WASHINGTON, June 27 (UPI) -- Paying families to motivate them to donate a deceased loved one's organs for transplantation could help end the longstanding shortage of available donor organs, according to a new book published by a Washington think tank.
"A lot of people are dying as a direct result of a public policy that denies procurement payments to cadaveric organ donors and their families," said David Kaserman, an economist and co-author of the book, at a June 24 forum at the conservative American Enterprise Institute. "There are a sufficient number of potential donors to completely eliminate the shortage." AEI is the book's publisher.
But in the highly charged debate over whether "cadaveric" human transplant organs should be sold or not, critics of this approach contend that such a move would be ineffective and would push public health policy down a dangerous and slippery slope towards an uncontrolled marketplace for human organs -- even from living donors.
In their book, "The U.S. Organ Procurement System: A Prescription for Reform," Kaserman and co-author economist A.H. Barnet argue that by embracing free market principles and repealing federal law to allow for payments of around $1000 to families of the deceased with viable transplant organs, the "artificial" shortage of human transplant organs would end.
Kaserman is chairman of the department of economics at Auburn University in Auburn, Ala., and Barnett is chair of the department of economics, international studies and public administration at the American University of Sharjah in the United Arab Emirates.
Since the first kidney transplant from a live donor in 1954, the number of organ transplants performed each year has grown to 22,854 in 2000. But organ supplies have never equaled demand. The waiting list for organ transplants currently stands at around 80,000 people: 5,800 people died in 2000 while waiting for a donor organ match.
There is a growing realization that something needs to be done to better address this problem, even among traditional opponents of market-based solutions.
On June 19, the American Medical Association approved a plan that would allow for research into the use of payments as a way to encourage families to donate the organs of the deceased. Other potential incentives that have been discussed include paying the funeral expenses for the donor or giving tax credits to the families.
In addition, on June 27 the United Network for Organ Sharing -- the non-profit group that maintains the nation's organ transplant waiting list under contract with the U.S. Department of Health and Human Services -- is scheduled to examine whether it should support a lifting of the ban on organ sales by Congress, in order to allow demonstration projects to evaluate the impact of financial incentives.
According to Ronald Dworkin, a practicing anesthesiologist and a senior fellow at the conservative Hudson Institute, it is not unreasonable to believe that sales of human organs can work, given the success of payments for blood, plasma and female eggs for artificial insemination.
"I do not have a problem with this kind of payment for even living donors, at least not for kidneys," Dworkin. "Anything that will increase supply with reasonable market mechanisms, I don't have a problem with it."
Dworkin noted, however, that he does not support payment for liver donation, because the surgery for the donor carries too high a risk. (A living liver donor actually donates only a portion of his liver, because no one can survive without at least part of their liver.)
Kaserman and Barnet argue that the current system is a "failure" for not taking full advantage of the estimated 13,000 to 29,000 potential organ donors out of the 2 million deaths per year in the United States.
Kaserman has powerful first-hand knowledge of the problem: he has had two liver transplants, the last one 10 years ago.
There were 5,984 cadaveric organ donors in 2000 and Kaserman and Barnet believe that organ donations could easily double or triple to meet current demand without exhausting the potential supply. The two economists argue that by allowing market dynamics to drive the organ procurement system, prices would "rise and fall as necessary to equilibrate supply and demand and thereby eliminate the shortage."
In addition, they "conservatively estimate" that the creation of a market for cadaveric donor organs would yield social benefits -- relative to the current system -- of more than $1 billion a year because of the additional lives that would be saved.
Sharon Hunt, M.D., a Stanford University cardiologist and current chair of the American College of Cardiology committee on heart failure and transplantation, says the two economists are wrong about their estimates for potential donors, and about the effectiveness of their proposal.
"The biggest underlying flaw is when they state that the cadaveric organ shortage is not attributable to an inadequate number of potential organ donors," said Hunt. "I don't know where they got that number."
