Results for “organ transplant”
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The Economist on Organ Transplants

The Economist has cogent things to say on setting up a market for organs including the fact that organ sales are legal in, of all places, Iran and the shortage in that country has been eliminated.  Here’s another interesting point:

America already lets people buy babies from surrogate mothers, and the
risk of dying from renting out your womb is six times higher than from
selling your kidney.

Hat tip to Harold Kyriazi.

Organ Transplants

Bob Hickey, who lives near Vail, had needed a transplant since 1999 because of kidney disease. He met donor Rob Smitty of Chattanooga, Tenn., through Matching, a for-profit Web site created in January to match donors and patients for a fee.

On Wed. the transplant was performed. It is the first “publicly brokered” transplant to occur in the United States. It is currently illegal to pay donors so Rob Smitty, the donor, was not paid (Hickey did cover Smitty’s expenses). Hickey did pay to have his name listed by and this has upset a lot of people. No one seems upset, however, by the fact that the Hickey’s doctors were paid, his nurses were paid, the hospital was paid etc.

See my article for more on organ donation. Kieran Healy at Crooked Timber comments on the definition of death and another organ donation case in the recent news.

Thanks to Taggert Brooks for the link.

Innovative Solutions to the Shortage of Transplant Organs

Millions of people suffer from kidney disease, but in 2007 there were just 64,606 kidney-transplant operations in the entire world.

Today in the WSJ I discuss innovative solutions to the worldwide shortage of transplant organs from places like  Iran, India, Singapore, Israel and elsewhere.  One interesting bit I haven't blogged about before is routine removal of organs without the donor's or their families consent.  China?  No.  America.  It's been legal here for decades.

In a number of U.S. states, medical examiners conducting autopsies may and do harvest corneas with little or no family notification. (By the time of autopsy, it is too late to harvest organs such as kidneys.) Few people know about routine removal statutes and perhaps because of this, these laws have effectively increased cornea transplants.

Here is another bit on the shadowy definition of death:

Organs can be taken from deceased donors only after they have been declared dead, but where is the line between life and death? Philosophers have been debating the dividing line between baldness and nonbaldness for over 2,000 years, so there is little hope that the dividing line between life and death will ever be agreed upon. Indeed, the great paradox of deceased donation is that we must draw the line between life and death precisely where we cannot be sure of the answer, because the line must lie where the donor is dead but the donor's organs are not.

In 1968 the Journal of the American Medical Association published its criteria for brain death. But reduced crime and better automobile safety have led to fewer potential brain-dead donors than in the past. Now, greater attention is being given to donation after cardiac death: no heart beat for two to five minutes (protocols differ) after the heart stops beating spontaneously. Both standards are controversial–the surgeon who performed the first heart transplant from a brain-dead donor in 1968 was threatened with prosecution, as have been some surgeons using donation after cardiac death. Despite the controversy, donation after cardiac death more than tripled between 2002 and 2006, when it accounted for about 8% of all deceased donors nationwide. In some regions, that figure is up to 20%.

More on markets for organs, presumed consent, and point systems at the WSJ,

The Shortage of Transplant Organs

The Wall Street Journal has a front-page article and a debate between Julio Elias and Alvin Roth on alleviating the shortage of transplant organs.  This interactive graphic was good at explaining the idea of kidney swaps.  Elias and Roth should have discussed no-give, no-take rules and Lifesharers

I will be speaking to Congressional and agency staff about the organ shortage this Thursday at noon (this event is not open to the public.)

Addendum: Transplant surgeon Arthur Matas, mentioned in the WSJ article, is no
libertarian but argues for live kidney sales in a new Cato Policy

Incentives for Organ Donation

Lottery tickets for vaccination seems to have been reasonably succesful. What else could we use incentives for? Al Roth sends us to kidney surgeon Arthur Matas’s argument for testing incentives for organ donation:

A regulated system of incentives for donation could provide a sizable increase in the number of kidneys available for transplant. Yet incentives for kidney donation are illegal in the US.
…Initially, the concept of incentives for living donation can be unsettling (some have said “repugnant”4). Yet ethicists worldwide have argued that there is no ethical reason to prohibit incentives. And studies show that the public is in favor of incentives. Additionally, dialysis is more expensive than transplant; a regulated system of incentives would be cost saving to the health care system.

