May 31, 2007

Of Market Forces And Organ Donors

Until now, I have not commented on the story regarding the Dutch game-show giveaway of two kidneys, which may surprise CQ readers, since the issue is one that hits very close to home for my family. Michael van der Galien's post about the television competition for a dying woman's organs expresses frustration about how the controversy reflects on The Netherlands, but the show is only the symptom of a global problem with organ donation -- and a demonstration that market forces will prevail in any situation where demand far exceeds supply:

In the Netherlands we have a new television show: De Grote Donor Show (The Big Donor Show). What’s the show about you ask? Well, quite simple: this Friday 37 year old Lisa will donate one of her kidneys… on television. Three people who need a new kidney will be there. They have to answer questions. After that, Lisa will decide who gets her kidney. The viewers have an active role as well: they can SMS (to advise Lisa probably).

There is a lot of debate going on about this show in the Netherlands. Some consider it a good thing: we do not have enough people who are willing to donate their organs (after they die). This ’stunt’ or show, might make it easier for people to make the decision to donate their organs. However, there are also people who object, who find it tasteless. Members of Parliament have asked questions about the show, some want the government to ban it (it’s being broadcasted on a government-owned channel). ...

Well, this certainly puts the Netherlands on the map once again. I am very pleased to see that whenever the world talks about us, it is usual about something ridiculous, like now. Wouldn’t want the world to take us seriously, now would we? No, lets happily enforce the idea that we are more liberal than liberal, more tolerant and open-minded than tolerant and open-minded: no rules. No moral values. No nothing! Hedonism rules!

Reuters also noted this controversy a couple of days ago. The Dutch government and the EU registered protests with the broadcaster, BNN, objecting to the network turning organ donation (and death) into entertainment. BNN still plans on airing the program tomorrow night.

This follows on the heels of a Washington Post column that caught my eye a month ago by Dr. Sally Satel, arguing for a market approach to organ donation in order to increase the supply:

It is a sad time for the 96,000 patients waiting for kidneys, livers, hearts and lungs: The chasm between supply and demand grows wider each year. By this time tomorrow, 18 people in need of an organ will be dead because they did not get one soon enough.

Kidneys are in highest demand; currently, 71,000 people need a renal transplant. They will spend, on average, five years on dialysis while waiting for an organ from a deceased donor. At least half will die or become too sick to undergo a transplant before their name is called. ...

Lamentably, too many transplant professionals are resigned to rationing. The alternative is to create a larger supply of organs -- and the most likely way to achieve it is through a safe, regulated system in which donors can receive compensation for their organs. The idea of rewarding living donors for a kidney, or their estates if they give an organ after death, has long been taboo. Yet as thousands die every year the idea is being taken more seriously -- and it should be.

If we had not found a donor for the First Mate, she would not have survived long enough to get a cadaver donor in the present system. She had been on dialysis for only a year, and she barely made it to the finish line with a live donor. Another couple of months on that plan, and it would have meant the end for her. When I tell you that her donor is a hero, I mean that very literally.

So what do we do to save the lives of everyone else on the list? The simple fact is that we have a rationing system that does not work, as Dr. Satel explains. We have a demand that far exceeds the supply, and we have put in place regulations that artificially keeps the supply low -- for noble reasons, but those noble reasons are costing thousands of lives every year.

The kidney transplants with the best track record for success are live transplants, even those where the donor is unrelated to the recipient, as was the case with the FM. Many brave people volunteer for these every year, even for people they don't know. However, these donors face significant financial disincentives. The recipient's insurance covers 100% of the medical costs, but the donor loses time at work, a significant period of recovery in some instances, and restrictions on activity. By law, they can receive no compensation. If they could, it's at least possible that more would donate.

And that's just the American system. In the single-payor systems, the supply problem is not organs as much as it is transplant surgeons. Three years ago, the London Telegraph reported that viable kidneys had to be discarded due to the lack of qualified transplant surgeons. The government rationing of compensation for doctors provided no incentive to spend the extra time and money to learn that specialty. It created a shortage on another part of the distribution chain that ended up with the same result: people who needed organ transplants didn't get them in time.

When we ration irrationally, we get irrational results. The BNN show tomorrow night is an example of this. Denied the ability to acquire a kidney through some rational method, these kidney-failure victims will abase themselves in public in order to save their lives. Denied a rational method of receiving compensation for her donation, the terminally ill woman will have to choose other, less objective means for rationing her kidneys. It sounds terrible, and it is, but you'd better believe that I would have jumped at the chance the first few months of this year to get one of those kidneys, had we not already found a donor.

