Tuesday, February 19, 2008

Tuesday Column: We are short of kidneys. So why not buy them?

What kind of society would routinely bury or burn its most valuable resources rather than use them?

I am talking about our own body parts. The Nobel Prize winning economist Gary Becker reckons that each still-usable kidney we bury is worth $US15,000; each still-usable liver: $US35,000.

Don’t doubt that there are people prepared to pay that much money. Right now more than 1,800 Australians are waiting for kidneys, livers and so on - hooking themselves up to equipment each night and gradually getting sicker while waiting for that phone call that may never arrive.

Some of them live in Canberra.

One in every five will die before the phone call comes.

To an economist, it’s a straightforward problem of matching supply to demand.

Big promotional events such as the current National Organ Donation Awareness Week notwithstanding, the supply of usable kidneys, livers and corneas is actually falling - in the main because fewer or us are dying in road accidents.

Meanwhile the number of people whose lives (or sight) could be saved continues to climb...

Non-economists put forward non-economic means of boosting the supply to match demand. On this page today a former ACT Health Minister Gary Humphries comes out in favour of “presumed consent” – changing the legal assumption that says if a dead person didn’t explicitly decide to donate, their organs can’t be used to one that says unless they explicitly forbad donation, their organs are available for recycling.

For reasons that haven’t been made clear the Commonwealth Health Minister and her Parliamentary Secretary have ruled out changing the presumption of consent, as has an expert committee whose report they are yet to release.

In Britain by contrast the new Prime Minister Gordon Brown is pushing ahead with the idea.

It may be that our leaders are worried about upsetting the families of accident victims. It may be that they care more about them than they do about the lives of the people their inaction could be condemning to death. If so, it sits poorly with our Prime Minister's claim that his decisions will be “evidence-based”.

For economists, presumed consent is just one of a number of good ideas for boosting supply to match demand. Most of them involve money.

One argument against presumed consent is that is that it isn’t real consent. Andrew Oswald of the University of Warwick wants to use money to make it real.

He has suggested that each year’s UK income tax form include a box that taxpayers can tick to unequivocally grant the authorities the right to harvest their organs after they die. In return they would get a small tax deduction. Oswald guesses that as little as 10 UK pounds or $A20 would do the trick. Most of us are surprisingly amenable to small bribes.

In Australia such a scheme would cost less than $200 million, chickenfeed compared to the billions the government spends annually on a Private Health Insurance Rebate that as far as anyone knows doesn't save a single life.

It would save the government money as well. It wouldn't need to buy all those dialysis machines. The net cost to Wayne Swan's budget could be close to zero.

If you want to keep money out of it economists can help there as well. Alexander Tabarrok of George Mason University sees the whole thing as a trade: I agree to give you something after I die if needed in return for you agreeing to give me something after you die. But he says if there’s no trade there should be no deal.

His slogan would be “no give, no take”. Spare parts would be available only to people who had signed up some years before to donate their own. A less severe rule would move people who had previously signed up as donors to the top of the queue. It would motivate me.

And then there’s live trade. Most of us have two kidneys. We only need one. If I sell one I don't need to someone who has none in return for money, both of us have been made better off, probably a lot better off. Economists call this a gain from trade.

It is true that I would be taking a risk in order to earn the money. But people take risks in return for money all the time, construction workers on building sites and coal miners among them. Most of the time we don't seem to mind.

In any event the risk of dying from such an operation is small - apparently about the same as the risk of dying during cosmetic surgery.

Doctors are naturally resistant to the idea of removing kidneys from healthy people. Their oath requires them to do no harm. But they are already taking kidneys from healthy brothers, sisters, wives and husbands who donate their organs out of love.

All that the Nobel Prize winning economist Gary Becker proposes that that they also do it for people who sell their organs for money.

If you find the idea abhorrent you are in good company at the moment. But our idea of what is abhorrent changes over time. Once it was widely regarded as abhorrent to lend money for interest. Life insurance (where I make a bet that my loved one will die early) was similarly regarded as beyond tasteful.

The US Economist Virginia Postrel argues that by restricting living donations to friends and family (and sometimes helicopter pilots like Kerry Packer's) we are discriminating against people who don’t have friends or family.

She means it. Two years ago she donated one of her kidneys to an acquaintance because she knew no-one else would. She says it would have felt better had money changed hands.

She has an answer too for people who say that the poor would be the most likely to lose their organs in a legal trade in living kidneys, creating a one-way traffic in body parts to the rich.

She says we could give anyone who donated a living kidney a one-year tax holiday. That's not worth much to a poor person but it's worth an awful lot to a rich one. “Suddenly all of the founders of Google would be lining up” she says.

They are ideas worth taking seriously. What's happening now is an appalling needless tragedy.

While writing this article I logged on to www.australiansdonate.org.au and typed in my Medicare number. I'd signed up as a donor in 45 seconds.


