Doctors Weigh Ethical Question of Organ Sales Currently, United States law bans the sale of human organs. Yet some doctors believe that permitting the carefully regulated sale of kidneys could save lives and money. Critics counter that lifting the ban would open a black market for kidney sales and undermine fundamental human values.
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Doctors Weigh Ethical Question of Organ Sales

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NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan in Washington.

Two weeks ago, the Wall Street Journal reported on two transplant surgeons, longtime friends, who take opposite and very public sides on the contentious issue of kidney sales. Currently, U.S. law bans all sales of human organs, but thousands of patients die every year while they wait on the list for a kidney transplant.

Dr. Arthur Matas argues that the shortage of kidneys can be solved by a carefully regulated program to compensate donors. His friend and opponent, Dr. Francis Delmonico, believes that lifting the ban would create a black market in kidneys and undermine the fundamental values in our society.

Today, Drs. Matas and Delmonico join us to talk about buying and selling kidneys.

Later in the hour: Robin Givhan on the hypocrisy of plastic surgery. We worship beauty but ridicule those who pursue it.

First, though: human organs, economics and ethics. If you're waiting for a kidney or if you've had a transplant, we want to hear from you. Should the ban on organ sales be lifted? 800-989-8255. E-mail us: talk@npr.org. You can also join the conversation on our blog at npr.org/blogofthenation.

We begin with Dr. Arthur Matas. He's professor of surgery and director of kidney transplant program at the University of Minnesota in Minneapolis, and he joins us from Minnesota Public Radio in St. Paul.

Nice to have you on TALK OF THE NATION today.

Dr. ARTHUR MATAS (Surgery; Director, University of Minnesota Kidney Transplant Program): Thanks for having me.

CONAN: And what's wrong with the system that we have now?

Dr. MATAS: This problem with the system we have now is simply that there just aren't enough organs for all of our patients. Currently, patients are suffering and dying while waiting for a transplant. The average time for - or the average wait for transplant in this country is about five years, and in some parts of the country it's about eight years.

CONAN: And your proposal, as I understand it, is not for a free market in kidneys but a very carefully regulated program.

Dr. MATAS: That's correct, and it's very critical to separate this or distinguish it from a free market because free market's been tried elsewhere in the world and they failed. And I think that the only way this will work is with a very carefully regulated market.

CONAN: And how would somebody get compensated for, well, a kidney? We only got two.

Dr. MATAS: The compensation would come from the government because, really, the government is currently the payer for dialysis - for the majority of dialysis. It also could come from the recipient's insurance company, and it could consist of a package of life insurance, health insurance, compensation for any lost wages or expenses in the donation procedure, and then either a cash payment or a tax benefit. It could be possible to have a menu of options. And then, the kidneys would get allocated just as we allocate deceased donor kidneys, so that every one on the list would have the opportunity to be transplanted.

CONAN: So the equity, the fairness of the current system would continue. What would change is that people would be offered compensations, some cash maybe or some tax benefits of some sort to donate, well, to sell their kidney?

Dr. MATAS: That's correct.

CONAN: And the problem that a lot of people have with this is that, well, this would encourage a lot of poor people to damage their health.

Dr. MATAS: Well, I think we accept kidney donation now. And so - the only difference between compensation in our currently accepted kidney donation is the money. And there is no reason to believe that poor people are going to damage their health anymore than our currently accepted donors. We do an excellent job of screening potential donors. And there's no doubt that there is a risk albeit small to kidney donation, but this would be no different than what we're doing on a regular basis around the country.

CONAN: Mm-hmm. Recently, there were three - four patients, I think, at three Chicago hospitals who were infected with HIV after receiving infected donor organs. Who would oversee the sale of kidneys, make sure they're safe?

Dr. MATAS: Again, I think it needs to be a government-regulated system and the government would regulate this. We're good - although you can see from this one albeit very rare example, not perfect - at screening donors, but we currently screen deceased donors, and there's no reason why we - and we currently screen our current, living altruistic donors. There is no reason why these same techniques couldn't be applied to the compensated donor.