I'm not suggesting a kidney bazaar, where the highest bidder gets the organs and only the rich can find transplants. However, we have to find a system that generates a much larger supply for organs than the one we have now, and we have to move away from the old methods of rationing if we want to save lives. Satel's proposals put us on the right track. It's certainly less disturbing than grinding up embryos to find elusive treatments for diseases, and much less ethically objectionable.

UPDATE: Virginia Postrel, one of the heroes who donated one of her kidneys not long ago, has more thoughts about the "egregious" status quo (via Instapundit).


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Comments (17)

Posted by TomB | May 31, 2007 7:07 AM

It is a tough one Captain, and you know it first hand. But then, would I sell my kidney to have a downpayment for this dream house?
One other difficult problem is for the accident victims: will the doctor try to do everything to save my life, or will he balance my chances against my organs. In the perfect world I'd trust the doctor, but what about the real world?

Posted by Larry J | May 31, 2007 7:46 AM

Why is it that only the organ donor is expected to play his part for free? The transplant doctors don't work for free. Neither do the surgical staff nor the hospitals. Except in rare cases, they all get paid as they should.

Strong controls would need to be in place to prevent abusing poor people, but some nominal form of compensation might increase the supply of organs. It seems worth a try to let the market work. It's obvious the current system is failing.

Posted by Brendan | May 31, 2007 9:52 AM

I have long argued that "ethical" doctors argue for organs to be donated because it would be "unethical" for the family to get a few thousand dollars for one (and, frankly speaking, if the market opened up, that is what they would be worth). Doctors continue to make this arguement for one reason. Supply and demand. When there are many organs out there, you will see a spike in organ transplant doctors. They will still make great money, but not what they make now, and they won't be part of the elite club. Ask an organ doctor what they think of plastic surgeons. They'd sneer at them. Yet plastic surgeons fill a need in the supply/demand curve, and many surgeons go in for that because other options aren't available (ie, there aren't that many slots open for the high fallutin organ transplant surgeon). Make a heart or a liver worth 10K (which would hardly affect the overall price of the transplant at all) and many will get over their squeamishness of donating. And with the supply so high, people will take a chance on someone who might not be a world class surgeon, and will isntead go to the guy who hangs his shingle down on 5th ave...

Posted by CAL | May 31, 2007 10:05 AM

I agreed with you right up to the point about not wanting a kidney bazaar. Either you want a market to do the rationing or you don't.

Most of the post was about how the current system doesn't work because there isn't enough supply at the current price - some feeling good about yourself for helping out your fellow man less some costs associated with recovery time (if live donor).

You want to change that by allowing monetary compensation but you don't actually want the markets to decide the amount? Presumably the authority setting the price will set it below the market price so there will still be a gap between supply and demand at whatever price they set. Why not let the market do its thing? The rich will pay thru the nose for organs from young healthy people who exercise regularly while the less well off will get the homeless guys who is trying to get his next fix, but that is still better than not having enough to go around. If the price is high enough, we might even be able to exclude marginal organs altogether instead of treating them as mana from heaven.

Posted by bayam | May 31, 2007 11:16 AM

It sounds like this could also be framed as a moral / religious issue, perhaps not so different from stem cell research. It's another example of why science and the free market should be allowed to operate without the morality police in charge.

Posted by dave | May 31, 2007 11:34 AM

Here's my answer to the general problem with supply:
Everyone in the nation makes a decision today whether or not they want to donate their organs upon death. Your answer, yes or no, is indicated on your license, and is legally binding. Of those that end up needing an organ in the future, those who answered "yes" go to the front of the line. The problem now with supply and demand is that a lot more people are willing to accept an organ when they need one, but not nearly quite as willing to give one up. Asking people to make a decision up front would be a good incentive to help people decide to be a donor, because they know that if they do, they will also get one if they need it. I believe this solution would greatly increase the supply side.
This does nothing for those who currently need an organ, for the up front question can only be asked of those who currently do not need an organ. It also doesn't help if a live donor is needed. I do think it could be useful, however.

Posted by Joe Doe | May 31, 2007 11:38 AM

"I'm not suggesting a kidney bazaar, where the highest bidder gets the organs and only the rich can find transplants. "

Wow - you think the rich have a problem finding transplant organs today? Really?

