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									     Paying for Organs…A Modest

              Luke Brewster, MD, PhD, MA
               John J. Brems, MD, FACS

               Transplantation Ethics
Transplantation is one of the great success stories of modern medicine
Emphasize high likelihood of benefit to recipient
Nonmaleficence to donors
Aggregate benefits and risks to the donor/recipient pair
      Ethics Statement of the Vancouver Forum on the Live Lung, Liver,
      Pancreas, and Intestine Donor. Transplantation, 2006;81:1386-7.
Transparent allocation and monitoring of organs to recipients
Historically “to pay for organs is against the principles of organ
transplantation”…and “…donors must not be viewed primarily as a
resource for transplants.”
   Crippen JS. Treatment of Hepatocellular Carcinoma after Transplantation and
   Human Rights. Hepatology, 2007;45:263-65.
   American Society of Transplantation. Statement on Ethics. http://a-s-
               A Kind of New Argument
         The extraordinary has now become commonplace
            Exacerbated the discrepancy between recipient
            candidates and donor organs
         Mandated Choice failed
         Living donors are the most common donors
         Simple solution has been proposed
         Pay for donor organs
         “For every complex problem there is a simple
         solution. And it is always wrong.”
            Mencken HL. Prejudices: second series. 1920 p. 158.
            New York: Knopf

           Chicago School of Economics
 Unclear how the market would
impact organs as a commodity.
 Will not meet demand and may
contribute to increasing the demand
by increased supply
 Nonprofit status confines costs
     Goodman C, et al. Transfusion,
 Would require regulation which
throws instability into market forces
 Can oversight substitute for
 Repugnance to such an idea
                    Wisdom of Repugnance
Application of market economy to human

   Sanal, A. “Robin Hood” of techno-Turkey or organ
   trafficking in the state of ethical beings. Cult Med
   Psychiatry, 2004;28:281-309.
   Kevorkian J. Solve the Organ Shortage: let the
   bidding begin! Am J Forensic Psychiatry,
“It is a concept that takes a while to sink
in. When you first hear about it, it doesn’t
sound right.” –Dr. Matas
   Wall Street Journal, Nov. 13, 2007;A1.
Leon Kass. The Wisdom of Repugnance: why we
should ban the cloning of humans. New Repub

            Keep the scars, lose the kidney,
                   spend the money

Goyal M, et al. Economic and health consequences of selling a kidney in India. JAMA,
   Who will the donors be and who pays?
  Need all donors be paid? Are they just “used cars”?
     Rothman DJ. Ethical and social consequences of selling a kidney. JAMA 2002;288:1640-41.
     Sells RA. The case again: buying organs and a futures market in transplants. Transplant Proc
  Caste System
     “Autonomy doesn’t trump everything else….The upper class
     preying on the lower class…. May work in an economic model, but
     not in a justice model.”
         Dr. Thistlethwaite, University of Chicago Magazine
  Resources (organs) will move like wealth to the powerful
  further stagnating vertical movement in society
  Vulnerable are not covered medically in our society
  Legal implications for all

Why don’t you take
the procurement fee                                             Then I get the
and I’ll sue the                                                institutions?
transplant surgeon?
              Protection of Living Donors
The complex interaction and analysis of data implicitly benefits
the recipient (risks/benefits)
75% want to donate, no matter costs
  Will payment make complications more acceptable?
All organs are not equal, certain blood groups, ages, and types of
organs are more valuable
  Kulkarni S, Cronin DC II. Ethical tensions in solid organ transplantation: the price of success. World J
  Gastroenterology, 2006:28:3259-64.
Gresham’s law
  Quality organs pushed out of the market because there is no good way
  to establish that they really are worth more
Offshore donors and/or recipient
Futures market for donors and its conflict with autonomy

                   The Money Experiment
      Pay more for certain types
      Led people with higher risks to donate blood or blood
      products for money
      Richard M. Titmuss. The Gift Relationship: From
      Human Blood to Social Policy. New York: Pantheon
      Books, 1971.
      Contamination of the blood bank pool
           Transfusion, 1994;34:116-21
           Transfus Sci, 1997;18:379-86.
      The use of contaminated organs can cause great harm to
      many people and is not easily defended
            Where do we go from here?

              Common Ground
Ethical application depends heavily on the success to the
recipient and safety to the donor over time.
Donors should be properly monitored postoperatively
with long term follow up.
Eliminate disincentives to organ donation
  Lost income and direct costs
  Canadian Medical Association Journal, 2006;174:797-8.
Regional organ exchanges?
When we work together we can achieve great things

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