Is it ever right to buy or sell human organs?

Satel: The global organ shortage has spawned illegal and unregulated organ markets. The World Health Organization estimates that five to ten per cent of all kidneys transplanted annually--perhaps 63,000 in total--are obtained in the organ bazaars of Africa, Asia, Eastern Europe and South America. Thus, we face a dual tragedy: on one side, thousands of patients who die each year waiting for a kidney; on the other, a human rights fiasco in which corrupt brokers deceive indigent donors about the nature of surgery, cheat them out of payment and ignore their post-surgical needs.

"The World Health Organization estimates that five to ten per cent of all kidneys transplanted annually--perhaps 63,000 in total--are obtained in the organ bazaars of Africa, Asia, Eastern Europe and South America." --Sally Satel, M.D.Altruistic appeals to organ donation have not yielded enough organs for transplantation. Not all developed countries have made the most use of posthumous donation, and of course they should. Unfortunately, much of the world transplant establishment--including the World Health Organization, the Transplantation Society and the World Medical Association--focuses exclusively on obliterating organ trafficking. While at face value this may seem reasonable, in reality it is a lethally one-sided prescription, because trying to stamp out underground markets either drives corruption further underground or causes it to flourish elsewhere. Government-sponsored compensation of healthy individuals who are willing to give one of their kidneys to save the life of a dying stranger is the best short-term solution.

Chapman argues that organ donation after death is the only practicable solution for organ recipients.

Satel: Let me say a few words about myself. In August 2004 I became one of those whose 'drive for survival' became very strong. That's when I learned I had idiopathic renal failure. After a year of searching for a donor among people I knew well--and coming up empty--a casual (but now very dear) friend stepped in to spare me years of life-draining dialysis and premature death.

I am well aware of my good fortune. Many people without a donor are failing on dialysis, and some have no access to dialysis at all. And they will follow that survival instinct to foreign lands, despite the sickening knowledge that their new organ might come from an executed prisoner in China or an illiterate labourer in India. I, for one, had considered it. Your reference to 'opportunistic human cannibalism' took me aback. The tragedy we face is symmetric: hapless donors and wretched patients are locked in a morbid embrace. I outlined one model for disentangling them--a government-regulated programme of in-kind benefits to well-informed donors, offered by a third party and distributed to the next ill person, not the wealthiest. What innovations have you offered?

I realize that most types of organs must come from deceased donors. But let's be realistic about the extent to which deceased donation can help. You tell of Chinese prisoners who are shot for their organs. This horrific practice is precisely the kind of extreme situation that takes place when there is no legal alternative. If anything, it is an argument in favour of safe and legal means of rewarding donors. Developed countries must enlarge the pool of transplantable organs, by rewarding living and posthumous donors, if they are to keep some of their citizens from becoming reluctant participants in organ trafficking. Voluntary and compensated live donation for kidneys and deceased donation (compensated or not) can and should exist side by side.

Chapman argues that deceased donor programs are the central issue for organ donation.

Satel: I agree that countries can and should make better use of deceased donation. But even in Spain, which has the world's highest deceased donation rate, individuals continue to die waiting. Even non-renal organs, which are in lesser demand than kidneys, are not produced in adequate numbers, according to the Spanish National Transplant Organization. As for the US, you are mistaken. Of the roughly two million Americans who die annually, only 10,500-13,000 possess organs healthy enough for transplanting. Meanwhile, 85,000 Americans are waiting for kidneys.

I challenge your assertion that deceased donation evaporates when patients can obtain their organs from compensated donors. In Iran the government began compensating living kidney donors in 1988 and since then the waiting list for kidneys has dwindled. Yet Iran also established a deceased programme to increase the supply of livers, hearts, and lungs in 2000. Before passing a law allowing deceased donation, less than one per cent of kidney transplants came from deceased donors, but by 2007 this had risen to 16 percent.

Altruism, while a glorious virtue, is simply not enough. You have succumbed to the straw man argument that giving an organ for free is noble but doing so in exchange for material gain is a sordid affront to human dignity.

This is a false choice. Transactions on a black market are dangerous because they are illicit, not because they are transactions. There is a fertile middle ground on which to establish safe, legal programmes that protect donors who would be happy to accept enrichment for saving the life of another. Humanitarian and financial motives intertwine all the time. Are we any less grateful to the firefighters who rescue us because they are salaried?

Sally Satel, M.D., is a resident scholar at AEI.

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