The Meat Market by Alex Tabarrok
Economist
Alex Tabarrok (b. 1966) is an associate professor at George Mason University,
where he earned his Ph.D. in 1994. He also serves as the Bartley J. Madden
Chair in Economics at the Mercatus Center, a research institute at George Mason
University focused on market-driven ideas. In addition, he is the research director
of the Independent Institute, an organization that studies social and economic
issues. The author, coauthor, and editor of several books, including Modern
Principles: Microeconomics (2009), Tabarrok has published widely in the field
of economics. Additionally, he blogs at the economics Web site
marginalrevolution.com. “The Meat Market” was originally published in the Wall
Street Journal in 2010.
Background on organ donation and shortages of donor organs
Currently, most donor organs come from patients officially pronounced brain dead. Short[1]ages of donors, and the thousands of people who die each year waiting for transplants, have led many in the medical community and the federal government to advocate a more aggressive practice: donation after cardiac death (DCD) rather than after brain death. Some question the ethics of such “organ harvesting,” particularly if done in the high-pressure, fast-paced environment of hospital intensive care units and emergency rooms. The fact remains, however, that more than 100,000 people are now waiting for transplant surgeries. According to official government statistics, this number is rising faster than the number of available donors. The overwhelming majority of these patients need kidneys (86,142), followed by livers (16,022), and hearts (3,149). In the United States, individual states enact their own donation laws; many allow people to become prospective donors by consenting to their driver’s licenses. According to Donate Life America, as of 2010, 86.3 million Americans were enrolled in these state donor registries.
ü Harvesting human organs for sale!
ü Yet right now, Singapore is preparing to pay donors as much as 50,000 Singapore dollars (almost US$36,000) for their organs.
ü Iran has eliminated waiting lists for kidneys entirely by paying its citizens to donate.
ü Israel is implementing a “no give, no take” system that puts people who opt out of the donor system.
ü Millions of people suffer from kidney disease, but in 2007 there were just 64,606 kidney-transplant operations in the entire world.
ü In the U.S. alone, 83,000 people wait on the official kidney-transplant list.
ü But just 16,500 people received a kidney transplant in 2008, while almost 5,000 died waiting for one.
ü Some American doctors routinely remove pieces of tissue from deceased patients for transplant without their, or their families, prior consent.
ü And the practice is perfectly legal.
ü In several U.S. states, medical examiners conducting autopsies may and do harvest corneas with little or no family notification.
ü Few people know about routine removal statutes and perhaps because of this, these laws have effectively increased cornea transplants.
ü Routine removal is perhaps the most extreme response to the devastating shortage of organs worldwide.
ü Innovation has occurred in the U.S. as well, but progress has been slow and not without cost or controversy.
ü Organs can be taken from deceased donors only after they have been declared dead.
ü There is little hope that the dividing line between life and death will ever be agreed upon.
ü Indeed, the great paradox of deceased donation is that we must draw the line between life and death precisely where we cannot be sure of the answer because the line must lie where the donor is dead but the donor’s organs are not.
ü In 1968 the Journal of the American Medical Association published its criteria for brain death. But reduced crime and better automobile safety have led to fewer potential brain-dead donors than in the past.
ü Both standards are controversial-the surgeon who performed the first heart transplant from a brain-dead donor in 1968 was threatened with prosecution, as have been some surgeons using donation after cardiac death.
ü Despite the controversy, donation after cardiac death more than tripled between 2002 and 2006, when it accounted for about 8% of all deceased donors nationwide.
ü In some regions, that figure is up to 20%.
ü The shortage of organs has increased the use of so-called expanded-criteria organs, or organs that used to be considered unsuitable for transplant.
ü Kidneys donated from people over the age of 60 or from people who had various medical problems are more likely to fail than organs from younger, healthier donors, but they are now being used under the pressure.
ü Why would anyone risk cancer? Head surgeon Dr. Michael Phelan explained, “The ongoing shortage of organs from deceased donors, and the high risk of dying while waiting for a transplant, prompted five donors and recipients to push ahead with the surgery.”