Hunt says that the pool of available donors is in fact on the decline. Transplants from living donors have actually surpassed the number of transplanted organs from cadaveric donors, and the overall number of cadaveric transplant organs has decreased, she says
Though more data is need on the subject, she says that this is probably the result of advances in medical care, along with laws -- such as those requiring the use of motorcycle or bicycle helmets -- that protect people against common accidents that lead to brain death. In addition, Hunt believes another component to the problem is that transplant procedures have become so successful that everyone who could conceivably receive a transplant is now applying for one, causing the number of potential transplant candidates to skyrocket.
"We will never have that many brain-dead people," she said. "It just will not happen. There will always be a disparity between supply and demand, and offering a thousand bucks is just piddle in terms of what it will contribute to the solving the problem. The solution is going to have to be some wholesale alternative, like xeno-transplantation." (Xeno-transplantation -- which has been tried experimentally with very limited success -- involves the transplantation of organs from animal donors such as baboons or pigs. )
Critics say there are many potential problems with allowing the sale of organs for transplantation, including the exploitation of the poor by turning them into living "organ farms" for the well-to-do. Other concerns center on the possibility that family members might prematurely end the medical care of seriously or terminally ill relatives in order to sell their organs.
Kaserman and Barnet, however, argue that that their proposal would not make a marketplace for human organs. "It is important not to confuse (the $1000 payments) with markets," said Kaserman. "This is not a market for organs. This is the current system, just adding another degree of freedom for the organ procurement entities."
Henry Aaron, a senior fellow in economic studies at the center-left Brookings Institution, said that although there could be benefits to instituting financial incentives to promote organ donation, he still has concerns.
"My reaction is that on balance you are going to get a large supply (with financial incentives) and that would probably be a good thing," said Aaron. "(But) I think it is important to make sure that one's access to organs is not conditioned on ability to pay. That would get ugly."
Tom Miller, director of health policy studies at the libertarian Cato Institute, says that while Kaserman and Barnet offer a good compromise plan that aims to capitalize on the benefits of free-markets, it does not go far enough.
"It is half of the job, but not he whole job," said Miller. "I suppose it is an improvement from the status quo, and certainly they identify a flaw in the system."
Miller notes that the current system provides compensation for pretty much everyone involved but the donors or their families.
But James B. Young, M.D., a cardiologist and medical director of the Kaufman Center for Heart Failure at the Cleveland Clinic Foundation, told UPI that although changes are needed to increase the incentive for the donation of cadaveric organs, Kaserman's and Barnett's plan is not the right answer.
"I am no entirely sure this is the right number or the right way to do it," said Young. "Essentially I think it would be better to give individuals indirect payments such as tax breaks or tax incentives, as opposed to flat payments."
Young added that in recent years his perspective on this has reversed because of the failure of other efforts, such as education, to increase donations over the last decade beyond 50 percent of potential candidates. "The bottom line is something needs to be done, and some sort of recompense is reasonable," he said.
Nevertheless, he said that allowing even the small step of some sort of financial remuneration opens door to the "intensely dangerous" possibility that economic enterprise will develop around donor organs, and the possibility that organs could be coerced for sale.
Despite Kaserman's protests that they are not advocating an open market for organs, the two economists spoke at the forum of the potential for for-profit organ procurement companies, and said they support moves beyond the initial step they proposed.
"My attitude is "Don't dictate what the market can and can't do ... let's let the market work," said Barnett. "I see no reason to limit what the market can do."
According to Hunt, this is a myopic solution that ignores the reality of the situation.
"This (policy proposal) looks like an economist's view," she said. "It is an interesting theory based upon a market focus. If these guys go into the real world of medicine, I think they would see that their nice theory would never work."
To understand the future of this debate, Dworkin says that one has to step beyond medical textbooks and read the ideas of 19th century French political writer Alexis de Tocqueville on the formation of public opinion. De Tocqueville said that public opinion relies upon one individual standing up and leading others, in order to change the prevailing social attitude.
"You already are seeing nibbling round the edges (of this idea), but people are nervous," said Dworkin, likening the issue of payment for transplant organs to another fractious public debate. "It is like drug legalization," he said. "Everyone is suspicious (of the drug war's effectiveness). Some think maybe we should be doing something about this, but the (the mainstream critics) are afraid to take the step."