CONAN: And, again, for the person who wants to sell a kidney, would there be a negotiation? Could you say - or would there be a menu where you can pick one from column A and one from column B?

Dr. MATAS: I think you have to - again, it would need to be a national system. There would have to be a determination of what the value of the package, if you will, would be worth, and there would be a menu. So, for example, I think that we need to provide health insurance for all donors, so health insurance could be part of the package. But for a person who already has health insurance, they may choose something else from the menu.

CONAN: Joining us now is Dr. Francis Delmonico, a transplant surgeon at Massachusetts General Hospital. And he joins us from the studios of member station WBUR in Boston.

Nice to have you on TALK OF THE NATION today, too.

Dr. FRANCIS DELMONICO (Transplant Surgeon, Massachusetts General Hospital): Thank you.

CONAN: And why do you defend a system that allows 4,500 people a year to die, waiting for a kidney?

Dr. DELMONICO: Well, defend the system that allows for people to die at all. The system that we have currently can be improved. So that's the first important element to bring to attention. But the premise or contention that the system of a regulated market might impact significantly those that are dying on the list necessitates an assessment of those who indeed are dying on the list. There's a substantial proportion of those who die on the list, who may be dying inactive, not able to receive an organ. And I don't have the data for this, but one might speculate about their suitability for transplantation.

So the premise that people are dying on the list and would - that would be solved by a market - may not hold if individuals are never to receive an offer. I also want to say something regarding the issues that Dr. Matas has brought forward that we do agree, and that is in the system that we currently have which is relying about half of the donation experience in the United States, it being live donors, we both agree that the care of the live donors can be substantially improved in follow up. We both agree that the cost for live donation should be covered.

That the government should address what might be inadequacies of insurance coverage or the coverage of these patients - and they become a patient when they're a live donor - after their donation event by making certain that any complications that might occur will not be borne by the individual as result of the donation. So the premise that people are dying and would be solved necessarily by a compensated package of a cash payment may not be a reality when we examine carefully those who are dying on the list and the suitability of the individuals who are dying.

CONAN: Mm-hmm.

Dr. DELMONICO: That's one important point to make. And then, secondly, there is an aspect of what Dr. Matas and I agree and that is that compensation with care is something that could be delivered to enhance the well-being of live donors that have been forthcoming to be donors in the United States.

CONAN: Short of actual cash money.

Dr. DELMONICO: Short of actual cash money, Neal, because once you introduce cash money, you don't - I know that Dr. Matas is well intentioned by saying that this would be a regulated market, but that's not the reality of what exists in the rest of the world. Once you introduce a market, you introduce differences in payments by gender and ethnicity. You introduce difference in payments because that comes with markets. We are in a global market…

CONAN: So…

Dr. DELMONICO: …of transplantation, and patients go from one country to another these days to seek out what might be the best price of a donor. They go to the Philippines. They go to Pakistan. They've gone to China. They can go to India. These are realities of markets - global markets in the world regarding transplantation that - although Dr. Matas would want to make some restriction about this, he brings no justification as to why there should be restriction once you introduce a cash payment.

CONAN: When you're saying some kidneys would be more valuable than other certain blood types? What are you talking about?

Dr. DELMONICO: Well, blood type could be, but it's not so much that as the gender of an individual. There are price differences that are occasioned by gender and ethnicity in the world. Those are realities that come along with markets.

CONAN: Does it make a medical difference as to whether a donor is male, female, Caucasian or African-American or whatever?

Dr. DELMONICO: It may make a difference by this - the size of the individual, being a male, and it might by their age. So you make a presumption that someone who wants to come forward at 50 years of age, there would - there could conceivably be a difference by age of the live donor related to their capacity in kidney function to deliver to any individual on the list. And, once again, we know for certain that there are ethnic differences that occur in markets that would be visited upon these kinds of markets as they are being occurred in other countries of the world.

