It is a sad, true, and often reprised story; the need for solid organ donations egregiously exceeds the supply. The palpable desperation experienced by those who wait, but also frequently die, has led to a variety of proposals aimed at increasing organ supply. Some of these remedies are just and some are not. Designated donation, informed utilization of marginal donors, “opting in” (as in LifeSharers), and also, in qualified instances (that is, those governed by strict quality and safety standards for donor and recipient), living liver donations, each can fall on the positive side of the ledger. Unfortunately, other efforts targeting an increase in the organs available for transplant—such as treating donated organs as commodities either in regulated or “black market” transactions, do not fulfill criteria for just procurement. However, organs as commodities schemes are becoming increasingly prevalent. Some contemporary examples of both brands of commodities trading, regulated or illegal, in the realm of solid organ transplantation should suffice.
First considering “Black Market Organ Trafficking,” the Rotterdam Conference in April, 2007 noted that illegal trafficking in solid organs was estimated to comprise 10% of all transplants performed worldwide.[1] Trafficked kidneys alone in this specific context might account for 10,000 transplants internationally per year.[2] In addition, some countries have “regulated” their commodities market and have paid fees to donors that they determine to be fair and reasonable. Regulators have presumed that justice would be served solely by moving the sensitive transaction away from underground black markets. Unfortunately, the organ directedness in both venues is invariably a poor person’s kidney to a rich recipient. In fact in Iran, a commercial (that is, government regulated) system has been in effect since 1988.[3] Has it worked? Is it just? It appears to have failed on both counts. Regulated transfers have taken over 90% of the entire market, have decreased voluntary donations, have marginalized postoperative donor care, and finally, the policy has again benefited the rich to the detriment of the poor.[4],[5] The bottom line is government regulation does not redeem pay for organs in significant ways. It has become clear, however, that organs are not just another commodity to trade and that regulation of the activity is beset by injustice—similar in many ways to black markets. Other potential donors are watching the market transactions too. When China began to accept paying recipients from Hong Kong, live “gift” donations fell by 15%, and in Israel, by 30% when local insurance companies agreed to cover “Transplant Tourism.”[6]
It would be remiss to ignore a critical part of this transplant equation—the donor as person. Whether it is illegal or regulated, a commodities trade not only victimizes donors, but leaves them worse off then they were before they donate. Sehgal’s classic study is incriminating in this regard.[7] Poor donors comprise a particularly disadvantaged group: their average family income declined by one-third after donation, three-quarters remained in debt, and 86% had deteriorating health as a result of surgery to donate.
The organ as commodity is a recurrent theme and requires an immediate revisit. Singapore is considering legalizing an organ trade in kidneys.[8] A member of Parliament there disingenuously suggested that “desperately poor people” are willing to donate for a “hopefully improved life” despite multiple proofs to the contrary. An Australian physician proposed that his government pay $47,000 per donation.[9] Both Asian nations suggested the policy revision despite their neighbor, the Philippines, recent sanction of pay-for-organs because the poor were consistently being exploited.[10]
Organs should not be sold, in either a regulated or unregulated marketplace. They are not commodities and every model of their sale to date has preyed on vulnerable persons who end up worse for the “bargain,” not better. Commodity trading in organs will unjustly continue to be a buy low (for the recipient)—sell high (for the donor) proposition during which the prohibitive cost will be borne by those who have the least.
[1] Heneghan, T. “Human Organ Trafficking Threatens Donation Schemes.” Reuters April 2, 2007 (http://uk.reuters.com/article/2007/04/02/science-organs-dc-idUKL0224269220070403 accessed July 22, 2008).
[2] Ibid.
[3] NewsMax.com Wires. “Demand Soars on Kidney Transplant Market.” http://archive.newsmax.com. Accessed July 22nd, 2008.
[4] Ibid.
[5] Tober, DM. “Kidneys and Controversies in the Islamic Republic of Iran: The Case of Organ Sale.” Body & Society 2007; 13: 151–170.
[6] NewsMax.com Wires. “Demand Soars on Kidney Transplant Market.”
[7] Goyal, M; Mehta, RL; Schneiderman, LJ; & Sehgal, AR. “Economic and Health Consequences of Selling a Kidney in India.” JAMA 2002; 288: 1589–1593.
[8] CBS News. “Singapore Considers Legal Kidney Trading.” http://www.cbsnews.com, accessed July 21st, 2008.
[9] The Associated Press. “Doctor Proposes Paying $47,000 for a Kidney.” http://www.msnbc.com, accessed July 22, 2008.
[10] Ibid.
