Selling a kidney? Read this!

Nurse: Beyond the stuff of urban legends, there really is a black market for organs– kidneys, especially, since a living donor can give one up and essentially have no ill effects. To be simplistic, the black market thrives because there are more people with kidney failure than there are willing– or cadaverous– donors. Iran has a program that allows the government– and the recipient, through a 3rd party– to pay the donor a “modest sum”. This brought up all kinds of stuff for both of us!

Lawyer: Hmm. The part about the recipients paying the donors was more immediately troubling to me. Access question — who gets the kidneys? Definitely legal issues here — in terms of ownership rights. Comes up in property law — in what way do you own your body/organs?
Nurse: I’d be inclined to say you own your body/organs more than anything else in the world– more than your shirt, more than your house. They are absolutely yours.
Lawyer: We can certainly conceive of different kinds of ownership — ownership that allows you to exclude others (you can’t just TAKE my kidney) or that allows you to give it away, or destroy it after its removal, but NOT sell it. These different sorts of rights can be separated from each other. At the minimum, we could say that you don’t own your body at all — all you have is a right to protect it against unauthorized invasion. So you can’t sell it or rent it out (prostitution, for example), and you can’t even control what happens to your body after you die (though in our society, you can) — see what I’m saying? Different types of legal rights we could or could not grant. Related question about who owns tissue excised from your body during non-elective surgery. (One case I studied involves the spleen removed from a patient with a rare form of leukemia being used for research and subsequent profit without his consent — and the court, though divided, allowing it, and granting him ZERO rights to any of the profits.)
Nurse: Is it ever ethical to pay living organ donors for their organs, as is done in this case (Iran)? There are of course lots of protections in place for the donors, including who can evaluate their suitability. Also, it’s a pretty small payment– but likely enough to be essentially coercive to someone who is hard up. in the article, doctors say they believe donors act out of altruism, but why then include a financial component at all? i can see including care for free, but why cash?
Lawyer: This might be part of the problem, too. . . people who are desperate might actually “under-price” this sort of thing. I’d venture to guess that in a real competitive market for this sort of thing, the value of all the pain and future uncertainty of giving up a kidney would be a lot more than $1200. But I agree — why cash at all? If it’s altruism, pay for their care, pay for some monitoring after the procedure, maybe even pay them for their time — but not for their organs.
Nurse: Normal consent procedures certainly won’t cut it, if you ask me– people frequently sign without understanding, knowing that the procedure is in their best interest. in this case, it’s in someone else’s interest, not their own. that changes the calculus drastically. to truly accept the risk, the donor must have a fairly sophisticated understanding.
Lawyer: How would you accomplish a “super-consent”? Is there such a thing already in place for other types of situations? Research?
Nurse: Research is the closest case I can think of, and research consents are far more extensive than a basic procedure consent. They can be pages and pages and pages, whereas a regular consent form that we’d use in the hospital is one page, with a minimal amount of information written in.
To what extent can the government intervene? it’s illegal to sell your organs, no? why? would a regulated system circumvent the concerns at all?
Lawyer: The government can intervene in that they can make it illegal to sell your organs — basically, if a doctor removes your kidney, you have no claim to payment. Of course, there can be all sorts of other “payment” that doesn’t leave a paper trail… bag of hundred dollar bills, etc. (cf. gestational surrogacy — can’t actually pay someone to do this for you. But you can over-pay them for nutrition during gestation, etc.)
Nurse: People CAN sell plasma and eggs, and both of these donation procedures carry some risk. not as much as nephrectomy, but still.
Lawyer: Is it just about the risk of the procedure itself, or also about possible compromised future health? (I mean, you definitely don’t need all your plasma or eggs, but don’t you need both your kidneys? Need as in, there’s a reason we have 2? Is the second one really just a backup? What are the increased risks of living with a single kidney? Will the health care system have to bear the cost of this risk, especially for the aforementioned patients who are indigent?)
Nurse: You really only need one. The risk of living with one is that you’re screwed if your one kidney fails. Otherwise people can live with a single kidney and have no adverse affects.
Lawyer: A further curiosity: are there really any other organs where we could see this come up? Most of the things we desperately need, we don’t have two of (e.g. liver). So, nurse, is this just, always and forever, about kidneys?
Nurse:  Well. . . for now it is. It is possible to transplant part of a liver from a living donor. I believe it’s somewhat riskier, but in general it’s fairly successful. And like our earlier discussion, things like blood, plasma,and  eggs are certainly part of the discussion.
Lawyer: I am also curious about alternatives. I know there has been work on artificial hearts — what about kidneys? (I mean, obviously, short of lifetime dialysis.)
Nurse: Well, dialysis IS really an artificial kidney.  And as of now, it’s the only other way to do it. And if we wanted to open up a can of worms about cost, both financially and in terms of quality of life, that would be a good one!