We accept kidney donation. Any successful argument against incentivized donation must be able to differentiate it from our currently accepted conventional donation. Notably, incentives are legal for plasma, sperm, and egg donation or surrogate motherhood, and certainly there are risks involved with egg donation and surrogate motherhood. Gill and Sade5 argue that the only difference between donating and selling is monetary self-interest, and monetary self-interest alone does not warrant legal prohibition.

It is time to move past the feelings that incentives are wrong to the reality that as a result of a potentially preventable shortage of organs, patients on the waiting list are dying or becoming too sick to transplant….It is time for professional societies and patient groups to advocate for changing the law to allow trials of incentives for donation.

See many previous posts at MR on organ donation and blood donation.

New Zealand to Compensate Organ Donors

New Zealand will now compensate live organ donors for all lost income:

Today’s unanimous cross-party support for the Compensation for Live Organ Donors Bill represents a critical step in reducing the burgeoning waiting list for kidney donations, according to Kidney Health New Zealand chief executive Max Reid.

“The Bill effectively removes what is known to be one of the single greatest barriers to live organ donation in NZ,” Mr Reid says. “Until now the level of financial assistance (based on the sickness benefit) has been insufficient to cover even an average mortgage repayment, and the process required to access that support both cumbersome and demeaning. The two major changes that this legislation introduces – increasing compensation to 100% of lost income, and transferring responsibility for the management of that financial assistance being moved from WINZ to the Ministry of Health – will unquestionably remove two major disincentives that exist within the current regime.”

Eric Crampton (former GMU student, now NZ economist who supported the bill) notes that a key move in generating political support was that New Zealand MP Chris Bishop framed the bill as compensating donors for lost wages rather than paying them. A decrease in the disincentive to donate–an increase in the incentive to donate. To an economist, potato, potato. But for people whose kidneys fail in New Zealand, the right framing may have been the difference between life and death.

This is also a good time to remind readers of Held, McCormick, Ojo and Roberts, A Cost-Benefit Analysis of Government Compensation of Kidney Donors published in the American Journal of Transplantation.

From 5000 to 10 000 kidney patients die prematurely in the United States each year, and about 100 000 more suffer the debilitating effects of dialysis, because of a shortage of transplant kidneys. To reduce this shortage, many advocate having the government compensate kidney donors. This paper presents a comprehensive cost-benefit analysis of such a change. It considers not only the substantial savings to society because kidney recipients would no longer need expensive dialysis treatments—$1.45 million per kidney recipient—but also estimates the monetary value of the longer and healthier lives that kidney recipients enjoy—about $1.3 million per recipient. These numbers dwarf the proposed $45 000-per-kidney compensation that might be needed to end the kidney shortage and eliminate the kidney transplant waiting list. From the viewpoint of society, the net benefit from saving thousands of lives each year and reducing the suffering of 100 000 more receiving dialysis would be about $46 billion per year, with the benefits exceeding the costs by a factor of 3. In addition, it would save taxpayers about $12 billion each year.

Some Good News on Organ Donation

Representative Matt Cartwright (D-PA 17th District) has introduced the Organ Donor Clarification Act. The act would:

  • Clarify that certain reimbursements are not valuable consideration but are reimbursements for expenses a donor incurs
  • Allow government-run pilot programs to test the effect of providing non cash incentives to promote organ donation.  These pilot programs would have to pass ethical board scrutiny, be approved by HHS, distribute organs through the current merit based system, and last no longer than five years.