ü Expanded-criteria organs are a useful response to the shortage, but their use also means that the shortage is even worse than it appears because as the waiting list lengthens, the quality of transplants is falling.
ü Routine removal has been used for corneas but is unlikely to ever become standard for kidneys, livers, or lungs. Nevertheless, more countries are moving toward presumed consent.
ü Under that standard, everyone is considered to be a potential organ donor unless they have affirmatively opted out, say, by signing a non-organ-donor card. Presumed consent is common in Europe and appears to raise donation rates modestly, especially when combined, as it is in Spain, with readily available transplant coordinators, trained organ-procurement specialists, round-the-clock laboratory facilities, and other investments in transplant infrastructure.
ü The British Medical Association has called for a presumed consent system in the U.K., and Wales plans to move to such a system this year. India is also beginning a presumed consent program that will start this year with corneas and later expand to other organs. Presumed consent has less support in the U.S. but experiments at the state level would make for a useful test. It’s all part of the growing black market in transplants. Already, the black market may account for 5% to 10% of transplants worldwide.
ü If organ sales are voluntary, it’s hard to fault either the buyer or the seller. But as long as the market remains underground the donors may not receive adequate postoperative care, and that puts a black mark on all proposals to legalize financial compensation.
ü Only one country, Iran, has eliminated the shortage of transplant organs-and only Iran has a working and legal payment system for organ donation. In this system, organs are not bought and sold at the bazaar.
ü Patients who cannot be assigned a kidney from a deceased donor and who cannot find a related living donor may apply to the nonprofit, volunteer-run Dialysis and Transplant Patients Association (Datpa).
ü Datpa identifies potential donors from a pool of applicants. Those donors are medically evaluated by transplant physicians, who have no connection to Datpa, in just the same way as uncompensated donors.
ü The government pays donors $1,200 and provides one year of limited health insurance coverage. In addition, working through Datpa, kidney recipients pay donors between $2,300 and $4,500.
ü Charitable organizations provide remuneration to donors for recipients who cannot afford to pay, thus demonstrating that Iran has something to teach the world about charity as well as about markets.
ü The Iranian system and the black market demonstrate one important fact: The organ shortage can be solved by paying living donors. The Iranian system began in 1988 and eliminated the shortage of kidneys by 1999.
ü Moreover, this proposal would save the government money since even with a significant payment, a transplant is cheaper than the dialysis that is now paid for by Medicare’s End Stage Renal Disease program.
ü In March 2009 Singapore legalized a government plan for paying organ donors. Although it’s not clear yet when this will be implemented, the amounts being discussed for payment, around $50,000, suggest the possibility of a significant donor incentive.
ü So far, the U.S. has lagged behind other countries in addressing the shortage, but last year, Sen. Arlen Specter circulated a draft bill that would allow U.S. government entities to test compensation programs for organ donation.
ü These programs would only offer noncash compensation such as funeral expenses for deceased donors and health and life insurance or tax credits for living donors.
ü Two countries, Singapore and Israel, have pioneered nonmonetary incentive systems for potential organ donors. In Singapore, anyone may opt out of its presumed consent system. However, those who opt out are assigned a lower priority on the transplant waiting list should they one day need an organ, a system I have called “no give, no take.”
ü Many people find the idea of paying for organs repugnant but they do accept the ethical foundation of no give, no take-that those who are willing to give should be the first to receive.
ü In Israel a more flexible version of no give, no take will be phased into place beginning this year. In the Israeli system, people who sign their organ donor cards are given points pushing them up the transplant list should they one day need a transplant. Points will also be given to transplant candidates whose first-degree relatives have signed their organ donor cards or whose first-degree relatives were organ donors.
ü The worldwide shortage of organs is going to get worse before it gets better, but we do have options. Presumed consent, financial compensation for living and deceased donors, and point systems would all increase the supply of transplant organs. Too many people have died already but the pressure is mounting for innovation that will save lives.