Reach a Conclusion on Organ Donation.

Andrew B December 8, 2011 at 7:37 am

Bone marrow, plasma, sperm, and eggs grow back and do not force any changes in lifestyle. At minimum, having one kidney places you in increased risk of having none in the future. Can people fairly evaluate that risk?

Andrew' December 8, 2011 at 7:47 am

But only if we go ahead and re-illegalize it. If there are plenty of kidneys on the market, then there is no future risk of having none.

Rahul December 8, 2011 at 7:52 am

No matter how well-stocked the market is; kidney transplants are definitely riskier than switching to your internal evolutionary backup.

Andrew' December 8, 2011 at 9:35 am

Not for the person you provided your kidney to.

NAME REDACTED December 8, 2011 at 10:07 am

Eggs don’t grow back.

Petar December 8, 2011 at 10:43 am

I’ve read somewhere that the most common reason for losing kidney function are diseases which attack both kidneys. So, that risk is smaller than it seems, but of course not negligible. I’m afraid I don’t remember any numbers, though.

Dan Weber December 8, 2011 at 11:40 am

If that’s really the only sticking point, how about requiring buyers of kidneys to purchase lifetime kidney insurance for the donor?

The donor loses about a week of life and the recipient gains about a decade of life. That’s huge, and the thing is that the donor can easily find themselves benefitting at the other end: if there is a 1:1000 chance of kidney failure, the potential donor is loses around that much life just by losing the chance to be an easy kidney recipient in the future.

Austin December 8, 2011 at 12:14 pm

The risk of needing a “backup” kidney is basically 0, unless you plan on getting stabbed in the other one. You never have one kidney naturally fail by itself.

Some interesting odds:
Being born with a single kidney: 1 in 750
Commercial fisherman dying a given year: 1 in 850
Dying by donating a kideny: 1 in 3000
Dying by driving 25,000 miles: 1 in 3000

Rahul December 8, 2011 at 1:22 pm

Not true. Renal cell carcinoma often requires nephrotomy (chemo and radiation don’t seem to work) Risk of getting it: 1 in 6000 per year.

http://seer.cancer.gov/statfacts/html/kidrp.html

Austin December 8, 2011 at 3:46 pm

You’re right, but the 1:6000 number isn’t comparable to the others. You’re assuming that the rate of occurrence stays the same, that your survival rate would be 0, and that a risk of dying down the road from cancer is equivalent to a risk taken now.

If you only have 1 kidney, the odds of kidney cancer likely go down (It seems that this would follow the fact that the cancer occurs independently of the other kidney. In other words, half the time you’re donating the kidney that would have gotten cancer. I can’t find hard evidence of this, other than that having a solitary kidney and getting cancer is “rare” http://www.ncbi.nlm.nih.gov/pubmed/15491735 ).

Then there’s the conditional probability aspect. Survival rates for renal cell carcinoma are only high in the early stages, where a partial nephrotomy is effective. In other words, most survivals of kidney cancer happen when having only 1 isn’t that big of a deal. The five year survival rate is is 74% (vs 80%), and the 10 year is 45% (vs 63%) http://www.ncbi.nlm.nih.gov/pubmed/12131287 .

And then you have to consider net present value. A risk you take now (donating) isn’t comparable to a risk you’ll take in 30 years (cancer). At a discount rate of 5%, a risk in 30 years is only 23% as costly. So depending on your age and your discount rate, the increased risk of dying down the road is even less.

I’m not competent enough to combine these values into an odds that can be used comparatively, but I stand by my statement of the risk of only having 1 kidney is basically 0.

Rahul December 8, 2011 at 4:37 pm

I think the jury is still out whether kidney donation increases donor risk in the long run. Forget the need for a backup kidney; what if having one kidney increases your risk of dying from other ailments e.g. hypertension

http://www.ccdt.ca/english/publications/background-pdfs/Medical_Risks_Living_Kidney_Donor_Garg.pdf

I’m not saying the increased risks are proven. Just that we don’t know. Look at the responses from physicians; most seem to swing on the side of increased medical risks.

