A Cost-Benefit Analysis of Government Compensation of Kidney Donors

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http://onlinelibrary.wiley.com/doi/10.1111/ajt.13490/full

Original Article
A Cost-Benefit Analysis of Government Compensation of Kidney Donors
      P. J. Held, F. McCormick, A. Ojo^, and J. P. Roberts
DOI: 10.1111/ajt.13490
American Journal of Transplantation
Early View (Online Version of Record published before inclusion in an issue)

Abstract
From 5000 to 10 000 kidney patients die prematurely in the United States each year, and about 100 000 more suffer the debilitating effects of dialysis, because of a shortage of transplant kidneys. To reduce this shortage, many advocate having the government compensate kidney donors. This paper presents a comprehensive cost-benefit analysis of such a change. It considers not only the substantial savings to society because kidney recipients would no longer need expensive dialysis treatments—$1.45 million per kidney recipient—but also estimates the monetary value of the longer and healthier lives that kidney recipients enjoy—about $1.3 million per recipient. These numbers dwarf the proposed $45 000-per-kidney compensation that might be needed to end the kidney shortage and eliminate the kidney transplant waiting list. From the viewpoint of society, the net benefit from saving thousands of lives each year and reducing the suffering of 100 000 more receiving dialysis would be about $46 billion per year, with the benefits exceeding the costs by a factor of 3. In addition, it would save taxpayers about $12 billion each year.

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https://www.washingtonpost.com/news/in-theory/wp/2015/12/28/compensation-for-organ-donors-a-primer/

In Theory Opinion
Compensation for organ donors: A primer
By Robert Gebelhoff

The number of people who are in need of new kidneys in the United States is growing, but so is the waiting list for new organs. About 7 percent of the entire Medicare budget is spent on dialysis treatments for people with end-of-life kidney disease. The issue has become such a burden  that some are calling for the government to take a new approach: paying for people to donate their kidneys.
Last month, a group of researchers published in the American Journal of Transplantation a cost-benefit analysis for a government-funded program that would offer $45,000 to living kidney donors. They calculated that such an approach would not only fulfill the entire waiting list, but save a whopping $46 billion a year — an amount that has attracted the attention of a handful of economists.
There’s one problem: Paying for human organs is illegal almost everywhere in the world. The U.S. strictly banned payments for organs in 1984 under the the National Organ Transplant Act. The medical industry has long referred to compensation for organs as taboo, as evidenced by the uproar following claims that Planned Parenthood has been selling body parts of aborted fetuses.
Some opponents take issue with the “commodification of the human body”: In 2002, a group of doctors even compared compensating donors to prostitution. Others raise more practical concerns, arguing that compensation would end up exploiting poor people or that it would may lead to a system in which donors are not fully aware of or pushed to disregard the risks involved.
Advocates for a change in U.S. policy, however, argue that thousands of people put on waiting lists for new kidneys don’t get considered — which ultimately translates to their drawn-out, painful and expensive deaths. There are many cases of altruistic donations, but they barely make a dent in the 100,000 people currently on transplant waiting lists. As a result, up to 10,000 people die prematurely each year in the U.S.
The proponents for change also say that a ban on selling organs helped to create the global black market for organs, mostly in the developing world. The literature on this topic is terrifying: stories of political dissidents killed to have their organs harvested or impoverished citizens tricked into dangerous operations. Some advocates say that a government-regulated system of compensation could help end organ theft.
The discussion is bound to become more important in the future, especially as risk factors for kidney failure — such as high blood pressure and adult onset diabetes — continue to rise in the U.S.
This opens a debate: Should we shift the ethics of our healthcare system to improve the lives of people experiencing kidney failure? Or do we wait, and hope that science offers an alternative solution?
Over the next few days, we’ll hear from:
Sally Satel, resident scholar at the American Enterprise Institute and practicing psychiatrist at the Yale University School of Medicine,
Francis Delmonico, Harvard Medical School professor of surgery at the Massachusetts General Hospital, and Alexander Capron, professor of law and medicine at the University of Southern California,
Scott Sumner, economist at Bentley University and blogger at The Money Illusion,
Benjamin Humphreys, nephrologist and chief of the division of nephrology at Washington University in St. Louis,
Josh Morrison, kidney donor and the executive director of WaitList Zero,
Scott Carney, senior fellow at the Schuster Institute for Investigative Journalism,
Nancy Scheper-Hughes, founder of Organ Watch and anthropology professor at University of California, Berkeley.

