Economists' study says paying for organs would cut wait lists

Kidney and liver sales would add 10% to 15% to the cost of transplants, a study says. Others say organ markets would exploit poor donors.

By Kevin B. O’Reilly — Posted Jan. 28, 2008

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Nearly 100,000 Americans are waiting for an organ transplant. Every day, the wait for 17 of those people ends in death.

It is a wait that could be drastically shortened or even eliminated if a market for live and cadaveric organs were allowed to operate, according to a paper co-authored by Nobel Prize-winning economist Gary S. Becker, PhD, and published last year in the Journal of Economic Perspectives.

The study comes on the heels of what observers say is slow but steady progress in breaking down opposition to testing the idea of financial incentives in an effort to combat an organ shortage growing by 5% each year. But resistance among many in the transplant community is still fierce, as other efforts such as paired donation exchanges begin to take off.

Dr. Becker and co-author Julio Jorge Elias, PhD, estimate that a $15,000 payment for kidneys would increase the number of transplants by 44%, to about 20,000 a year. It would take nearly $40,000 in cash to donors to net a two-thirds jump in the number of liver transplants, to more than 8,600 a year.

In the case of kidney transplants, the donor payment would add just 9.5% to the cost of a transplant, while liver transplants would cost 11.2% more.

The authors based their estimates on how much it would take to convince a person earning the median American salary of $35,000 to become a donor, considering the actuarial value of a statistical life, the small risk of death in surgery, the quality-of-life impact and the value of the time spent in recovery.

Dr. Becker said it is only a matter of time before policymakers warm up to the idea of increasing the supply of organs by offering cash to donors.

"The force pushing toward recognition of the potential of [financial incentives] is the different circumstances we're in now, where so many people are on the queue and quite a few will die waiting," Dr. Becker said. "There is an alternative that can eliminate those problems efficiently and not very expensively, and people will come around to the view that they'll see the great benefits versus the terrible burden imposed by the present system."

Frances L. Delmonico, MD, a transplant surgeon at Massachusetts General Hospital, said paying donors for organs would exploit the poor and send a terrible message to the global transplant community.

Paying for organs "may make business sense, but it cannot be the fabric of public policy," Dr. Delmonico said. He said the growing popularity of testing financial incentives is not reflected on Capitol Hill.

"I'd be pleased to see Gary Becker in Washington and fight [for organ markets] every step of the way," he said.

Alvin E. Roth, PhD, agreed that financial incentives face an uphill battle. Dr. Roth is an economist at Harvard who helped design the New England Program for Kidney Exchange to help facilitate paired-kidney donations.

The U.S. Dept. of Justice ruled last year that such exchanges do not violate the National Organ Transplant Act's ban on "valuable consideration" for organ donation. The law would have to be changed to allow a pilot test of financial incentives.

Dr. Roth said via e-mail that the idea of a market for organs strikes many people as "repugnant." He also said he does not "see any strong reason to believe that there is going to be a dramatic change soon, certainly not so strong as to abandon other approaches, which can be implemented now."

He said a well-constructed national kidney exchange that garnered wide transplant center participation, and included three-way exchanges and integrated nondirected donors, "could make a substantial contribution to closing the gap between the number of transplants we can do now, and the number of new transplant candidates each year."

Benjamin Hippen, MD, is a nephrologist specializing in renal transplantation at the Carolinas Medical Center in Charlotte, N.C. He supports paying organ donors -- or "vendors," as he calls them. He said support for testing the idea is growing in the transplant community, though the American Society of Transplant Surgeons opposes such a pilot.

An April conference co-sponsored by ASTS will focus on compensation to living donors and other ethical dilemmas in transplant ethics.

"We have been talking about this for about 20 years, and more than ever in the last two years," said Dr. Hippen, who chairs a United Network for Organ Sharing subcommittee considering financial incentives for organ procurement.

UNOS adopted policy in favor of studying the idea. American Medical Association policy calls for pilot-testing several methods for increasing organ donation, including presumed consent, mandated choice and financial incentives, but the latter for cadaveric donors only.

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