CONAN: Mm-hmm. So Dr. Delmonico suggests, Dr. Matas, that once you've opened Pandora's Box, once you create a market, well, market's going to take over.

Dr. MATAS: But that's not true for a regulated market. The reality of it is when you look at living donor results, which is what we're talking about today, and with our screening techniques, there is not much difference between one organ and another. And it would be very easy to set a fixed compensation prize in the United States and limit the market to the United States or a geographic area where we can ensure protection of the donors. So the fact that unregulated markets have failed elsewhere is really not a condemnation of anything other than unregulated markets. And it has no bearing on the very limited regulated market which we're talking about today.

The other issue of the fact that patients dying on the list need to be looked at - we've looked at patients dying on the list. People dying on our waiting list are often young, they're often easy to find a kidney for, and they've just been waiting a long time. Everybody who goes on the list is a transplant candidate when they go on the list. The reason people die while waiting for a kidney is they get sick over the years and years that they're on dialysis, and ultimately, either die or they get taken off the list before they die and we don't even see them in the death statistics.

CONAN: Dr. Delmonico, we just have about 30 seconds or so before our break. But I wanted to ask you, you also were talking about fundamental values in our society as represented in the current system which would be overthrown, you think, if we went to a market system no matter how regulated?

Dr. DELMONICO: Well, Neal, that's a view of the Institute of Medicine that examined Dr. Matas' proposal and other proposals of these kinds of markets. And they rejected it because as I'm - quoting them now, "because they're incompatible with the fundamental values and norms that govern transplantation, and because international markets and organs from living individuals appear to involve the exploitation of impoverished people."

I want to say one other thing about the wait list. Dr. Matas brings to attention data from his own center. Those are not the data of the United States, the entire country, in which the proportion of individuals who are dying on the list of an older population. Furthermore, those patients have been waiting for at least a year in an inactive phase on the list. And markets would not solve that issue. I wish to reiterate that and strongly emphasize that as the case.

CONAN: And we're going to ask somebody to turn off their cell phone.

We're talking with two transplant surgeons today about the issue of kidney sales. If you'd like to join the conversation, give us a call: 800-989-8255. E-mail us: talk@npr.org.

I'm Neal Conan. You're listening to TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington.

For the average patient waiting for a kidney transplant in this country, the wait is three to five years, as long as 10 years in some parts of the East Coast. Evidence, argues Dr. Arthur Matas, that it's time to pay donors for their kidneys to alleviate the shortage of kidneys for transplantation.

Dr. Matas is our guest today. He's a professor of surgery and director of the Kidney Transplant Program at the University of Minnesota. On the other side of the debate: Dr. Francis Delmonico, a transplant surgeon in Massachusetts General Hospital in Boston.

If you're waiting for a kidney or if you've had a transplant, we want to hear from you on this issue. Should the ban on organ sales be lifted? 800-989-8255. E-mail is talk@npr.org.

And why don't we start with Jill(ph), and Jill is with us from Ann Arbor in Michigan.

JILL (Caller): Yes, hello.

CONAN: Hi, Jill. You're on the air.

JILL: Thank you for having me.

CONAN: Sure.

JILL: I - in December of 2005, I donated my kidney to my father. I was 39 at that time and he was 69. And he's doing very well as am I.

My issue is that I don't believe - I mean, the whole of point of being a donor is that you're doing something to help save someone's life. And to get, you know, money in return or some other item, doesn't seem right. I do agree that health care for that person donating should be absolutely offered if they don't have their own insurance. I fortunately had my own, but it was covered under my father's insurance, anyhow.

But I'm wondering whether or not people should be put on a donor list earlier than they are currently. I think there's a number of 20-some percent of kidney function before you could put your name on the donor list. Some people, you know, maybe at a more critical state than they could be if they were added on earlier and to educate family members about what it takes and friends, so that they realize that it's not quite as big of a deal.

CONAN: Mm-hmm. Dr. Matas, let me ask you, would - under your proposal, Jill's idea of donating a kidney to her father, would that have been affected?