Gary Becker,
Should the Purchase and Sale of Organs for Transplant Surgery be Permitted? The Becker-Posner Blog, January 01, 2006

Gary Becker and Julio Jorge ElĂ­as,
Introducing Incentives in the Market for Live and Cadaveric Organ Donations, The Journal of Economic Perspectives, Volume 21, Number 3, Summer 2007 , pp. 3-24(22)

Stephen Dubner and Steven Levitt,
Flesh Trade, New York Times, July 9, 2006

Alexander Tabarrok,
A Moral Solution to the Organ Shortage, The Independent Institute, February 19, 2001

Alexander Tabarrok,
How to Get Real About Organs, Econ Journal Watch, Volume 1, Number 1, April 2004, pp 11-18

Virginia Postrel,
"Unfair" Kidney Donations, Forbes Magazine, May 6, 2006

Virginia Postrel,
The surgery was simple; the process is another story, USA Today, October 25, 2006

Sally Satel,
Death's Waiting List, New York Times, May 15, 2006

Sally Satel,
A living donor let me live on, USA Today, October 25, 2006

Alvin E. Roth,
Repugnance as a Constraint on Markets, Journal of Economic Perspectives Volume 21, Number 3—Summer 2007—Pages 37–58

Tim Harford,
Repugnant Markets, BBC Radio, July 12, 2007

Ian Walker,
The greatest gift, Background Briefing, ABC Radio National, 17 September 2006

Catherine Waldby,
The logistics of altruism, Australian Review of Public Affairs, June, 2007



Dave Bath said...

I see a few issues with paid-for organs (including blood), with some overlap on (what I consider worthwhile) change to implied consent.

(1) The draft EU Charter of Human Rights probably has a lot of good reasons for section 3.2 (including "the prohibition on making the human body and its parts as such a source of financial gain") - although I'd permit selling hair for high-quality wigs.

(2) Quality control issues need more attention when financial gain is involved, which is why the US blood supply generally has more quality control problems than Australia's.

(3) There are issues of fairness when we consider epidemiological issues: with financial gain, the cohort of poor people are more likely to sell kidneys, while more likely, because of lifestyle and environmental factors, to be affected with kidney disease sometime in the future.

Anonymous said...

Great. I just went through the online donation process, then was told the system was down. D'oh!

Anonymous said...

Peter, couldn't agree more. People should be able to sell one kidney if they wish.

Furthermore, if donations were done more widely, then those who donated would have a good chance of finding a return donor if their kidney failed.

Donation could come with lifetime private insurance that would pay the cost of purchasing a kidney if yours failed; the premium would be part of the payment. We know the percentage risks of kidney failure pretty accurately, so this would be an easy risk to price.

Once a market was established, and the insurance in place, the risks of being adversely affected would be quite small.

People could make their own decisions. Those who didn't want to donate wouldn't be forced to, and those who wanted to could get the market rate for the inconvenience. We'd all be better off.

Quality control would be easier than with the blood supply because the number of transactions is significantly lower : many fewer kidney donations, even in a functioning market, than blood donations.

Anonymous said...

Peter, have you considered that you (and others writing on this subject) may be looking at the wrong side of the equation?

In Australia, there's been an overwhelming amount of positive reaction and comment to organ donation for the last several years. Even so, we are told the donation rate has not changed significantly, with the usually reported figure being that Australians donate organs at half the rate of Americans.

I find it hard to believe that with so much positive sentiment (I don't think I've heard any negative sentiment) towards donation next-of-kin are still saying no at a much higher rate than Americans.

I'd like to suggest an alternative theory. Imagine you are an overworked emergency doctor, it's nearly midnight, and you've just pronounced a road-trauma victim brain-dead.

You have a couple of options. The first is to go to the family and convince them to donate the victim's organs. Quickly, you think through the consequences:

- Instead of getting some sleep in the middle of your long shift, you will have to stay awake keeping the dead body of a smashed up young person, barely older than your son, 'functioning'.

- The nurses, although they won't say it explicitly, will be upset with you for increasing their workload. They, like you, didn't sign up to look after dead bodies.

- Like the nurses, the hospital administrators won't say anything, although you know they want the bed cleared as soon as possible. If this causes the hospital to go on ambulance standby, there will be financial penalties, not to mention the lives that could be lost as paramedics (also annoyed) detour to further away hospitals.

- The family will stay around all night, waiting for the organ harvesting and the machines to be turned off. The presence of the mourning family will depress everybody. This is not going to be a pleasant work place tonight.

Depressed, you fantasise about the second option, not asking the family, or at least discouraging donation, if you do ask:
- The victim is taken to the morgue.
- You get your rest and come back to a pleasant workplace, looking after living people rather than a dead body - this is what you signed up for!
- Nurses are happy.
- Hospital administrators are happy.
- Paramedics are happy.
- Grieving family goes home.

Now Doc, what do you do?

I suggest that some economists need to look at the incentives relating to organ donation inside the health system.

One way to do this would be to work with the coroner to identify factors affecting organ donation rates such as hospital, time, doctor, number of beds available, etc. I'm tipping that some patterns would show up.

N.B I don't work in the health system and, as such, all of the above is based on knowledge from reality T.V shows meaning that it could be way off base.

Peter said...

But it sounds plausible.

Our paper reported this week on a case (admittedly some decades back) where the mother had to fight the hospital in order to get her daughter's organs used.

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