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https://www.washingtonpost.com/news/in-theory/wp/2015/12/28/generosity-wont-fix-our-shortage-of-organs-for-transplants/

Generosity won’t fix our shortage of organs for transplants

By Sally Satel

My interest in the national organ shortage began one steamy afternoon in August 2004. That day, my doctor told me my kidneys were failing. As a physician myself, I knew immediately that I would need to find a replacement organ or else face a shortened life tethered to a dialysis machine. My search was rocky at first, but finally I did get a kidney from a casual friend — now a very dear one.
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https://www.washingtonpost.com/news/in-theory/wp/2015/12/29/our-body-parts-shouldnt-be-for-sale/

Our body parts shouldn’t be for sale

By Francis Delmonico and Alexander Capron

Organ transplants have extended and improved the lives of more than a million patients over the past 60 years. This is a testament to the dedication and creativity of medical professionals as well as to the generosity of both living and deceased organ donors.
Nonetheless, the rising rate of kidney disease means that some patients won’t get the transplant they’re waiting for. That shortage of organs has led to proposals to lift the prohibition on payment that has been part of U.S. organ donation law since 1984. But buying organs would be wrong. And aside from being wrong, it would also harm existing, voluntary donation programs and be ineffective in increasing the supply of organs. There are better ways to increase the number of organs donated than paying for donations.
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https://www.washingtonpost.com/news/in-theory/wp/2015/12/30/the-moral-case-for-paying-kidney-donors/

The moral case for paying kidney donors

By Scott Sumner

A recent study in the American Journal of Transplantation just reached what to many people may be a shocking conclusion: Taxpayers would be able to save thousands of lives and about $12 billion per year if the government started compensating people for kidney donations. According to the study, “these numbers dwarf the proposed $45,000-per-kidney compensation that might be needed to end the kidney shortage and eliminate the kidney transplant waiting list.” For economists who have long advocated for the creation of a market of organ transplants, this news is not surprising.
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https://www.washingtonpost.com/news/in-theory/wp/2015/12/31/will-lab-grown-kidneys-fix-our-transplant-waiting-lists/

Will lab-grown kidneys fix our transplant waiting lists?

By Benjamin Humphreys

Kidney failure is a growing problem in the United States, with more than 100,000 new cases per year. There are not enough kidneys available to transplant all of these patients, so the majority are treated with dialysis. The therapy is certainly life-saving but is also costly, inconvenient for patients and itself causes accelerated heart disease. The risk of death for an average dialysis patient is 20 percent per year.
Dialysis patients make up about one percent of the Medicare population, but paying for dialysis costs seven percent of the entire Medicare budget. Clearly there is a strong need for innovative new therapies and approaches to the problem. We already have some new ideas being developed — at-home and portable dialysis, for example. Yet simply improving the existing technology is an evolutionary change, one that falls well short of what is actually needed: a new kidney that frees patients from devices entirely.
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https://www.washingtonpost.com/news/in-theory/wp/2016/01/01/its-time-to-treat-organ-donors-with-the-respect-they-deserve/

It’s time to treat organ donors with the respect they deserve

By Josh Morrison

Each year in America, 35,000 people are added to the kidney transplant waiting list — 20,000 more than the number of people who actually receive one. There are more Americans who fail to receive a lifesaving transplant than there are homicides committed in the United States annually, yet there is more news coverage of gun violence in one day than there is of transplants in an entire year.
The media attention that kidney transplant does attract often revolves around a tired debate about incentives framed by two unacceptable responses: Should we treat people like human vending machines and purchase their organs with cash? Or should we do nothing, repeat the words “pure altruism,” and let thousands of people continue to die each year?
There’s a better way: a path of transplant support that treats organ donation like a public service and honors donors like public servants. That means giving donors lifetime health insurance to offset the risks of donation; providing them with annual research stipends to enable long-term follow-up; and paying for lost wages, travel and childcare expenses when they take time off to donate. It means making sure all patients and their families receive specialized education about transplants.
The goal of transplant support is to make kidney transplants easy to ask for and easy to give. Right now, asking for a transplant is hard. As many as 80,000 patients who are eligible for a transplant are not even listed. Seventy-five percent of kidney recipients feel inadequately educated about live donation. Imagine asking a friend to borrow money; now imagine asking for an organ. It’s not an easy conversation, which is why education and ensuring donor health is so important.
The risks of donation are manageable but real, and while scientific understanding continues to improve, it is still imperfect. Kidney donors accept these risks individually. But because their sacrifices aid us all, they deserve the best health care possible. They deserve lifetime health insurance and lifetime follow-up. Yet they currently receive no health-care guarantee — just two years of required follow-up by transplant centers, and no coverage for lost wages, travel and childcare expenses.
Some say that kidney donation needs to be a “pure gift,” meaning donors should not receive different treatment for having donated. But by and large, these people have never given or received an organ. Treating donation as an isolated act of individual generosity imposes an enormous burden on recipients, who may unjustly feel guilty that they can never repay their donors’ generosity.
Donors are proud to have been able to save the lives, and studies show that more than 19 out of 20 are satisfied with their decision. Donation is an act of public service that society should support and honor with tangible commitments, and donors merit the same level of respect given to police officers, firefighters, soldiers and teachers. But so far our society has displayed a thankless response in the face of those who give of themselves to save another’s life. Donors deserve better treatment than they have so far received.
So why has such a crucial issue been given such short shrift? It’s not because the problem has been solved: 2014 saw the lowest number of living kidney donors — 5,537 — since 2000, when 50,000 patients were on the waiting list. Today, more than 100,000 are waiting, and the list grows each year.
Transplant rates have stagnated, leaving more and more patients to perish on dialysis. It’s not because the cost is prohibitive: a transplant saves Medicare hundreds of thousands of dollars per patient and saves private insurers even more. Ending the kidney shortage would save health-care providers approximately $6 billion per year. And it’s not because the organ transplant shortage is a problem without a solution. There are solutions; we’re just not implementing them.
If 1 in 10,000 Americans donated a kidney each year, there would be no transplant shortage. Supporting donation — making it better for the donor and easier for the recipient — will dramatically expand access to lifesaving organs. Right now, America is not providing that support.

