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Ending The Organ Shortage With Sanity

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Dear Jack,

I have been thinking about a lot of things recently and wanted to get your opinion on a number of ideas.

"The infliction of cruelty with a good conscience is a delight to moralists." These words of the philosopher Bertrand Russell (1872-1970) well characterize our national and state governments that have enacted laws prohibiting the commercialization of human organs. An ethically debilitated society thereby compels thousands of anguished patients to die unnecessarily hoping and awaiting for organs now senselessly squandered by a moralizing, quasi-theocratic society and a self-righteous medical guild, -- all, of course, with a good conscience.

Over a decade ago in an international journal I insisted that it is justified and necessary to buy and sell human organs.2 A few years later I expanded the idea by proposing an unfettered and well-regulated auction market as a better, indeed the only practicable, solution.3 Now the State of Pennsylvania is risking infringement of the immoral federal ban by offering to pay $300 (that is less than $50 per organ!) to any family whose member donates organs at death.4 Furthermore, the medical establishment has relented and endorsed a small payment ostensibly to help cover funeral expenses involved. These token gestures, however welcome as a start, are an affront to human dignity in general and to the family and memory of the deceased donor in particular. Only an ethically misguided government and an autocratic medical guild could be that parsimonious.

 

It is almost impossible to price arbitrarily and fairly such valuable human organs which have different values because of availability. Kidneys, being paired, tend to be the least expensive and in some foreign countries in the past have sold for as little as $1,500 and as high as $100,00 each.5 Livers are more difficult to remove from a donor and are unpaired so they should cost more. Hearts and lungs must come from brain-dead donors whose hearts are still beating; they are the most expensive, especially fragile lungs so vulnerable to infection. Trying to establish prices through thousands of individual one-on-one negotiations would be unseemly, chaotic, and essentially unworkable.

The solution lies in the supply-demand process of a free auction market for organs similar to an ordinary stock market. The most valuable and essential item in transplantation is the procured organ. It legitimizes the whole endeavor. To insist that it be the only altruistically donated item in an extremely expensive, capital-intensive undertaking is absurd, while all medical personnel, hospitals, laboratories, and suppliers are very well paid.

Any procured organ is more valuable than the surgeon's skill, if for no

other reason than because it is in shorter supply than the skill. In any commercial arrangement the price of a vital organ should be higher--

much higher--than the surgeon's fee.

There are obvious advantages from an auction system, especially

one of national scope and preferably international. A successful high

bidder, whether wealthy or not, would gladly pay the price for immediate procurement. The introduction of a strong, even irresistible monetary incentive would increase enormously the willingness of the next of kin to permit donation. That would activate the huge dormant source of organs which is lost every year through ineffective motivation of families to donate, a loss of approximately 90% of more than 20,000 potential donors. In a very short time an ensuing oversupply of organs offered for auction could lead to plummeting prices and even to the fortuitous consequence of essentially altruistic donation now so passionately advocated. The major portion of any price paid would by established formula go to the donor's family. Other substantial allocations would cover, wholly or in part, medical fees and cost of hospitalization and materials; would finance research; and would establish a special auction fund to bid on behalf of poor or indigent patients.

Other less obvious advantages are noteworthy. Private funding through auction would help ease the financial and litigious burdens of organized health care plans and would eliminate the need for demeaning solicitation (or begging) for funds to aid uninsured families. More surgeons would work more often to hone their skills, improve their results, and earn higher incomes in the process. There would be no extra cost to taxpayers; and otherwise idle money would filter through and help stimulate the economy. All this can be accomplished with the potentially huge amount of money accrued through consistently highest possible prices for multiple organs in a now greatly expanded (if not maximal) pool of donors.

Other than the wounded psyche of certain dogmatic critics, who of course moralize with a good conscience while thousands die, where's the disadvantage? Invariably "sanctity" of the human body is invoked. But transplantation is a medical procedure having no real or justifiable connection with the theological concept of sanctity. Ask the parents of an infant with an implanted baboon's heart if they feel that their infant's body

has been desecrated. Ask an adult with a purchased implanted kidney if he or she is or feels less "sacred." Will a transplanted pig's heart blaspheme a human adult who bought it? The real immorality is to nurture and sacrifice innocent pigs for their organs (which certainly will not be free) while callously letting available human organs rot because to commercialize them would be a "sin." Furthermore, the myth of sanctity is enforced immorally through law to prohibit a healthy adult, with fully informed consent, to sell a kidney to save another life, or to sell a portion of liver to save a child. It is ethical today for a parent to donate a piece of liver to the child; but if there were no parents or relative to donate, moralizing critics would preserve "sanctity" and doom the child by prohibiting the sale of the life-saving fragment by a stranger.