Dr. MATAS: No, I don't think it would be affected. Going on the list early won't help in the sense that the problem is that there's a total shortage. So if everybody goes on earlier, it's still going to be the same number of people going on and still the same way. I think she brings up a good point, though, that donors are heroes, and we need to treat them as heroes. And even in a compensated system, they need to be treated as heroes.

There's - the reason to consider compensation is because the total number of altruistic donors, that is donors who are donating without compensation, just isn't enough to solve the current tremendous shortage. But it certainly shouldn't change the fact that we need to consider all donors, either compensated or not, as heroes.

CONAN: Dr. Delmonico?

Dr. DELMONICO: Well, Jill does indeed bring a very important point forward and that is Dr. Matas is a making a presumption that the heroes - and we both see them that way, as heroes - that the jewels of the world would remain in a - in either in a constant or increased state if there were to be a market. But that's not the experience of the world.

We should travel to Israel that is contending at the moment with a very difficult decision as to how they should try and reward live donors because many Israelis are leaving the country for transplants. The point is that if there is a market available where someone can go and buy an organ, then altruism suffers as a result of this.

That is the reality. It's the reality of Israel. It's the reality of what was experienced in Hong Kong. And there's certainly other locations of the world that we can point to, that mention - that bring to attention altruism does not stay stable, when one can just go and buy an organ from a poor person in the Philippines.

Dr. MATAS: If I can just address that. Again…

CONAN: Quickly, because we want to give some other people a chance. But go ahead, Dr. Matas.

Dr. MATAS: …I simply need to - We need to quick - we need to stay away from examples in other countries. But if the total number of organs goes up, then that will help solve the problem, even if altruistic organ donation goes down. So that's - it's a trial that needs to be done.

CONAN: Jill, thanks very much for the call. We're glad to hear that both you and your father are doing well.

JILL: Thank you for having me.

CONAN: Okay. Bye-bye.

Let's go to Boyd(ph), and Boyd's with us from Tonopah, Arizona.

BOYD (Caller): Hi, Neal.

CONAN: Hi.

BOYD: Yeah. My wife, at the age of 25, got E. coli poisoning and had to go on on dialysis. And by the age of 30, she was dead - and just because the politics of the list. And I'm - absolutely believe that people should be able to sell a kidney or whatnot - she'd be here today. It's just crazy out there, the way the politics work.

CONAN: What do you mean by politics of the list?

BOYD: Yeah, the politics of the list. It's just unbelievable. And…

CONAN: And what do you mean by - what are politics of the list?

BOYD: Well it's - I really don't know the - all the ins and outs of it. But as she was put on the list, and she was constantly bumped down and others were put up there. And even though she was - then she had to go on hemodialysis, which was - basically destroys your blood while it's cleaning it, and I watched her die for the lack of a kidney that could have been hopefully bought some, you know, just - I…

CONAN: Did you at all consider the idea of going overseas, to the Philippines or India or someplace?

BOYD: No. No, absolutely not. I agreed with the doctors. Stay here in this country and control it in this country, here, and regulate it.

CONAN: Mm-hmm.

BOYD: But no, I would - we never even considered going overseas because that's - what are you buying? You know, it's - no, not at all. I would keep it in this country.

CONAN: Boyd, we're so sorry for your lost.

BOYD: Well, thank you.

CONAN: And thanks very much for the call.

BOYD: All right.

CONAN: Dr. Delmonico, I wanted to ask you, what - why might somebody go up or down the list, awaiting a transplant?

Dr. DELMONICO: Well, it's very difficult to make an assessment. And I, again, am saddened to learn of this caller's particular experience. But I'm not certain that a compensated market would have resolved…

CONAN: I was just asking about a compensated market, in this case. I mean, he was talking about the politics of the list as it's…

Dr. DELMONICO: Well, it's hard for me to make some assessment of the politics. I think you asked the appropriate question, what did he mean by politics? This system is very well developed and carefully prescribed in the United States and it's under constant review, so I'm not certain what he meant by the politics.