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https://www.washingtonpost.com/news/in-theory/wp/2016/01/04/if-youre-willing-to-buy-a-kidney-youre-willing-to-exploit-the-poor/

If you’re willing to buy a kidney, you’re willing to exploit the poor

By Scott Carney

What would happen if the United States legalized the sale of human organs? Economists will note the seductive market logic: With regulation, proponents of legalization suggest the organ shortage will disappear, the market will arrive at a fair price for human tissue and new laws will regulate away criminal elements.
For argument’s sake, let’s assume that the United States would be able to create its own equitable system. What would happen in the rest of the world? Whether we like it or not, we live in the era of globalization, and if the U.S. legalizes the market for body parts, there is no reason to think that international economies won’t play a role in how a patient decides to procure transplant organs.
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https://www.washingtonpost.com/news/in-theory/wp/2016/01/05/the-market-for-human-organs-is-destroying-lives/

The market for human organs is destroying lives

By Nancy Scheper-Hughes

If you would be willing to ask a living person to sell his or her kidney to you, be aware that you enter a moral, social, ethical and political gray zone. While it may mean that you wouldn’t have to resort to organ waiting lists and dialysis treatment in the event of kidney failure, you’d be putting the seller and yourself at risk.

Be aware that the sale of organs has damaged the families of sellers and their communities — in Syria, India, Sri Lanka, Kazakhstan, Moldova, Ukraine, Brazil, Egypt, the Philippines, Turkey and wherever political refugees wash up on the shores of Europe. A kidney for an (un)safe passage to freedom: This is the unbalanced agreement demanded of many families fleeing political conflict and drought. In the watery slums of Manila, the obligation to sell a kidney for the financial sake of the family is being passed down from the father to his wife to their underage sons and daughters, whose bodies are seen as a family piggy-bank.

Despite what you may have heard from some advocates of compensation for kidneys, the kidney is not a “spare” organ. If you were able to talk to kidney sellers across the world as I have, you would find that even years after the operation, sellers suffer from the operation’s negative effects on their bodies, minds and lives.

Medical journals do not report on the invisible and long-term medical, psychological and social consequences of selling a kidney: chronic pain, depression and suicide, self-hatred, distorted body image (“half-man syndrome”), a sense of bodily emptiness and evacuation (the body without organs), anger, regret, isolation — and even physical abuse, battering and forced exile from their native communities.

Economically, kidney sellers are worse off a year after selling their kidney. Because most sellers are poorly educated, unskilled laborers who rely on the strength of their bodies, many are excluded from their previous work that required them to lift heavy objects, to leap and jump, to be unconcerned about the effects of ordinarily rigorous work on their bodies. In Bangladesh and Pakistan, kidney sellers refer to the kidney removal as “the day of my death,” a reference to their economic, psychological and social decline.

Underground markets run by organ brokers and kidney hunters exploit the desperation of both buyers and sellers. Even regulated systems, such as the ones established by the Ministries of Health in the Philippines and in Iran, rely on independent “match makers” and intermediaries. The result is the collaboration of surgeons and hospitals with local “kidney hunters” who are unregulated and ply their trade based on deceit and exploitation. Hospitals and transplant teams cannot be left with the responsibility of monitoring the paid donation of living people’s organs.

Even governments that have attempted to regulate kidney selling have proposed exploitative means — granting visas to undocumented day-laborers and promising work to economic and political refugees in exchange for kidneys. Last month, Turkish authorities arrested a suspected international kidney broker, Boris Wolfman, who was allegedly recruiting desperate Syrians from refugee camps and detention to sell a kidney in exchange for legal protection.

In the United States, mandated independent advocates for living donors, who represent the needs and motives of every living kidney donor, have failed to identify cases in which force, coercion and fraud have motivated individuals to forfeit an organ. Such was the case of the infiltration of U.S. hospitals and transplant units by an international kidney brokering scheme that trafficked poor kidney sellers from Israel (most of them new immigrants) to provide kidneys to foreign transplant tourists and American citizens. The head of the scheme was finally caught in a police sting and pleaded guilty in federal court in Trenton, N.J.

Imagine the difficulties and complexities of developing far more rigorous and complex regulations on the selling of body parts. Who would oversee the system? Transplant surgeons? Nonprofit groups? Medicare? Or would independent donor advocates be burdened with uncovering the true motives or hidden coercion behind U.S. transplants?

In the final analysis, money for kidneys is not the issue; it’s the irresponsibility and hostility toward kidney sellers. So, if you are willing and able to pay someone for an organ to save your life, it is best that you choose someone you know — perhaps even someone you love. You should be able to watch out for the seller over the long term, especially in the case that this person’s health fails. You can’t put a price on life, but you can exchange money with a promise of mutual trust and care.