Importantly the legislation has been endorsed by the American Medical Association and a number of other groups including Fair Allocations in Research Foundation, Transplant Recipients International Organization and WaitList Zero.

See my piece on the organ shortage in Entrepreneurial Economics and previous MR posts for more.

China to stop harvesting organs from prisoners

The mainland – which has long been criticised by international human rights groups for using organs harvested from executed prisoners as its main source of organ transplants – will completely ban the practice from next year.

All organs used in future transplants must be from donors, the Southern Metropolis News quoted Dr Huang Jiefu as saying. Huang is former deputy director of the health ministry and director of the China Organ Donation and Transplant Committee.

Major transplant centres had already stopped using executed prisoners’ organs, said Huang, who chaired an industry forum in Kunming on Wednesday.

There is more here, via Mark Thorson.  The article notes China has one of the lowest voluntary organ donation rates in the world.  0.6 individuals out of a million sign up to donate their organs after they die, and that means the number of actual donors is lower yet.  If you google around, you will find some ambiguity as to whether the donation rate or the “register to donate rate” is that low, but as far as I can tell (try this Chinese source) it is the actual register to donate rate, in part because they just aren’t many ways to register right now.  Please let us know if you have additional information on this point.

Wikipedia by the way reports:

The wait times for organ transplants for organ recipients in China are much lower than elsewhere in the world, and there is evidence that the execution of prisoners for their organs is “timed for the convenience of the waiting recipient.

Here are some of Alex’s earlier posts on a market for transplanted organs.

Australia to Compensate Organ Donors

Australia once again proves that it is a world leader in innovative public policy with an experimental plan to compensate (living) organ donors.

Workers who want to donate a kidney will be offered up to six weeks’ paid leave under a federal government plan to reduce the waiting list for life-saving organs.

Health Minister Tanya Plibersek and parliamentary secretary for health and ageing Shanye Neumann say the government will put up $1.3 million over two year for a trial that will be reviewed in 2015.

Ms Plibersek says living donors will be paid six weeks on minimum wage, totalling up to $3600, to help take the financial pressure off before and after the major surgery.

…the scheme is one step towards bridging the gap between the number of kidney donors and recipients.

The proposed experiment does, however, contains a peculiar restriction which is worth highlighting because it illustrates a tension between economics and ethics, at least ethics as conventionally understood (e,g, Michael Sandel). The compensation “will only be available to donors who have a job.”

The idea, I believe, is to avoid any hint of “exploitation” or “pecuniary coercion.” The problem is that another word for pecuniary coercion is incentive. Thus, the goal is to increase the supply of organs without creating an incentive to supply organs, at least not a strong incentive. To help navigate this invisible line the amount paid is low and the only people who can receive compensation are the ones who don’t need the money. In short, the plan discriminates against the unemployed so that no one can accuse the government of exploiting the unemployed by giving them too much money.

Nevertheless, although the amount is small and restricted, Australia’s willingness to experiment with the idea of compensation in order to save lives is laudable and potentially groundbreaking.

Hat tip: Andrew Leigh.

Addendum: For other innovative approaches to the worldwide shortage of transplant organs see my articles here and here.

The Golden Rule of Organ Donation

Here is Joseph Roth, president and CEO of New Jersey Organ and Tissue Sharing Network:

Caseworkers from our organization recently went to the hospital to visit the family of a woman who suffered a stroke. The woman was dead, but machines continued to keep her organs functioning. She was an ideal candidate to be an organ donor. Her husband, it turns out, was on the waiting list to receive a heart.

Our caseworkers asked the husband if he would allow his wife’s organs to be donated. The husband, to the shock of our caseworkers, said no. He simply refused. Here was a man willing to accept an organ to save his own life, but who refused to allow a family member to give the gift of life to another person.

…Cases like this are rare, thankfully, but are nonetheless troublesome.

