symposium

0 Comments | Insight on the News, May 7, 2001 | by Robert J. Cihak, | Michael A. Glueck, | James F. Childress

Q: Should Congress allow the buying and selling of human organs?

Yes: Let the free market multiply the number of critically needed transplant organs.

"Kidney desperately needed. Will pay market rate." Can we expect this as a routine classified ad of the future? Will entire Websites be dedicated to such transactions? While many of us find the idea of buying and selling human organs a little creepy at best, it is one potential solution to the critical shortage of transplant organs in the United States. And, there are many other possible incentives in addition to cash.

We have one liver, heart and pancreas, yet most of us are born with two kidneys. We only requite one kidney to live a normal life. Therefore, in the United States, with a population of 280 million persons, there should be enough extra kidneys to go around.

More than 1,000 Americans die of kidney failure every year while waiting for a kidney transplant. Under the current system, only about 12,000 kidneys will be available this year. But as of March 10, there were 48,200 people who needed kidney transplants registered on waiting lists, more than twice as many as in 1992. That's almost four times as many people as available kidneys for the year.

The median waiting time before transplant increased significantly from 1990 to 1997 -- from 427 days to 1,196 days for females, more than an 18-month increase; and from 353 days to 1,033 days for males, a 22-month increase.

Probably because of these increasing delays in receiving a transplanted kidney, the death rate of people on the waking lists has increased from 63 patients out of 1,000 in 1990 to 79 in 1999. Ironically, better technology has increased the death rate of those waiting for a kidney.

More patients are eligible for transplantation because of improvements in management of medical problems for patients with failing organs and better prevention of organ rejection. Surgical procedures for both donors and recipients have become simpler and safer than when the first operations were performed in the 1960s.

Life expectancy for voluntary donors is not lessened, and health problems don't increase. Only one out of 50 life-insurance companies surveyed charges higher life-insurance premiums if you're a kidney donor.

According to the current United Network for Organ Sharing (UNOS) report, kidneys from living donors have about half the failure rate of kidneys from dead donors. Only a few percent of kidneys from living donors failed to survive the first year after transplant, compared with a 10.6 percent failure rate for kidneys from dead donors. The one-year survival rate for patients who received a kidney from a living donor was 98 percent. After five years, 21.6 percent of kidney transplants from living donors had failed, compared with a 35.3 percent failure rate for kidneys from dead donors. Of the 12,488 kidney-only transplant patients treated in 1999, a total of 4,457 kidneys (36 percent) were from living donors.

Kidney failure can be managed for a limited time with dialysis, a time-consuming procedure often requiring hours of treatment every other day. But dialysis is second-best to kidney transplantation.

As well as being more satisfactory medically, kidney transplantation also is financially more effective. UNOS is the private, nonprofit agency that maintains the nation's organ-transplant waiting lists under contract to the U.S. Department of Health and Human Services (HHS). According to its 1994 report, "the government's cost of dialysis averages $40,000 annually, and its cost for a kidney transplant averages $87,000 during the first year. Costs during each year thereafter total about $12,000." In other words, over time, successful kidney transplants cost less than dialysis.

So what's the problem? Well-intentioned government intervention may have done more harm than good. HHS Secretary Tommy Thompson, who recognizes the problem, recently announced that he will launch new national efforts to encourage organ donation as one of his first initiatives. Unfortunately, not even the most ardent government-inspired voluntarism can meet the need.

The National Organ Transplant Act of 1984 (42 U.S.C. [sections] 274e) bans privately acquiring, receiving or transferring kidneys and other organs in the United States under penalty of as much as $50,000 in fines and five years in prison. This virtually ensures a shortage of kidneys, as well as other organs.

The current system requires willing American buyers to travel overseas to acquire a kidney. According to news stories, about 400 people per year purchased a kidney in India in the early 1990s before the Indian government outlawed the practice. We don't know how many Americans might have taken this route, if any. If any Americans did buy kidneys overseas, they freed up a place on the waiting list for another patient who stayed in the United States.

The lawmakers and regulators who created the current system apparently believe that a mandated system both works better and is more ethical than allowing choice for individual patients and potential donors. But just look at the current Medicare system to see a government monopoly at work.