My last article gave a cursory overview of some of my thoughts on organ scarcity. It didn't, however, address specifically how a solution to that problem could work or why any of a plethora of proposed organ allocation schemes would function most effectively. I believe there is one way to best deal with the high demand for organs and relatively short supply. And it stands up beautifully to the barrage of criticisms thrown at it.
I am convinced that the best way to approach organ allocation is simply to allow a free market in human organs. I want to convince you, too.
I must tell you that proponents of an organ market have been making their case for years; some of these basic arguments are not my own but part of a discourse on the subject. If you are interested in reading about practical considerations and ethics in organs markets, I have listed some intriguing resources at the end of this article.
Now, for the objections.
- Some organs – such as kidneys – can be removed and sold while the donor is still alive, but who would want to sell organs which kill the donor when removed?
This is usually the first objection raised after anyone broaches the subject of making organs into commodities. You cannot benefit from the sale of your organs if you are not alive. This problem is best addressed by allowing a futures market in organs. In a futures market, individuals could sell the right to harvest their organs after they die. Benefits would become part of the individual's estate, and would be paid to their next of kin. Alternatively, sellers could be paid a small amount of money during their lifetime for the rights to harvest their organs; the sum paid out would reflect the probability of the seller dying in a manner suitable for organ harvesting.
The organ seller would enter into a contract with a firm – it could be a lifetime contract or an annual one. This is an interesting essay which details how the author envisions practical futures markets in organs.
Of course, organs like kidneys and lobes of the liver can be removed without killing the donor. These types of organs could still be sold in a futures market. They would probably be more commonly sold in the manner of most other goods. Sellers would have a choice between making a large, immediate profit from the sale of non-vital organs or selling vital organs on a futures market.
- An organ market would encourage organ thieves. It also encourages the killing of comatose and brain dead patients to harvest their organs and make a profit.
Everyone has heard the urban legend about the guy who goes to a bar, has a few too many drinks, and wakes up the next day in a bathtub full of ice with one of his kidneys missing. It's just that – an urban legend.
Practical considerations prevent organ theft from becoming a real threat. Any organ transaction requires that several immunological factors, such as blood type, match between the donor and the recipient. The possibility of finding a match for a specific recipient in a random victim of organ theft is practically zero. It would not be profitable for organ thieves to randomly attack victims; nor would it be feasible for them to search and target a specific match for the recipient.
Additionally, organs must be harvested surgically and handled in a very specific manner in order to be viable for transplant. Organ thieves would have to hire a qualified surgeon to do the job. Many qualified surgeons make so much money that they have no incentive to get involved with shady organ thieves. The potential costs of being caught would be immense enough to deter participation in organ thievery even for those surgeons in training or in financial trouble.
Another factor that makes organ stealing implausible is physical distance between the donor and the recipient. A live victim would have to be sedated and transported to a location near the recipient before he knew he was being robbed of an organ. If the victim was murdered in another location, his organs probably would not be viable once they reached the recipient anyway. However, a significant market in the development of new technology instrumental to the preservation and transport of organs exists. Companies such as Organ Recovery Systems are making it possible to harvest and transport organs from donors whose hearts have stopped beating. (Thanks to Dr. Ron Klatz for drawing my attention to this technology.)
Some people also worry that doctors will encourage their families to "pull the plug" if they end up on life support and their organs are viable. For many people this is a very real concern. But an organ market would increase the supply of organs so much that it would lessen the impetus for doctors to pressure families of brain dead or comatose patients. A patient truly concerned about this should make it clear to his family that he does not wish to be an organ donor, or that he does not want to be an organ donor unless he is already completely dead – i.e. his heart has stopped of its own accord. Anyone who wishes to be an organ donor can stipulate to his family which specific organs he wants to donate, and to whom he wants them to go.
Remember that organ donation is completely voluntary, as would be organ sale.
Some people complain that under the current system, doctors and transplant surgeons pressure families to remove their loved ones from life support in order to profit from harvesting their organs. If the family were allowed to reap some of this profit, money from organ sales could even help to offset the enormous hospital costs associated with keeping a loved one on life support. I refuse to believe that any family would decide to remove a loved one from life support just to make money from the sale of his organs.
- An organ market would supply poor quality organs – those who would be most likely to sell their organs have organs that are of the worst quality.
This is not true, but even if it were: aren't organs of poor quality preferable to no organs at all? Right now, the supply of organs is so short that nobody has a choice about which organs they receive. A market in organs would increase the supply so much that recipients would probably be able to choose among several matching organs.
Legitimate organ brokerage firms would emerge. They, or insurance companies, would do diagnostic testing to ensure donor-recipient match. They would screen potential donors for diseases and probably establish a rating system for the quality of donor organs. The organ's price would take into account several factors: organ type, organ quality, current supply and demand, surgical costs, transportation costs, diagnostic testing costs, and a finder's fee. I'm sure that broker firms would have an incentive to screen donors carefully – imagine the lawsuits which would result if a recipient contracted a disease from a donated organ. Over time, these firms would build reputations for safety and quality. Consumers could choose among them just as we choose among competing companies for any other product.
