Americans have never much liked British kidney pie, but now we are embroiled in a kidney stew all our own. Fifty thousand Americans need kidney transplants each year, but only 8,000 donate approximately 12,000 kidneys each year — many patients die before a transplant becomes available.

Although organ donations of all kinds have increased almost 10 percent in the last three years, the number of candidates for organ transplantation has increased by about 30 percent. More patients are eligible for transplantation because of improvements in several areas: better management of patients with failing organs; improved surgical techniques which are safer and less stressful to both donors and patients; and better prevention and management of organ rejection.

The National Organ Transplant Act of 1984, which bans the purchase and sale of kidneys in the United States, ensures a shortage of kidneys as well as other organs. Lawmakers apparently believe that that their mandated system both works better and is more ethical than allowing choice for individual patients and potential donors.

However, according to Loyola University economists William Barnett, Michael Saliba and Deborah Walker, writing in the Winter 2001 issue of “The Independent Review,” this mandated and paternalist system essentially sets up a monopoly. They argue that a free market in kidneys would improve both the quantity and the quality of kidneys supplied. More people would have incentives to donate kidneys. Under their proposal, no one who needed a kidney transplant would go without one. The poor aren’t shut out because the federal government actually functions as the payer-of-last-resort. Available kidneys are in short supply, not short financial resources.

For those who still have moral qualms about allowing a free market in kidneys, Robert M. Sade M.D., a heart surgeon and professor at the Medical University of South Carolina, proposed an in-kind market for organs several years ago: Require adults to sign an organ donor card as a precondition for receiving a transplant. Alex Tabarrok, research director of The Independent Institute, has further developed this idea recently.

This policy would encourage individuals to sign donor cards in exchange for priority status for a transplant should they need one. Children would be automatically eligible to receive transplants but, at age 16, they would have the option of signing their own donor card.

“We may still disagree on whether organs should be commodities traded on the open market, but few could argue with the notion that those who are willing to give should be the first to receive,” Tabarrok concluded.

We admire these fresh ideas and out-of-the-box thinking on a national dilemma. We think that with some fine-tuning, reasonable proposals can be considered.

  1. Perhaps most Americans are not yet ready to trade kidneys on an open free market — for them, the practice is just not morally, ethically, and spiritually acceptable or palatable at this time. Donating or receiving a kidney means more to us as humans than giving or receiving other goods. The relationship is inherently more “intimate” than other transactions. This is part of the ethical basis for the current organ donation system, without other compensation for the donors.

  2. At the same time, we don’t think that maintaining kidney control under the current government monopoly is a good idea. History shows that monopolies do not tend to be altruistic — there are always trade-offs and favoritism among the power brokers. In addition, unanticipated consequences always occur, such as excessive paperwork, bureaucracy, mandates and autocratic policing. The unanticipated consequences seen in government-sponsored managed care and Medicare should give us pause — do we really want the government to decide who urinates and who doesn’t?

  3. How about allowing donors or their surviving families to receive payment for hospital and/or funeral expenses? Let’s also consider giving financial support for health insurance for them and their families.

  4. We could adapt Tabarrak’s suggestion of an organ donor card for adults, available each time we renew our driver’s licenses.

  5. We should educate potential donors about the safety of organ donation. For example, according to Mark W. Johnson, M.D., Assistant Professor of Surgery at the University of North Carolina Medical School and Director of the Renal Transplant Program, the surgical procedures for both the donor and recipient have become much less complex and safer than when the first procedures were done in the 1960’s. Dr. Johnson notes that some people are advocating implied consent for available donor kidneys unless expressly denied by the donor or next of kin.

People who voluntarily donate live kidneys do not have a lowered life expectancy or increased health problems. If anything, voluntary donors actually live slightly longer, according to some studies! Forty-nine out of 50 life insurance companies surveyed do not increase premiums for individuals who have donated a kidney. We believe that Americans, if given incentives and choice, will step forward when called upon, once we better understand the moral and medical issues of donation and transplantation. This is one area in which the country always excels!

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