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Last week the Singapore Parliament voted to amend the Human Organ Transplant Act. It is now legal for a needy patient to cover the expenses incurred by the generous soul who donated a kidney to him. “This is a bill about fairness,” said Minister of Health Khaw Boon Wan, “being fair to donors who do suffer financial consequences as a result of their act of donation. Our current law shortchanges them.”
With passage of its new law, Singapore joins more than 20 other countries, including the United States, Britain, France, the Philippines, the Czech Republic, Denmark, Turkey, Saudi Arabia and Sweden that allow donors to accept repayment of associated costs such as lost wages, child care and travel. To its credit, Singapore’s new law establishes a national registry for long-term follow-up of living donors and allows recipients or government-approved charities to provide limited health insurance coverage to donors. The U.S., where I live, has no such long-term registry. Nor has our government made clear the legality of paying for the donor’s follow-up health care.
I heartily applaud the health minister for his passionate advocacy of this humane new bill. Yet it will do little to solve the desperate organ shortage. And as Mr. Khaw acknowledged last week, “The more we pretend that the black market in organ trading can be legislated away by simply prohibiting any kind of payment to the donors, the more it will grow.”
Indeed, illicit organ trading was headline news in Singapore last September. Tang Wee Sung, 56, the former head of the country’s oldest department store chain, CK Tang Ltd., was jailed for a day and fined 17,000 Singapore dollars ($11,000) after pleading guilty to charges that he tried to buy a kidney from a 26-year-old Indonesian man. Reportedly, the broker who arranged the transaction, and who also pleaded guilty to charges stemming from his involvement, was to receive S$300,000.
According to Singapore’s Straits Times, Mr. Tang did eventually receive a legal kidney transplant in January, but it’s unlikely the new law would have shortened the time he had to wait for an organ. Nor will it help those currently languishing on dialysis, an expensive and generally debilitating procedure in which the blood is circulated outside of the body and cleansed of toxins that a healthy kidney normally removes. In 2005, the most recent year for which data are available in Singapore, there were 557 people waiting for a kidney; only 96 of them underwent a transplant.
The health minister knows he cannot “run too far ahead of public opinion,” as he puts it. In fact he had to focus much of his energy on making a clear distinction between what is reasonable payment, which the bill allows, and what is an inducement, which it does not.
So as Singapore adjusts to its worthy new law, I hope Mr. Khaw and his colleagues will next consider moves to increase the supply of organs through appropriate incentives. In fact, I hope my own country will do this too.
My colleagues and I suggest a system in which a donor can accept a reward for saving the life of a stranger. A third party (the government, a charity or insurer) would provide the benefit and newly available organs would be distributed to the next in line–not just to the wealthy. Donors would be carefully screened for physical and emotional impediments to safe donation, as is currently done for all volunteer living kidney donors. Moreover, they would be guaranteed follow-up medical care for any complications.
Many people are uneasy about offering lump-sum cash payments. A solution is to provide in-kind rewards, such as a down payment on a house, a contribution to a retirement fund or lifetime health insurance, so the program would not be attractive to people who might otherwise rush to donate on the promise of a large sum of instant cash.
Not only will more lives be saved through legal means of donor rewards, but fewer people will haunt the black-market organ bazaars of places like China, Pakistan, Egypt, Colombia and Eastern Europe. The World Health Organization estimates that 5% to 10% of all transplants performed annually–perhaps 63,000 in all–take place in these clinical netherworlds.
The debate in Parliament last week foreshadowed the challenge ahead. Some lawmakers worried that simply covering expenses would open a back door to black-market sales. In response to this concern, the new law drastically raised the penalty for purchasing and selling and brokering organs from a fine of up to S$10,000 or up to a year imprisonment or both to a fine up to S$100,000 or up to a 10-year sentence.
The truth is that trafficking will stop only when the unmet need for organs disappears. Unfortunately, much of the world transplant establishment, including the World Health Organization, the international Transplantation Society and the World Medical Association, focus solely on suppressing organ trafficking. Though well-meaning, these groups seem to overlook the time-worn truth that trying to stamp out illicit markets either drives them further underground or causes them to reappear elsewhere.
Singapore has just taken an important step in enhancing transplant practice. No donor should incur financial hardship from giving such a precious gift. The next step by Singapore, the U.S. and the rest of the world is to encourage more donors to make the same momentous sacrifice by allowing them to be rewarded for saving a life.
Sally Satel, M.D., is a resident scholar at AEI.
Singapore’s new law is a positive step toward making the transplant market more transparent.
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