Of course, all this is a small risk if I can save, say, my son’s life. By all means, I’d donate. But that’s a conscious risk-benefit decision. But it’s disingenuous to advertise that kidney donation is a “zero risk” procedure; something that people can routinely adopt as a feel-good altruistic act (quite different from blood or plasma donation etc.).

IMHO, public-policy focusing on (compensated?) cadavric donations is the better option.

Rahul December 8, 2011 at 7:44 am

The risk of dying on the surgery table is one part. What the article fails to mention is the risk that further in life the recipient having some kidney problem and left with no backup kidney to fall back upon. What’s that risk number?

When wealthy white people find their way onto the kidney waiting list, they are much more likely to get off it early by finding a donor among their friends and family

That’s an interesting statement. Is there sociological evidence that poverty makes for a less altruistic social network?

Andrew' December 8, 2011 at 7:48 am

The poor can’t miss a month of work. They are being dys-compensated for altruism.

Mark December 8, 2011 at 8:58 am

Also, a family member of the donor may later need a transplant and end up with an organ that is not a good match.

Andrew' December 8, 2011 at 9:36 am

Only if you assume today’s situation. In the future, the way it will be is there will be kidneys everywhere. We’ll be tripping over kidneys if we get our heads out of our colons.

roystgnr December 8, 2011 at 3:29 pm

We’ll be tripping over kidneys if we get our heads out of our colons.

The combination of mixed metaphors and subject matter here is awe-inspiring.

Right Wing-nut December 8, 2011 at 8:52 am

The objection to payment for organ transplants is wrapped up with fear of losing control at the end of life. The effect of paying for organ transplants is going to have a tremendous impact on end of life decisions, and NOT in favor of the expressed wishes of the dying. Indeed, I myself am not marked as an organ donor precisely because of such concerns. Advocating in favor of payment for organ transplants or opt-out policies without addressing these concerns is arrogant at best.

Dean December 8, 2011 at 10:19 am

The dying are the only ones who can give permission to have their organs donated.

And are you really concerned that if you were an organ donor, ER doctors wouldn’t treat you as well?

Dan Weber December 8, 2011 at 11:30 am

It’s a common fear. The organ donor crowd has been trying to debunk it for decades but it persists. The big thing is that the doctor treating you isn’t the same one who evaluates you for transplant.

Here’s one recent take: http://well.blogs.nytimes.com/2009/04/16/the-reluctant-organ-donor/

Andrew' December 8, 2011 at 11:41 am

Wait a second: “It’s like totally not a problem…at all…ever…because we like totally fixed it!”

Dan Weber December 8, 2011 at 12:17 pm

I don’t understand. Do you think the concept of the doctor treating you being separate from the people who evaluate you for organ donation is a recent development? It’s been that way at least since the 1980′s. (And probably forever, because doctors who do organ transplants are specialists and not going to be working in the trauma ward.)

Andrew' December 9, 2011 at 2:02 am

No I agree, it’s probably unrelated. But if so it also doesn’t make sense to say “there is zero cause for worry, because we fixed it.” If someone fixed something, then there was cause for worry.

Cliff December 8, 2011 at 11:57 am

So then allow it for living donors at least

Mountain John December 8, 2011 at 10:00 am

I’m presently in que to be a living liver donor for a member of my family. I always find that a dimension missing to the arguments of those advocating for allowing compensation is a discussion of the way organs are presently allocated. While rejection rates are higher in liver donations from a live donor, overall success rates are comparable to cadaveric transplants because sick patients are constantly being “bumped” up the list. This results in only very ill (read: high chance of failure) patients receiving cadaveric organs. I’d love to read a QUALY analysis on giving cadaveric organs only to the very ill. I wonder what the impact of a “reset” would be: allowing all very ill patients to die and allocating all cadaveric organs to healthier patients. What should be be optimizing in a health cares system anyway? QUALY? some other metric? (I’m in Canada).

Alex Tabarrok December 8, 2011 at 10:16 am

Yes, I wrote about this here

http://marginalrevolution.com/marginalrevolution/2010/06/optimizing-kidney-allocation.html

it is known as the Life Years from Transplant criteria.