Roth continues:

Our proposal — we call it the Golden Rule proposal — would permit health insurers in New Jersey to limit transplant coverage for people who decline to register as organ donors. It would be the first such law in the nation. No one would be denied an organ. But under the proposal, insurers could limit reimbursement for the hospital and medical costs associated with transplants of the kidney, pancreas, liver, heart, intestines and lungs.

I am not in favor of messing with the insurance system for this purpose but have argued for a more direct approach. Under what I call a “no-give, no-take” rule if you are not willing to sign your organ donor card you go to the bottom of the list should you one day need an organ. Israel recently introduced a version of no-give, no take which gives those who previously signed their organ donor cards points pushing them up the list should they need an organ transplant–as a result, tens of thousands of people rushed to sign their organ donor cards.

Hat tip to David Undis whose excellent group Lifesharers (I am an adviser) is implementing a private version of no-give, no take in the United States.

Here is my piece on Life Saving Incentives and here are previous MR posts on organ donation.

CA Organ Donor Law

California has a new law creating a live donor registry for kidney transplants and requiring California drivers to say yay or nay on whether they want to be organ donors when they renew their drivers' licenses.  The law was passed with the prodding of Steve Jobs who last year had a liver transplant.

The live donor registry is very good. The required declaration is mixed but I hope it works.  I see it as follows.  The benefit is that if a potential donor has said yes to organ donation then next of kin almost always agree to their wishes so if more people positively affirm that is good.  The cost, however, is that now "no" really means "no" and next of kin will presumably agree to that as well.  Previously, next of kin might have said yes to non-signatories.  Let's use some back of the envelope figures:

100 potential donors
20 signed organ donor cards
80 do not sign but, among these, half the families say yes so 40.

Total: 60 donors.

So with declaration you need more than 60 to agree to be organ donors, i.e. a huge increase in those saying yes.  It could happen if what people say on surveys about supporting organ donation is true but I would have been much happier with even a small incentive to sign.  How about a free iPhone for signatories?  Or at least some more minutes!

See here for more on incentives and organ donation.

Addendum: Nudge blog has some helpful comment–the law appears to be closer to mandated ask than mandated choice.

Presumed Consent and Organ Donation

A New York assemblyman wants NY to adopt a presumed consent law for organ donation. 

The legislation, introduced by Assemblyman Richard Brodsky, a Westchester Democrat, is in two parts: the first step would end the right of the next of kin to challenge the decisions of their dead or dying relatives to donate their organs.

In a second measure, which is far more contentious, people would have to indicate in official documents – their driver’s licenses, most commonly – that they specifically don’t want to donate organs. If the box is not checked, it is presumed the person wants to donate.

The first thing to note about this proposal is that contrary to what Brodsky suggests, the problem isn't families who refuse to follow the wishes of the potential donor–as a rule, families who know, follow.  The problem is that families often don't know what their loves ones would have wanted because many people don't sign their organ donor cards.  

In fact, the way presumed consent actually works is not by overriding the wishes of the family it's by making the wishes of the potential donor more clearly known to her family.  In most presumed consent countries the family still has the ultimate say in practice because what doctor is going to want to go against the wishes of the family in a time of grief?  Instead, presumed consent increases the probability that families say yes by changing their background information from my loved one didn't opt-in to my loved one didn't opt-out. 

So under presumed consent we get more families saying yes–but not all–and there are other constraints such as the number of people who die in a way that makes their organs available for transplant and the availability of transplant surgeons and facilities to do the operation and so forth.

In a roundtable on this issue with Sally Satel, Art Kaplan and others, Kieran Hiely notes:

Spain’s success is due to effective management of the transplant
system, not a simple legal rule. Similarly, Italy’s donation rate grew
rapidly in the 1990s thanks to investment in its system, not because of
its long-standing presumed consent law. Some countries, notably
Austria, do have “true” presumed consent, with no kin veto. But they do
not outperform countries like the U.S. by any great margin.