CONAN: Would somebody rise or fall on - in their place on the list if they were more or less, you know, medically capable of accepting a transplant?

Dr. DELMONICO: Well, as Dr. Matas mentioned earlier, there can be instances in which an individual is found to be temporarily inactive and then not suitable at that moment or time for a transplant. I'm not certain whether this pertain to this patient that was just brought to attention. But I wish to convey to the American public that it's not a matter of politics when one goes on to that list. In the United States, once you're on the list, the rules apply very carefully, and it's not a matter of a political assignment as to whether someone gets a kidney. So I wish to make that assurance. And I, again, I'm saddened by the mention of this patient's death, but I would be very weary of ascribing that to a political event, whatever is meant by politics.

CONAN: Let's get another caller on the line. This is Pete(ph), Pete with us from Charlotte, North Carolina.

PETE (Caller): Hey, how's it going?

You're talking about live donors right now. I'm wondering what will happen, you know, in the future if you open the door here with, you know, the Pandora's Box as you mentioned. My sister works at a place where she gathers parts from deceased people and she has firsthand seen things where people were on death's door that - anyway, basically, these people should not have been harvested from. And so you have this questionable activity without any compensation just because of the heavy…

CONAN: Demand.

PETE: …demand. So what's going to happen when doctors can charge, you know, get payments for this, you know, the - it's going to be really hard on them to resist the urge to, you know, make a lot of money. So what's going, you know, what kind of checks and balances can you put in place for that? I think it's going to be really hard, you know?

CONAN: Dr. Matas, let me ask you about that. Won't the injection of money and now, obviously, you're proposing a government-regulated scheme. But once compensation does get involved, aren't the stakes higher for everybody?

Dr. MATAS: I think the stakes are higher. I think you - the caller brings up a good point. And you need to recognize we already have compensation for sperm, for eggs, for surrogate mothers, all of which - or at least the eggs and surrogate mothers - have risks, and we have a very, very active system of compensation for, as the caller pointed out, deceased donors' parts: corneas and bone and so on.

So we're able to, to some extent, regulate this, but I think the question would be would we then have a system of compensation for deceased donor organs? And although I'm not opposed to it, it's a different proposal than what we're putting on the table today. After all, when you're talking about living donors, the compensation would actually go directly to the donor.

PETE: If I might add…

CONAN: Go ahead, Pete.

PETE: …well is on hold, because my wife and I have paid for a - to try to have an egg donor and so I know about, you know, that. And then she's actually being paid for her - not for her egg themselves, but what she's going through, the trouble, because it's, you know, hard on your body and everything. And I think, you know, maybe some kind, you know, absolute minimum, you know, with some kind of a top-end payment for, just the payment suffering makes sense but not just, you know, (unintelligible) with no controls whatsoever. So I'm kind of on defense on the whole thing, but I feel like hearing my sister's stories that, you know, that's more scary to me than anything else is that what will happen medically, doctors taking candidates for kidneys that shouldn't be candidates or something.

CONAN: Pete, thanks for the call. Dr. Delmonico…

Dr. DELMONICO: And I like to comment about that, Neal, if I may?

CONAN: Go ahead, please. Yes.

Dr. DELMONICO: I think there's a very important point to be made there. There's a doctor-patient relationship and that is based upon truth in the medical evaluation of the donor. Now, the donor comes forward and says, I need the $95,000 or whatever it is that Dr. Matas would want to assign to this individual. I need that money.

What will be the necessity of the physician in providing the money for this patient that's before the individual? And what of the intent of this potential donor to hide medical information that might be consequential to the transplant? For example, a social encounter that might enable the transmission, for example, of HIV or some other infection - that would not be revealed because the intent now is to receive that cash payment. This becomes a hazard in the disruption of the doctor-patient relationship that's so essential in the altruistic nature of organ donation in this country.

CONAN: We're talking with two transplant surgeons today. You just heard Dr. Francis Delmonico, also with us, Dr. Arthur Matas. They're friends, might not know that - listen to them on the radio, but they like each other, and they're on opposite sides of this argument over the compensation for kidneys.