One should not forget that blood, too, is an organ; and transfusions

are life-saving transplants bought for many years from countless sellers without an iota concern about sanctity. Even gametes have been commoditized: human sperm samples average $50.00 each; and recently human ova have sold for as much as $35,000 each, and are being offered

for $50,000 each!6

Many critics contend that an auction market would be unfair to the poor. As already mentioned, a considerable amount of money raised through auction would be used to bid for the poor. If that's not enough to quell concern, then here is a fool-proof solution: a successful bidder would receive the life-saving organ only by agreeing to buy another organ, any vital organ, through the auction market for a poor recipient high on the waiting list. If, for example, the successful bidder in need of a heart were wealthy enough, he or she might pay perhaps half a million dollars to guarantee having the heart, and in turn bid and pay perhaps thirty thousand dollars for a kidney to be given to a poor patient. If prices fall because of an oversupply of organs offered for sale, the heart may be procured for $10,000 by a bidder of only modest means who then could perhaps secure the requisite kidney for an indigent patient for less than $2,000. I am sure that no successful bidder with life at stake would balk or even flinch at this relatively tolerable added cost of such compulsory beneficence.

Potential donors are numerous. As pointed out above, only about one of every 10 families of brain-dead patients (whose hearts are still beating) opts for donation of all vital organs. Furthermore, out of desperation to meet the critical shortage of organs, criteria of donation recently were revised to enable procurement from fresh cadavers. This substantially expands the availability of at least kidneys and livers from hospitalized patients whose hearts have stopped beating (so-called NHBD or non-heart beating donors).7

An auction plan for organs can be well organized, well controlled,

and smoothly operational. The dire warnings of perpetually alarmist critics paralyzed by the "slippery-slope" bugaboo merely project their own strictly philosophical bias. Did the nation and the world slide down that slope through decades of paying for blood to transfuse? This pet platitude is anathema to rational solutions. Dr. Samuel Johnson (1709-84) said it well:

"Nothing will ever be attempted if all possible objections must first be overcome."8 The lives of over 60,000 Americans now waiting for organs and the six to twelve who die every day demand an attempt to auction them, no matter what the objections.

An auction market probably can function best if it is free of absolute governmental, political, academic, sectarian, or plutocratic control. It is best left to the common sense of honest and ordinary citizens aided by the organizational and operational guidance and counsel of medical and social economists with impeccable integrity, competence, and experience--such as, in my opinion, Lestor Thurow of the Massachusetts Institute of Technology and Uwe Rheinhardt of Princeton University. In addition the input of experts in commodity and stock markets would be helpful if not indispensable.

So-called implied consent laws, which have been debated in the U.S. and enacted in Europe are intentionally deceptive and ipso facto unethical; they in effect sanction the theft of organs. Coercive required request laws infringe the autonomy of medical personnel by compelling them to query grieving family members about donating; and this immoral measure has failed despite intensive solicitation. So, too, has pure altruism failed. Sacrificial pigs from sanitized sties are not yet available. Their organs will be costly, and it will be unethical to use them while ignoring the ample supply of human organs that, if given a chance, could cost less. The mass production of industrially and biologically fabricated organs through technology and tissue culture is not yet in sight. Without a doubt such fabricated organs will not be donated altruistically and will cost more than any surgeon's fee.

The overwhelming demand for organs calls for the proper inducement of donation to maximize their supply. The current organ procurement system is creaking badly. It needs the only proper inducement, the "grease" of money--and plenty of it--despite all the sophistry about laws, morals, and sanctity. After all, as was well stated two millennia ago "Necessity knows no law except to prevail."9

For the sake of humanity, heed necessity--let the bidding begin . . .

Solve the Organ Shortage: Let the Bidding Begin

6/17/00



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