I'm actually a bit more positive than Kieran, the best evidence is that presumed consent raises donation rates by perhaps 20-30%.  Not bad, but not enough to eliminate the shortage.  To do that, as Satel notes in her contribution to the roundtable it will take live donation.

Kieran also writes:

It’s also worth remembering that, since the 1970s, the U.S.
“transplant community” has worked hard to allay public concerns that
surgeons might be too eager to harvest organs, or that the state might
play too calculating a role in deciding what happens to the bodies of
potential donors.

The latter point is especially important in the United States.  Brazil, for example, switched to presumed consent and then switched back to opt-in when people became fearful and outraged and donation rates fell.  It's not hard to imagine similar blowback in the United States.

It's also worth remembering that considered as a whole the U.S. system is the best in the world.  Spain does have a very high rate of deceased donation, but it does poorly on live donation.  Iran leads the world on live donation because it compensates donors but due to religious feelings about the sacredness of the body Iran, like other Muslim countries, does poorly on deceased donation.  The US does well on both deceased and live donation and in total leads the world.

We can do better but we do need to tread carefully.


Akst on Organ Buying and Selling

Daniel Akst has some good questions:

It's illegal in this country to buy or sell organs for transplant. This is an unjust law made and enforced by people who desperately need neither organs nor money. It condemns kidney-disease sufferers to death and potential organ donors to poverty. It's a law that I will unhesitatingly break if one of my children needs a kidney, and I hope you will have the decency to do the same if a member of your family is in a similar situation.

…The unearned piety of those who condemn these transactions strikes me as outrageous. If someone has the right to abort her own fetus, why does she not have the right to sell her own kidney? By what authority does the state tell me I cannot save myself or my family members by paying money I earned to a willing seller of a surplus item?

Singapore to Pay Organ Donors

Big news on the effort to alleviate the shortage of human organs:

Singapore is to allow compensation for kidney transplants and for eggs.
A government proposal has been approved by a bioethics committee and
legislation will be introduced early next year.

to the BMJ, a sum of S$10,000 was mentioned. According to the Straits
Times, the health minister, Mr Khaw Boon Wan, mentioned "at least a
five-figure sum, possibly even six-figure" as appropriate
reimbursement. This would include expenses, such as transport and
medical costs, as well as loss of earnings. Also, the donor should be
covered for follow-up medical costs and higher insurance premiums as a
result of losing a kidney.

In other big news the National Kidney Foundation (NKF) is reconsidering their long-held opposition to compensation for organ donors.  The NKF is surveying people on financial compensation.  Marginal Revolution readers can raise the level of discussion and perhaps help save some lives by answering the survey here (it’s very short).

Thanks to Lloyd Cohen and Richard Darling for the pointers.

Financial Compensation for Organ Donors is Working

Only one country in the world has eliminated the shortage of transplant kidneys.  Only one country in the world has legalized financial payments to kidney donors.  That country is Iran.

In an important report, transplant surgeon nephrologist Benjamin Hippen argues that the Iranian system has saved thousands of lives and it should be used if not as model then to inform America’s efforts to eliminate its deadly shortage.

In the Iranian system organs are not bought and sold at the bazaar.  Instead a non-profit, volunteer-run Dialysis and Transplant Patients Association (DATPA) mediates between recipients and donors.  Recipients who cannot be assigned a kidney from a deceased donor and who cannot find a related living donor may apply to the DATPA.  The DATPA identifies a possible donor from a pool of people who have applied to the DATPA to be donors.  Donors are medically evaluated by transplant physicians, who have no connection to the DATPA, in just the same way as are non-financially compensated donors.

The government pays donors $1,200 plus limited health insurance coverage.  In addition, charitable organizations also provide renumeration to impoverished donors.  Thus demonstrating that Iran has something to teach the world about charity as well as about markets.  Will wonders never cease?  Recipients may also contribute to donor remuneration.

Hippen reports that the system works well, although better follow-up of donors would be an improvement.  He concludes with a call to legalize financial compensation in the United States.