Dr. Matas argues that there are thousands of people who die every year and we need to increase the supply of kidneys. Compensation, he argues, is the best way to do it. You're listening to TALK OF THE NATION from NPR News.

Let's go now to Joey(ph). Joey is with us from Tucson, Arizona.

JOEY (Caller): Hi, Neal.

CONAN: Hi.

JOEY: And hi to your guests. I'm a kidney patient awaiting - getting listed for transplant here in Tucson. And years ago, I considered the possibility of selling a kidney - I know it's still not legal. But my comment is that if I had been screened as a potential donor all those years ago, my kidney disease might have been caught early enough to actually maintain some function. And I'm wondering if that might be an unattended consequence of actually opening up kidney sales to the public.

CONAN: Dr. Delmonico, and perhaps a by-product but one that might be useful.

Dr. DELMONICO: Well, the person can come forward and we're - Dr. Matas and I are enthusiastic individuals to come forward and be donors. And we are also in complete agreement that there should be a very careful evaluation and assessment of this person who would come forward so that such a determination about their suitability for donation could be achieved. That occurs whether there is to be a cash payment or not.

CONAN: So Joey, if you'd gone ahead with that idea of selling your kidney in the past, you would have been assessed.

JOEY: Well, the fact is I wouldn't have been able to because my kidney function was even reduced back then not to my knowledge. But this kidney disease could have been arrested to the point where I actually still could have had some usable function.

CONAN: And might not need a transplant today.

JOEY: Exactly. Exactly.

CONAN: And I wonder, have you considered going overseas to buy a kidney?

JOEY: I could never afford that. I could never afford that. I'm, you know, my best hope since I really don't have a familial donor is to wait for some kid to kill himself on a street bike and, you know, harvest the parts.

CONAN: It's - well…

JOEY: It's pretty dark, but…

CONAN: It's pretty dark, yeah.

JOEY: …that's I'm sure I'm not the only one, you know, struggles with that. It's difficult, but someone else has to die so that I can live.

CONAN: Joey, we wish you the best of luck.

JOEY: Thank you.

CONAN: Appreciate it.

Here's an e-mail that we got from - this from Ross(ph) in Cincinnati. One of the university hospitals in Cincinnati has started to reward employees who donate a kidney or bone marrow by giving them extra PTO days - those are paid time off - up to five days for kidney, up to two days for bone marrow. This seems to me to be getting awfully close to paying for organs. Dr. Delmonico, is that the top of the slippery slope?

Dr. DELMONICO: No, I don't see that as the same at all. It's a non-fungible benefit of sort in which there can be a reward for an individual to be a donor to make certain that they have ample time to recover and return to work. I don't see that as the issue. What I see as a concern is that once you introduce cash payments, you have no justification to fix that.

We're in a global market of organs. People are traveling from one country to another to buy those organs. Why should there's - on what basis does Dr. Matas assume that people won't be wanting to come to the United States to sell their organs? If you're in a global market, why should we be restricting those from neighboring countries or from Asia to come to the United States as is now the case? That Asians are traveling to the Middle East to sell their organs.

CONAN: And let's give Dr. Matas a chance to answer in 30 seconds.

Dr. MATAS: Well, of course, paid time off is a benefit as is where other states have tax deductions. And the reason to limit this is because we can provide health care and long-term follow-up if we limit this to a specific country. If you make a global market, you can't provide health care and long-term follow-up and that's why I am only proposing a very limited, regulated market within this country.

CONAN: And the debate will continue, no doubt. Dr. Matas, thanks so much for your time today.

Dr. MATAS: Thank you.

CONAN: Dr. Arthur Mathas, professor of surgery; director of the Kidney Transplant Program at the University of Minnesota, with us today from Minnesota Public Radio. And Dr. Delmonico, thank you for your time.

Dr. DELMONICO: Thank you as well.

CONAN: Francis Delmonico, a transplant surgeon at Massachusetts General, with us today from our member station in Boston WBUR.

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