This remainds me of those rich folks (too many to enumerate) raising money for the kids in Africa. They would not donate a dime (see Bono's moving his tax heaven to avoid paying taxes) but are ready to advise us to do so and first to critize us for not doing enough. Now we have Bush donating 30 billions to Africa - paranoid about his "LEGO-cy". I mean, Irak did not work, immigration did not work (yet) - mm, let me see, Africa - that sounds doable and at least I can seal the "no hispanic left behind" program why "they" cry about Africa. How can one fail giving somebody else's money? Well, but that being the current president, wait and see how ... it would be almost funny if it would not come from my pocket. Still, 30 billion: 300 million = $100 dollars ( a Barbara Stress-and ticket). Good for nation building (I guess if one ads the illegals we can get a 20% discount too).

But back to the organs - if it is fine for a president to sell "his" country in the name of his dynasty, one can surely sell his organs in the name of freedom. Like - if politicians are allowed at all in our society, surely the prostitutions shuld be respected - after all, they do work.

Just wait for the govenrment to figure out how to tax this though (now that it seems that they cannot force people to donate their organs for "free" - that would work better, but they are not yet "there").

Posted by Laurie | May 31, 2007 1:20 PM

My best friend was on dialysis for 7 years waiting for a donor kidney. I miss her very much.

In some places in Europe, one has to check a desire to NOT donate, whereas in the USA, you must state your desire TO donate.

Let's institute this policy here. Let's help people get the help they need.

Noone wants to create a world where a person's body parts can be sold for more than he might make in his lifetime. Desperate people will begin raising children for sacrifical harvest.

Posted by Laurie | May 31, 2007 2:30 PM

My best friend was on dialysis for 7 years waiting for a donor kidney. I miss her very much.

In some places in Europe, one has to check a desire to NOT donate, whereas in the USA, you must state your desire TO donate.

Let's institute this policy here. Let's help people get the help they need.

Noone wants to create a world where a person's body parts can be sold for more than he might make in his lifetime. Desperate people will begin raising children for sacrifical harvest.

Posted by memomachine | May 31, 2007 3:51 PM


Keep in mind:

1. Hemodialysis (kidney dialysis) is very expensive.

Between the drugs, equipment costs, medical staff costs and the ancillary costs for surgeries, hospitalizations and other secondary treatments, such as cardiac, the average cost **per week** is approximately $10,000.

So. Every single kidney dialysis patient will on average cost about $10,000 a week to keep alive. That is each and every single week without interruption. So it costs about $500,000+ per year to treat one single kidney dialysis patient.

2. ESRD, End Stage Renal Disease, is covered by Medicare as it's considered such a life threatening disease. Which is a good thing considering #1 above.

3. The average span of time a dialysis patient remains on kidney dialysis until transplant is about 5 years, depending on which state the patient is living. Some states have shorter wait times, some longer. So, using #1 above, on average it costs about $2.5 million dollars per kidney dialysis patient to treat until he/she gets a transplant.

4. Some people don't do well with transplants. Some bodies transplants. And some simply cannot be treated with a transplant because of a heart condition or liver condition stemming from either dialysis or some other condition.

In such instances being on dialysis for more than a decade is entirely possible. The cost of which would be $5 million dollars per decade.

5. Transplants aren't forever. They have a definite lifetime of their own and can last from 5 years to 25 years depending on circumstances. A 40 year old kidney dialysis patient might end up with 2-3 transplants over his lifetime along with 12-15 years total on kidney dialysis.

6. If the patient, the patient's private insurance and Medicare, or any combination of the three, ponied up $300,000 cash state & federal tax-free plus free medical care to cover the surgery for transplanting a kidney to a waiting patient, the *government* would probably save about $2-$3 million dollars over the lifetime of the patient.

Even if you up the number to $500,000 cash state & federal tax-free the numbers are still overwhelmingly on the plus side as enormous amounts of money would be saved. Particularly, and this is a very strong point, as many more babyboomers begin to retire. The excess weight, bad diet, high blood pressure and stressful living will result in flood of new ESRD patients into the Medicare system.

And each one of them at the cost of at least $500k per year.


In organ transplants there really isn't a lot of rationality going on.

Posted by memomachine | May 31, 2007 3:58 PM


"Noone wants to create a world where a person's body parts can be sold for more than he might make in his lifetime. Desperate people will begin raising children for sacrifical harvest."

I'm very sorry to say that this has already happened. There are "orphanages" in both Ukraine and India, amongst others, where orphaned children were taken in and ... eviscerated for their organs, ligaments and other valuable tissue.