- An organ market exploits the poor. They do not get paid enough for their organs. They will sell their organs for drugs.
Although poor people would probably be the most likely to sell their organs, an organ market would not be exploitative – in fact, it would help poor people by increasing the amount of options they have for money making.
Realistically, the most common organ transaction would probably be that of kidneys. According to UNOS, there are more people currently waiting for kidneys than any other type of organ. A kidney can be harvested without killing the donor, and the donor can lead a relatively normal life with just one kidney after the transaction.
I won't claim that recovering from having a kidney removed is easy or fun. I don't want to downplay the fact that the donor's quality of life will probably suffer. However, allowing the sale of organs affords people a choice that they don't have under the current system.
We make economic choices every day – if I buy a cup of tea at Starbucks, I have shown that I prefer having a cup of tea to having a few bucks in my pocket. If I sell my kidney for $20,000, I have shown that I prefer $20,000 in my bank account to a kidney in my gut.
People choose whether or not to sell their organs. Choice represents economic power. The option to sell organs is one opportunity for poor people to lift themselves out of poverty. Nobody can force a person to sell his organs. But if he makes an informed decision to sell, more power to him.
If a person sells an organ in exchange for drug money – well, that's also his choice. My guess is that one of two things will happen if drug addicts decide to start selling their organs: either the addict will run out of non-vital organs to sell, or the addict will not be able to market his or her organs because they will be distressed from drug use and possibly infected with diseases. Of course, the reason drugs are so dangerous and expensive is precisely because of the "War on Drugs." That, however, is another subject for another column.
- Selling organs is dangerous, even for those organs which can be removed without killing the donor.
Isn't it more dangerous to have black market organ transactions?
Black market organ removals must be done in secret. Often this means they take place under poor or dangerous conditions. Sellers of organs on the black market take enormous risks because they essentially have no legal recourse if they don't get paid, or if they suffer complications from the surgery. Sellers may not be able to afford treatment for those complications, which could result in death. A legitimate market in organs would allow donors to choose a firm to broker their organ transactions, and to enter a contract where the specifics of the transaction were clearly delineated. Violating the contract would warrant legal action. Competing organ brokerage firms would have an incentive to gain a reputation for being the safest, the cleanest, and the highest paying (for the donor) or the most economical (for the recipient).
- An organ market is unfair. Only the wealthiest people could afford to buy organs.
Wealthy people on the UNOS waiting list already do buy organs on the black market. They also get preferential treatment if they are "important" enough. The current "fair" system is actually massively unfair.
If the market were legitimized the price of organs would plummet. Many more people would be able to afford them, because the supply would increase. Besides, having an organ market would in no way prevent people from donating their organs for free either in death or while they are still alive.
Regardless of a patient's financial status, a condition which requires having an organ transplant is bound to incur huge costs. The financial cost of staying in the hospital or getting treatment (such as dialysis) while waiting for an organ may surpass the price of buying an organ on a legitimate market. Consider, too, the opportunity costs of losing wages, missing time with family and friends, and enduring years of poor quality of living.
- Isn't it more ethical to use xenografting? What about other techniques?
No, xenografting is not more ethical. A market in organs facilitates voluntary exchange between the donor and recipient; the donor consents to sell his or her organs. Animals cannot give consent. And as far as we can tell, they do not experience altruism. An animal would not receive any benefit from having its organs involuntarily removed. We can reasonably assume that no animal would consent to having its organs removed, were it even able to give consent. Therefore, xenografting is not ethical.
It also poses additional problems. First, having a xenotransplant probably would be less cost-effective than buying an organ on a free organ market, at least with the present technology. There are also concerns about viruses which naturally occur in some species intermingling with human ones. Some scientists believe that this could potentially create a new pathogen which might be very dangerous. And perhaps the most significant problem with xenotransplantation is the issue of rejection by the recipient's body. Some companies are working to develop technologies that address these issues.
As far as other methods, a cost-efficient way of cloning single organs or body parts or a way of synthesizing organs would be an ideal solution to this problem, provided the parts were made available on an unfettered market. I don't doubt that these things may one day be possible with the continuing incentives for innovation that capitalism provides. However they are not available right now, so they can't be considered as a practical solution to the organ shortage at this point in time. (An interesting footnote: synthetic blood is already emerging as a possible solution to the ever-prevalent blood shortage.)
- Some religions prohibit organ donation as body mutilation.
Organ donation is voluntary. Organ sale would be voluntary, if it were legal. You decide what do with your body. On the same token we should all respect other people's wishes to do as they please with their own bodies. Ultimately, a market in organs boils down to one key concept: autonomy.
In 1999, someone attempted to sell a "fully functional human kidney" on eBay. Some debated whether or not the auction was a hoax. But bids apparently rose to $5.7 million before eBay decided to shut down the auction. Jeffrey Tucker tells me that the Mises Institute had to put out this notice. Why? A Mises daily article which extolled the virtues of a human organ market prompted numerous emails and phone calls from people asking to buy or sell organs.
These situations merely demonstrate the high demand for organs.
It's time to start thinking seriously about letting the market do what it does best – allocate scarce resources efficiently – with human organs.
January 3, 2005