Controversy: Should Selling kidney’s be Legal?

There is a brisk international market for kidneys. As I travel around the Middle-East I have met many nephrologists who tell me that paying for a kidney is very common, especially for their more wealthy patient’s. They cited Pakistan and the Phillipines as examples of where a kidney is easily bought. In these countries this practice is illegal but continues to thrive. For example it is reported that in 2006, foreigners received two-thirds of the 2000 kidney transplants performed annually in Pakistan.

The cost of a kidney? Around $3000 with most of the money going to middle-men. In Iran where selling a kidney is regulated a healthy kidney sells for about $6,000. In China, organs are often procured from executed prisoners. Nicholas Bequelin, a researcher for Human Rights Watch, according to Wikipedia, estimates that 90 percent of organs from China are from deceased prisoners

It today’s New York Times Op-Ed, Alexander Berger makes the case for selling a kidney. Berger writes: “People should not have to beg their friends and family for a kidney, nor die while waiting for one. Donating a kidney is one way to help. But it isn’t enough. The only way to really change the terms of the debate and end the waiting lists is to end the ban on compensation and create a legal market for kidneys.”

Pakastani farmers who sold their kidneys (link)

According to an article in Time, the black-market kidney trade is a growing problem, with the World Health Organization estimating that organ-trafficking accounts for 5% to 10% of all kidney transplants worldwide.

Dr. Arthur Matas, renal-transplant director at the University of Minnesota's medical school argues in support of allowing a regulated market for kidney’s. Frank Delmonico from Harvard Medical School disagrees. He states in the Wall Street Journal in 2007. "Payments eventually result in the exploitation of the individual…it's the poor person who sells." But Matas argues that compensating kidney donors is no different from sanctioning sales of other body parts. "People get paid to be surrogate mothers. People get paid for sperm and hair.”

Regardless of either Matas’s or Delmonico’s view on this issue it is currently illegal in the United States to sell a kidney. The federal ban on organ sales dates back to 1983 when Virginia physician Dr. H. Barry Jacobs proposed buying kidneys -- mostly from the indigent -- and selling them to whomever could afford to buy. His plan was met with widespread outrage. In Congress, then-Rep. Al Gore (D., Tenn.) introduced legislation banning the sale of organs. The bill became law in 1984. The punishment is five years in prison and a $50,000 fine.

In a 2008 meeting Istanbul leaders from various societies and disciplines looked at the issue of Organ Trafficking and Transplant Tourism. They formulated a statement that they termed The Declaration of Istanbul: “The legacy of transplantation is threatened by organ trafficking and transplant tourism. The Declaration of Istanbul aims to combat these activities and to preserve the nobility of organ donation. The success of transplantation as a life-saving treatment does not require—nor justify—victimizing the world’s poor as the source of organs for the rich.”

However, the debate continues in part because the practice continues in an unregulated way in many developing countries. In part, the debate reflects the widening gap between the waiting list and available kidneys (Fig.1). When a patient eligible for a kidney transplant dies on the waiting list, the ethics become at once more complex.

A few months back Dundee University's Sue Rabbitt Roff wrote a controversial article (published in the BMJ) that stirred much debate in the media. She wrote that selling a kidney could be used to pay off debts. Dr. Calum MacKellar, director of research at the Scottish Council on Human Bioethics, told the Guardian newspaper in the UK, "To place a financial value on human beings or parts of human beings undermines the inherent dignity of the human person and the innate as well as immeasurable worth of all individuals."

Fig.1

In the NY Times Op-Ed piece from today Berger proposes that: “A well-regulated legal market for kidneys would…ensure that donors were compensated fairly — most experts say somewhere in the ballpark of $50,000 would make sense. Only the government or a chosen nonprofit would be allowed to purchase the kidneys, and they would allocate them on the basis of need rather than wealth, the same way that posthumously donated organs are currently distributed. The kidneys would be paid for by whoever covers the patient, whether that is their insurance company or Medicare. Ideally, so many donors would come forward that no patient would be left on the waiting list.”

Right now, Frank Delmonico’s view seems to hold sway on this issue. He told the US Congress House Energy and Commerce Committee: "The sale of bodies or body parts would undermine the fundamental values of our society."

However, the continued practice of commercial kidney transplantation around the world suggests that the practice is not going away and probably won't go away unless two things happen. First, more organs need to be available, and second countries become unwilling to turn a blind eye towards illegal transplant practices. 

The main thrust of the Declaration of Istanbul is that the rates of deceased donor transplantation need to increase. However, the progress has been very slow or non-existent. Deceased donor trasnplantation requires resources, community education and acceptance, and above all, developed countries helping poorer countries with creating and maintaining a program.  

The overarching advantage of a regulated market for kidneys is that it gets kidneys to the people who need them, often desperately, and it creates a safe, organized and fair market for those willing to donate.

So, I guess I am not sure what the right answer is; at any rate, the debate continues!