7 thoughts on “Selling a kidney? Read this!

  1. I enjoyed this post. Two points I think could be developed more: Using data from Iran is highly problematic because any data counter government policy is suppressed. Some day soon we might feel like we’re seeing the whole picture in Iran but that day has not passed.

    The other question is how does paying for kidneys impact postmortem altruistic donation? Should we be concerned with the impact of paying for kidneys beyond the list of people waiting for kidneys? For instance I can imagine a kidney market impacting altruistic postmortem donation of livers.

    If you pay for kidneys, livers must be more valuable, since there isn’t a practical chronic “liver dialysis”, a liver transplant is life or death. (Throw hearts and lungs into this category). Now you’re paying for livers – would that really increase the number of available livers?

    Could lawyers with business agreements do a better job than a transplant coordinator when a family is dealing with a loved one’s death?

  2. Interesting questions. Thanks for the comment.

    Lawyer: My property professor discussed the impact on altruistic donation in terms of the “chump factor” — do you feel less likely to donate something because you might be able to get some money for it? It would be pretty hard to get accurate numbers on this. My instinct is that it wouldn’t have much of an effect, but I don’t know that that’s terribly testable.
    And re: Iran, yes, yes, yes. Tough to get good data even from a country that doesn’t do that. For now, we are, alas, in the realm of concepts.

    Thanks for reading!

  3. I recommend reading Ghods’ studies out of Iran. While the waiting list has been eliminated, he admits the program has not been ‘positive’ for the donors/sellers (and Ghods is an overall proponent, so what does that say?). Goyal’s study of India’s kidney sellers say the same thing – donors/sellers are still in debt post-surgery, have more health problems and a lower quality of life. Nearly 80% stated they would not recommend someone sell a kidney.

    i agree with the comments regarding Informed Consent. Currently, prospective LDs in the U.S. are NOT receiving full and true consent. UNOS/OPTN policies give great latitude to the transplant centers on the matter, and Housawi’s research revelaed that transplant professionals vary in what they tell prospective LDs, usually based on the THEIR opinion and not data or fact.

    The other issue in the U.S. is that while the medical community has been harvesting kidneys from living people for over 50 years, they’ve never bothered to track or follow them. This means there is virtually NO comprehensive data on living donors’ health and well-being. The idea that a person ‘only needs one kidney’ is rubbish – living donors are at a much higher risk of hypertension, cardiac problems and kidney disease/failure than two-kidneyed people. Since 1993, almost 200 living donors have registered on the waiting list in need of their own transplant. In addition, the contrast dyes used in MRI’s as well as chemotherapy can prove incredibly nephrotoxic to a one-kidneyed individual, affecting how that person is diagnosed and/or treated for certain illnesses.

    The reason it’s permissible to be paid for eggs or plasma is beause they are ‘renewable’ resources; a kidney is not.

    • Nurse: thanks for the comment– i’ll look at some of those articles, thanks for the tip.
      I’m glad to see the interest in consent– it’s a bit of a personal crusade for me!
      One final point: while your body does make more plasma, it doesn’t make more eggs. you don’t use all the eggs you have, sure– but strictly speaking, they’re not renewable, so it’s kind of an in-between.

  4. Elsewhere in the Middle East-
    Apparently Israel’s got some interesting legislation around organ donation in which people who are registered donors get bumped to the front of the line when they’re in need. Heard some about it on NPR this evening, but haven’t been able to track down the article. I really like this idea of body ownership though, and what kind of incentives it takes to buy part of a person,

  5. Pingback: How much are your eggs worth? « Nurseandlawyer’s Blog

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