• Kidney markets

    With Steve Jobs’ passing, organ donation and transplantation are in the news. Below I discuss a set of papers recently published in the Journal of Health Politics, Policy and Law that pertain to kidney donation and markets. Jobs had received a liver transplant. Some of the issues that arise due to scarcity of kidneys for transplant also pertain to livers and other organs. See the US Department of Health and Human Services organ donor website for more organ donor information.

    Today, the waiting list for kidney donations is about 85,000 patients long and growing. Total transplants per year numbers 17,000, over 10,000 of which are based on kidneys from cadavers. The rest are live donations. The costs in treasure and lives due to a lack of kidneys for transplant are high. Medicare’s ESRD (kidney failure) benefit cost the program $24 billion in 2007, or nearly 6% of the entire Medicare budget. Each year about 4,500 individuals per year die waiting for a transplant. Financial compensation for kidney donation (or any organ) is prohibited by US law and opposed by many on ethical grounds.

    The facts and figures above are from last month’s Journal of Health Politics, Policy and Law, which included several articles on the ethics and possible mechanics of kidney transplant markets. I read the paper by Rosen, Vining, and Weimer (pdf working paper here), as well as the two commentaries. In their commentary, Richard Hirth and Robert Merion did a nice job of summing up Rosen et al.’s proposal.

    Under [their] proposal, a transplant center or consortium of centers would line up a chain comprising pairs of otherwise incompatible voluntary donations. [See figure above, from Rosen et al.] This chain would be “seeded” by paying a living donor, whose kidney would be used to initiate the first of a series of cascading donor substitutions for downstream incompatible pairs. Specifically, a kidney from the voluntary but incompatible donor from the first pair would be used to transplant the compatible recipient in the second pair. This process would continue until no more pairs can be identified in which the donor in the previously incompatible pair is compatible with a recipient in a subsequent pair. The chain ends when the voluntary donor from that last incompatible pair donates a kidney that is allocated to a person in the existing deceased-donor recipient pool. Transplant centers would compete for the paid seed organ on the basis of having assembled a longer chain than those of other centers.

    This system has three notable merits. First, aside from the substantial hurdle of requiring federal legislative relief to enable payment to the seed donor, the system builds naturally and incrementally on evolving innovations in the existing system for paired and chain donation. In response to the shortage of deceased-donor organs, directed living donation became more prominent until peaking in 2004. However, directed living donation faces an inherent limitation: the need for compatibility between donor and recipient. This need led to the idea of paired donation, in which compatibility is achieved by trading organs across two or more incompatible pairs. The paired-donation concept, limited by the need to find pairs with two-way cross-compatibility, led naturally to the chain-donation strategy that has begun to emerge. The longest known chain involved sixteen transplants […]. Further, the sorts of nonprofit organizations presupposed by the chain-auction system have already developed to facilitate paired or chain donation, albeit without any donor payment components at present. As for the second notable merit, building on the chain approach and using chain length as a bidding mechanism for the seed kidney has the potential to leverage the purchased kidney to maximize the number of transplants from a single chain-auction kidney. And third, because the donations that ensue following that of the seed kidney are unpaid, nonauctioned donor organs, the proposed system avoids (or at least reduces) the cost problem of paying for kidneys that would have been donated even in the absence of financial incentive.

    They go on to comment on some of the limitations of the proposal:

    • Arbitrary, administratively set price “equal the savings to Medicare by converting two patients from dialysis to transplant.”
    • Bad incentives associated with a “bidding mechanism […] based on the claimed length of the chain to be seeded,” as well as penalties for failing to deliver the stated chain length.
    • A presumption that kidney chain donation rates would not be adversely affected.

    Then there are the ethical considerations, which are not covered by Hirth and and Merion, though are in the paper by Rosen et al., as well as in a commentary by David Frankford. I imagine they will come up in the comments to this post. To prompt you, let me ask, what are your reasons (if any) as to why we should not pay for kidneys (or other organs) under any circumstances? Or do you think there are instances where exchange of kidneys (and other organs) for money is ethically acceptable and/or justified? How should we balance the ethics of cost in taxpayer money and lives (as given in the opening paragraph to this post) with the ethics of a kidney market? What do you think of Rosen et al.’s proposal?

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    • So, in the US about 40% of people are registered to donate their organs when they die. Presumably if this figure could be doubled then twice as many organs could be transplanted from this source each year. If this were to happen we’d see the length of the waiting list shrink. Setting up a system of the sort discussed above is, I think, an inefficient policy that is the result of politicians and academics alike looking for a quick fix… Even if the above ideas are better thought out than the calls of “let’s copy Iran”.

