Resident Scholar Sally Satel

This was the question recently posed in the prestigious British Medical Journal. An American transplant surgeon (in favor of selling kidneys) squared off against an Australian nephrologist (against). In an accompanying article, a leading British transplant surgeon called for legalizing organ sales.

Coverage in the British press had a positive spin. "Surgeon: Organ trade should be legalized" was The Independent's headline; "Legalize trade in donor organs, pleads surgeon" was The Evening Standard's.

We cheer these headlines. The more attention is paid to the worldwide organ shortage and the rapacious underground market it has spawned, the more people, we hope, will support the idea of selling kidneys legally.

We do. One of us is a British transplant surgeon who has seen too many patients die for want of a kidney. The other is an American recipient of a kidney who was once desperate enough to contemplate obtaining a kidney in the overseas organ bazaar.

We believe in compensating healthy individuals who are willing to relinquish one of their kidneys to save the life of a dying stranger.

There really is no other option. As the world has seen, altruistic appeals to organ donation have not yielded enough organs for transplantation. An estimated 40,000 patients are waiting for a transplant in Western Europe, more than 6,000 of them in Britain. Fifteen to 30 percent will die on the waiting list.

Granted, not all countries have made the most use of posthumous donation and they should. But even in Spain, which is famously successful at retrieving organs from the newly deceased because of its robust procurement infrastructure, there are deaths on the waiting list.

We face a dual tragedy: On one side, thousands of patients who die each year for want of 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 5 to 10 percent of all transplants performed annually--perhaps 63,000 in all--take place in the clinical netherworlds of China, Pakistan, Egypt, Colombia, and the Philippines.

Unfortunately, much of the world transplant establishment--including the WHO, the international Transplantation Society and the World Medical Association--advocate remedies that do not go far enough. They insist on obliterating organ trafficking but ignore the time-tested fact that trying to stamp out underground markets either drives corruption further underground or causes it to flourish elsewhere. The truth is that trafficking will only recede when the crying need for organs disappears.

Opponents also allege that a legal system of exchange will inevitably replicate the sins of the black market. This is utterly backward. The remedy to this corrupt and unregulated system of exchange is its mirror image: a regulated and transparent regime devoted to donor protection.

We suggest a system in which compensation is provided by a third party (government, a charity or insurance) and overseen by the government. Because bidding and private buying will not be permitted, available organs will be distributed to the next in line--not just to the wealthy.

Finally, we suggest that lump-sum cash payments not be offered. By providing in-kind rewards--such as a down payment on a house, a contribution to a retirement fund or lifetime health insurance--the program would not be attractive to people who might otherwise rush to donate on the promise of a large sum of instant cash.

The only way to stop illicit markets is to create legal ones. Indeed, there is no better justification for testing legal modes of exchange than the very depredations of the underground market.

There is nothing wrong with selling kidneys. And until we do so, the fates of third-world donors and the patients who need their organs to survive will remain morbidly entwined.

Sally Satel, M.D., is a resident scholar AEI. Nadey Hakim, M.D., a transplant surgeon in London, was president of the International College of Surgeons from 2005-2007.