Kidney Vending: A Call to Action
by Megan Bridges
Currently, more than 100,000 Americans are on the kidney transplant waiting list, many of whom will die before a donor-recipient match is found. In fact, the numbers are staggering; 14 people die each day while waiting for a kidney transplant. The organ procurement system has failed tens of thousands of patients suffering from kidney failure and is in dire need of reform. While some advocates favor opt-out (or presumed consent) laws to increase organ supplies, others have argued for more controversial measures, such as a regulated organ market. The latter claim that the present ban on organ sales is responsible for current scarcities, and a repeal of the prohibition is necessary to eliminate the waiting list altogether. Consider the favorite example of kidney vending proponents: Iran.
Although Iran has garnered media attention in recent years for its obscene violations in human rights, it has triumphed in keeping patients off its kidney transplant waiting list since 1999. Unlike the United States, which passed the National Organ Transplant Act banning organ vending practices, and every other existing country, Iran stands alone in its sanctioning of a regulated organ market. A maverick among the international community, Iran’s unorthodox approach to organ procurement is highly successful; it is the only country to completely eliminate its kidney transplant waiting list. Not only does the Iranian model ensure that those waiting for kidneys receive kidneys, but it also improves health outcomes among recipients and accrues savings.
The Iranian model for organ procurement is as follows:
- Potential kidney recipients are identified and evaluated by kidney transplant teams
- Recipients are counseled to identify a biologically related living donor
- If no biologically related living donor is available or willing to donate, the recipient is referred to the Dialysis and Transplant Patients Association (DATPA), which will attempt to provide recipients with kidneys from deceased donors
- By six months, if the recipient does not receive a transplant from a deceased donor, DATPA identifies a kidney vendor for the recipient
- Vendors are evaluated by physicians who are able to veto a vendor’s candidacy at their medical discretion (Hippen, 2008, p. 3-4)
As the documentary film Iranian Kidney Bargain Sale details, kidney vendors receive two forms of compensation. The Iranian government offers vendors a fixed payment of approximately $1,200, in addition to limited health insurance coverage. The health insurance provided by the government terminates after one year of kidney removal surgery, and it only covers conditions related to the procedure. The second form of payment comes from the organ recipient, who offers the vendor between $2,300 and $4,500. Often, the vendor must negotiate prices with the recipient, who may very well be unable to meet pricing demands. In such cases the recipient must seek additional financial support from benefactors or find another vendor who is willing to sell their kidney for less.
While kidney vending has effectively rendered the kidney transplant waiting list obsolete, the Iranian system faces a major ethical dilemma. The general fear with an organ market is that it will endorse a system in which the rich benefit at the expense of the poor. For example, in the Philippines, a kidney transplantation “hotspot,” between 85% and 92% of vendors belong to the lowest economic classes of Filipino society. Vendors include servants, manual laborers, the homeless, and the unemployed looking to earn money on the black market to pay their debts. The majority of their customers are high wage earners, and over 60% are transplant tourists, foreigners who purchase kidneys and undergo organ transplantation abroad.
The Iranian system has partly addressed this concern. Only Iranian citizens are permitted to engage in the organ market, impeding the development of a black market supported by transplant tourism. Furthermore, both middle and low income patients are able to receive kidney transplants due to the generous aid of charities to meet vendor pricing demands. However, the poor continue to constitute the majority of organ vendors in Iran. Many vendors are enticed to sell their kidneys to support their families or pay their debts; the price of one kidney is equivalent to half a years salary for low wage workers. As the aforementioned documentary demonstrates, however, the payments earned through organ sales are only a temporary relief for vendors; many find themselves in similar or worse financial circumstances following the procedure.
Although many perceive organ vending as morally abhorrent, several ethicists argue that it is unethical to restrict autonomy. They believe individuals should be allowed to exercise complete control over their bodies, including selling their organs if they so wish. Furthermore, they argue that such prohibitions limit the poor’s ability to improve their financial circumstances by exhausting all means possible. While this argument is a reasonable area of contention among bioethicists, a more helpful approach in drafting legislation may be evaluating whether the benefits of a regulated organ market outweigh the costs to those involved.
Intuitively, preforming an invasive and painful kidney removal procedure on vendors seems to be in direct conflict with “Do no harm,” one of the first rules taught to medical students. However, a regulated organ market actually serves to protect vendor health and wellbeing. In countries with thriving black markets, vendors are frequently exploited due to their desperate financial circumstances and lack of education. Consequently, they are discharged early from hospitals and are not offered follow-up care. In Chennai, India, for instance, 86% of vendors report deterioration in their health following the procedure. In its repeal of the ban on organ sales, the United States can take measures to ensure that vendors receive adequate care once discharged. Such measures might include providing vendors with lifelong health care coverage or regular tax-free deposits into designated health savings accounts.
Increasing the supply of kidneys through organ sales also improves health outcomes among recipients. The years of life remaining for individuals on the waiting list is 10 years, and it is 20 years for those who receive kidney transplants. Not only do organ transplants improve life expectancy, but they also benefit ethnic minorities suffering from kidney failure. Although African Americans account for approximately 13% of the population, they make up 30% of the national waiting list. This data suggests that African Americans are disproportionately affected by kidney failure. Furthermore, they spend more time on the kidney transplant waiting list and have more difficulty in finding an organ match. A regulated organ market can increase the supply of kidneys and the likelihood that historically disadvantaged ethnic groups can find a compatible donor or vendor.
Lastly, organ transplantation accrues huge savings. Presently, 80% of patients on the kidney transplant waiting list are on dialysis, and the number of dialysis-dependent patients in the United States is expected to reach as high as 700,000 by 2020. Although dialysis is a costly procedure, it is fully funded by Medicare. In 2005, the cost of end-stage kidney disease entitlement exceeded $21 billion, accounting for 6.5% of the Medicare budget. Of that amount, only $586 million was spent on kidney acquisition and transplantation, while the rest was spent on dialysis treatment. By shifting from a dependency on dialysis towards a reliance on transplantation, savings are calculated at approximately $94,579 per patient. Therefore, in addition to providing vendors with health insurance benefits, they can also be paid as high as $80,000 and still produce a net financial saving to society.
By banning organ sales, the U.S. government has committed a great disservice to those on the kidney transplant waiting list. While the Iranian model is not foolproof, it has demonstrated that viable alternatives exist to the status quo in providing kidneys to those in need. The current organ procurement system in the United States is disgraceful, and policymakers must take action to ensure that no one else perishes while waiting to receive a life-saving kidney transplant.