Even here in the USA cadavers are routinely mined for biological tissue whether or not the families of the dead approve or not. Frankly it's a serious business now that a private word with the funeral director is needed explaining the virtues of a 12 gauge 000 shotgun shot to the groin should any such befall a beloved one lost to death.

Years ago I read science fiction detailing worlds where "organleggers" would form criminal syndicates where human beings weren't just traded and sold but parts of human beings ... and that the parts were often more valuable than the humans themselves. How terrible that slavery exists in the world. Yet how much more horrifying is the realization that the captive is just an intermediate step.

Posted by J'hn1 | May 31, 2007 5:46 PM

Hey Memo,
. Yes I remember Gil Hamilton and his phantom arm as written by Larry Niven.

Why not go after some compromise? Middle ground is often easiest to finagle.
Maybe some amount per organ towards funeral expenses? Condition matters, but enough to more than cover a nice funeral even if decent(but not great) organs (all major internal organs) are harvested. Let each state decide for themselves what the prices are. And what happens to any surplus.

Posted by memomachine | June 1, 2007 12:25 AM


Yeah I wish there were more Hamilton stories.

But, I think you misunderstand about the organ donation. An organ from a cadaver is never as good as an organ from a healthy living donor. The basis of this discussion lies less with cadaver donations, i.e. after death, and more akin to just compensation to living donors.

Frankly there are plenty of people with enough money to run such a system with little or no government intervention. Insurance companies alone would be able to easily justify paying for organs for their subscribers just on cost alone.

But this is absolutely illegal here in the US. Even if you travel to another country, such as China, on your return many doctors will refuse to treat you because there is a distinct possibility that the organ transplanted violated American ethical standards. And yes there is opportunity for abuse particularly if the transplant happens in another country. But if both patient and donor are in America and the transplant takes place in an American hospital and the ethics overseen by credited professionals, then the possibility for abuse drops a great deal.

And anybody who has ever been on or is still on kidney dialysis will tell you that a healthy kidney transplanted successfully into the patient is almost beyond price. Dialysis is that difficult to deal with.

But nothing compared to someone who needs a liver transplant. There's no treatment for liver ailments so any significant liver disease is a death sentence unless a donor can be found quickly that is willing to donate part of a healthy liver.

Posted by Adjoran | June 1, 2007 1:27 AM

We can agree on certain things, perhaps.

1. The current system is rationing, albeit not by money.

2. The problem is supply of suitable organs, which is too short to meet demand. Demand is certain to increase as medical knowledge progresses and enables more patients to be potentially successful recipients.

3. We all want to avoid an auction of body parts to the highest bidder, which is the real objection to payments to donors and a market system.

Possible solution? A pool of money from insurance companies and government to pay donors an amount which is a fraction of the costs of waiting on dialysis for a donor, but still substantial (adjusted up or down over time to ensure adequate supply) could be established. Prospective donors should undergo an evaluation process, including health checks, history, family history, and psychological interviews - similar to the intensive screening process for sex-change operations, although I regret the comparison.

Those donors who pass all checks are compensated, and their organs go to the next patient in line on the registry as determined by the current criteria for priority.

Probably not perfect, but a system which could deliver organs in time to save lives and compensate some of the heroes in a tangible way, if administered properly (which probably precludes direct government involvement).

Posted by Linda F | June 1, 2007 7:57 AM

Let's talk about basic principles:

a) reimbursement for actual costs (medical, lost income, ongoing medication needs)
b) flat fee going to the estate for post-death kidneys. That should help with burial costs and such.

I'm extremely uneasy with the idea of paying donors. It's too easy to imagine abuses of such a system.

Posted by Thanos | June 3, 2007 8:09 AM

The other thing that the current system encourages is a "black market" system of transplant tourism. In Pakistan recently ten were arrested for selling kidneys, but now the authorities have backed off.
It poses a clear ethical dilemma, and I'm not sure the hospitals are coming down on the right side of this.
In Pakistan, the money gained from selling a kidney can make a future for a whole family, on the other hand Pakistan probably doesn't have the best hospitals for the procedure.

Posted by Dave Undis | June 3, 2007 9:20 PM

Over half of the 96,000 Americans on the national transplant waiting list will die before they get a transplant. Most of these deaths are needless. Americans bury or cremate about 20,000 transplantable organs every year. Over 6,000 of our neighbors suffer and die needlessly every year as a result.

There is a simple way to put a big dent in the organ shortage -- give organs first to people who have agreed to donate their own organs when they die.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.

Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition. LifeSharers has over 8,800 members, including members in all 50 states and the District of Columbia..