      Governments should be spending more time and money securing the organs of dead people before they begin harvesting organs from society’s most vulnerable.

      My blog post on a similar topic: http://goo.gl/3KKmj

    • Kevin
      Dynamite post.

      The discussion is fraught with such polarity. Just when I hear a solid plea/dissertation for formation of a supervised legal market, another crops up and serves as a persuasive reason why its dangerous.

      One of the best intelligence squared debates i have heard is on this subject. It really gives you food for thought:
      http://intelligencesquaredus.org/index.php/past-debates/we-should-legalize-the-market-for-human-organs/

      Additionally, and an oft forgotten lapse, is donors receive no stipend to cover added costs, OOP expenses, or future complications,(above and beyond what their benefits entitle). Imagine, if an uninsured good Samaritan donates a kidney, beyond the initial costs of index stay and removal, he or she is on their own. What an incentive.

      Brad

    • @ Brad – Thanks, but this post is Austin!
      @ Chris – one reason for the low yield from cadaveric organs is the reluctance of medical personnel to harvest – even with donor information on the DL – unless they ALSO obtain permission from the survivors. They fear a backlash. (That’s why donor information also says: Tell your family about your decision).

      We could fix this, without the ethical questions with live donations, by making it clear that hospitals can rely on the donor info on the DL.

      • We could also fix this by making organ donation opt out. This way there is no ethical issue with paying for organs at all. We already have examples in the medical field (DNR orders, for instance).

    • The following passage from the paper didn’t make it into the post, but is a very interesting consideration on donation.

      [A] personal connection may change the motivation for donation from the purely altruistic to a mixture of altruism and obligation.

      The obligation may be tainted when the potential donor is subject to (most likely subtle) coercion arising from his or her relationship with the patient. This danger is recognized by the transplant community: “If a potential donor chooses to not proceed with the evaluation or donation process, the center may state that the donor did not meet the program’s criteria for donation to help avoid difficult social situations” (OPTN 2008a: 2, emphasis added). The concern about inappropriate advantage may also be raised with respect to relational donations. Those with larger families and more extensive networks of friends have a greater opportunity of finding an appropriate donor. Although this greater opportunity is generally not viewed by ethicists as an inappropriate advantage, it does remind us of the importance of a broad perspective on wealth in assessing distributional consequences.

    • It’s interesting how the discussion about organ transplants always relies on supply side economics rather than reducing demand. As Chris Sampson mentioned above, these sorts of paradigms are ‘easy’ fixes compared to coping with the foundation of the problem.

      The kidney waitlist is artificially inflated by approximately 1/3. Rob Stein of the LA Times wrote about it in 2007, and Delmonico and McBride’s analysis of the wait list in 2008 confirmed his conclusion. In 2002, OPTn allowed ‘inactives’ to remain in the transplant list indefinitely to accrue ‘wait time’ which factors into allocation prioirity -but only for kidneys. In other words, this 1/3 are ‘inactive’, meaning they couldn’t benefit from a transplant even if an organ did become available.

      Delmonico and McBride also revealed that 52% of the deaths on the wait list are inactive. So – those folks would not have been helped by an increase in supply.

      As for demand:

      The average age of end-stage renal disease onset in this the US is 64.4 years old. Should an 84 year old, who most likely has other health issues, be wait listed? Is it cost-effective to spend the hundreds of thousands of dollars to transplant an 84 year old then pay for the anti-rejection meds when life expectancy is less than 5 years? Is that a good use of deceased donor organ? Or is it worth the lifetime risk (most of which is unknown because we have no data) a living donor would assume?

      Also, and more importantly, the biggest cause of kidney failure in the US is diabetes. A much more efficient and cost-effective method would be to concentrate on prevention, diagnosis and treatment of diabetes before a kidney transplant became necessary. However, As Chris intimated and I second, this is a much more time-consuming proposition than harvesting kidneys from the public.

      Another consideration that every one of these proposals miss is that EVERY study out of EVERY country that has legal or illegal kidney markets (yes – including Iran) concludes that the system is beneficial to the recipient, surgeon, hospital, and govt, but highly detrimental to the kidney donor/vendor.

      The person relinquishing the kidney experiences greater financial difficulties, increased physical complaints, more psychosocial complications and a reduced quality of life.

      You can read more about some of those studies here: http://tinyurl.com/3qluktd

      It has been nearly 60 yrs since the first LD kidney transplant in the US . There are still no national standards of evaluation, selection, treatment or follow-up. No valid or reliable short term data, and NO long-term data on living donors’ health and well-being. Given that history and current state of affairs, there is NOTHING to indicate a US kidney market will be any more successful for donors/vendors than it has been for anyone else.