Rahul December 8, 2011 at 11:18 am

If we have money to buy kidneys why not buy cadaveric kidneys? Won’t they be cheaper? Is there a huge quality difference between a cadavaeric versus a live donor kidney?

PS. @Mountain John:

If you are willing to donate and your relation is willing to accept why is there a “queue”?

Andrew' December 8, 2011 at 11:43 am

There simply aren’t enough cadaveric Kidneys. Hopefully this problem will get A LOT WORSE.

Rahul December 8, 2011 at 1:12 pm

That’s because people don’t donate often enough. Not because they don’t die often enough.

Mountain John December 8, 2011 at 4:42 pm

@Rahul, there is a queue because in Alberta we have the capacity to only perform one living donor transplant per month. There are many “matched” pairs, but not the resources to perform the procedures.

Roy December 8, 2011 at 12:40 pm

Maybe if people who gave up a kidney, even for payment, were moved to the front of the list if they had kidney failure.

Andrew' December 9, 2011 at 2:07 am

(whispers: that’s called compensation…)

Sandra December 9, 2011 at 10:08 am

They already are. I donated a kidney to a friend two years ago. One of the perks is that should you ever need a kidney you get bumped to the front. Seems fair to me. Also. The original poster who had his kidney removed yesterday is probably realizing about now that it isn’t minimal pain. It is a substantial surgery with a substantial recovery time. While I remain really really glad that I donated my kidney the risks are not quite as trivial as portrayed here. I am also a pathologist so have a bit of medical training. I believe people should be compensated for out of pocket expenses and for those without sick leave, compensated for lost work time. Many expenses now are covered, lost time from work is not. I am not in favor of selling organs.

john malpas December 8, 2011 at 7:13 pm

And why were we evolved to have two kidneys? caprice?
Most everybody gets hypertension eventually which tends to make renal tissue unhappy.
And can a remaining kidney ‘grow’ – more nephrons?

JRPtwo December 8, 2011 at 8:54 pm

What surprised me was the NY Times reader commenters’ nearly unanimous opposition to payment. The allocation and payment issues were addressed in article. So, how can the status quo be so preferred that one new death to prevent 3,000 is too high a price?

Many justified their opposition with critiques of markets and the rich. Many others felt age 21 is too young to make such a decision. Few even mentioned those who would otherwise die. Readers quibbled over the exact quantity of risk that to my mind is some two or three orders of magnitude smaller than the benefit to the recipient. The idea of a personal decision motivated in part by money was so offensive that a death was preferable.

I guess this issue really separates the liberals from people who think like economists.

Andrew' December 9, 2011 at 2:08 am

Kidneys are the marijuana of organ donation. It’s such a no-brainer, but liberals will never do anything that even smells like economic liberalization.

Andrew' December 9, 2011 at 2:11 am

That is to say, zero of the knee-jerk, visceral complaints against live-organ sales apply to kidneys. We can debate selling organs and whether that has second-order effects on the rich and poor…after we get this kidney thing done.

Dave Undis December 9, 2011 at 9:57 am

As the death toll from the organ shortage mounts, public opinion will eventually support financial incentives for organ donation in the United States. Changes in public policy will then follow.

In the mean time, there is an already-legal way to put a big dent in the organ shortage — allocate donated organs first to people who have agreed to donate their own organs when they die. UNOS, which manages the national organ allocation system, has the power to make this simple policy change. No legislative action is required.

Americans who want to donate their organs to other registered organ donors don’t have to wait for UNOS to act. They can join LifeSharers, a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at http://www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. Non-donors should go to the back of the waiting list as long as there is a shortage of organs. Everyone can offer to donate their organs when they die, no matter what their medical condition or history is.

David J. Undis
Executive Director
LifeSharers

Sandra December 9, 2011 at 10:19 am

It is I treating that no one commenting (that I can tell) on this topic has actually donated a kidney except me. But a lot of you seem to think you know a lot about the subject. I take offense at the presumptions some express herein that this is some type of liberal-conservative issue. It’s a complex issue and it’s being trivialized by many posters here.

Sandra December 9, 2011 at 10:24 am

It is interesting. Darn auto correct

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