Pittsburgh Tribune-Review opinion piece, October 9th, 2005, by Bill Steigerwald
By Bill Steigerwald
It's a simple, deadly problem of supply and demand.
As of Wednesday, 89,576 Americans need organ transplants or they will die. Most need new kidneys and livers. Some need hearts, lungs and intestines. But there aren't enough new organs from either living loved ones and friends or from dead donors. Therefore, every year more than 7,000 Americans die waiting for transplant organs that never become available.
You'd think having 19 people a day die while waiting in line for kidneys and livers would be big news. Yet you really only hear about it when it's dropped into stories like The Washington Post's recent report on desperate organ-seekers who are using the Internet like a dating service to improve their chances of finding a matching donor.
No ethicist quoted in The Post story was upset about those 7,000 perennial deaths. They were more worried that people using the Internet were gaining an unfair advantage or undermining the official system that allocates all organs from cadavers anonymously to patients on hospital waiting lists.
No ethicist called for a congressional investigation into the causes of our permanent organ shortage. But the solution is as simple as Econ 101, say free-marketeers like law professor Lloyd Cohen of George Mason University: repeal the 1984 National Organ Transplantation Act, which prohibits people from buying or selling human organs, and allow people to be paid for donating their organs.
Cohen has spent 16 years urging market-oriented legal reforms that would increase the supply of organs from cadavers for transplant patients. His best idea, which he describes in Regulation magazine, is to create a futures market whereby "healthy people would be offered the opportunity to give an 'option' on their transplantable organs."
The organs, recovered after their donors die, would sell for a predetermined price of, say, $5,000 for a kidney. The money would be paid to the donor's heirs or estate.
Most medical ethicists reject the thought of letting the grubby hands of commerce infect the organ allocation process. They'd rather see organs buried and people die. But dignified, medically and morally sound ideas exist for using economic incentives to increase the supply of organs.
Selling body parts on eBay in not one of them. Neither is buying kidneys from poor people in the Third World. In fact, as Cohen told me Wednesday, this "organ tourism" would disappear if we allowed a market in the organs of dead people. So would the need for most living donors.
Cohen's idea, tragically, has been ignored for years. So have others, including the "rewarded gifting" idea of University of Pittsburgh neurobiologist Harold Kyriazi, which would allow money to be paid to families for the right to harvest organs from their recently deceased kin.
Just as we have ample amounts of blood, plasma and sperm, because we allow people to buy and sell them, we could also have all the life-giving major organs we need -- if we stopped relying only on love or altruism to supply them.
We should wise up and recognize the power of self-interest to do social good, Cohen says. "The only thing that keeps the current practice in existence is that those who suffer from it are still few in number and far from here," he said, adding that "the idea of condemning people to death on the altar of not recognizing self-interest as an important motivating factor is just evil, and absurd."
Bill Steigerwald is the Trib's associate editor. Call him at (412) 320-7983. E-mail him at email@example.com.
By Luis Fabregas, Friday, May 30, 2003
The federal government should pay up to $5,000 as an incentive for people to donate the organs of deceased relatives, according to a group led by a University of Pittsburgh researcher.
The proposal, circulated in a letter sent to members of Congress this week, aims to help the estimated 6,000 Americans who die each year waiting for hearts, livers and kidneys, said Harold Kyriazi, a Pitt neurobiology researcher who is leading the effort.
Kyriazi, whose group includes about two dozen scholars, transplant surgeons, religious leaders and organ donation experts, said the payment would be nothing more than a token of thanks for helping to save another life. A 1984 federal law bans the sale of organs, but the group wants Congress to study whether a cash incentive would boost organ donations.
More than 80,000 people are on transplant waiting lists, according to the United Network for Organ Sharing, the private agency that allocates donated organs nationwide.
"It's just human nature that if you're getting something, you should give something in return," Kyriazi said Thursday. "I wouldn't feel right to just ask for an organ. I would feel like a beggar. I would like to offer some kind of compensation as a way of saying thanks and keeping it at an even exchange level."
The proposal is the latest attempt to use money as a way to deepen the shallow pool of prospective donors. The American Medical Association in late 2001 said it intended to study whether it would support compensating donors' families. Perhaps most significantly, the American Society of Transplant Surgeons has said modest compensation would not be unethical.
At least one medical ethicist disagrees, calling the plan a bad solution that fuels the idea that "If you can pay for it, you can get it."
"It immediately says 'Gee, how much money is someone else's life worth?'" said Dr. Lawrence J. Schneiderman, a medical ethicist at the University of California, San Diego. "Anytime that you say we are going to give you money to do something, it brings it into the commercial area in that we are trying to get people to do something for the sake of something else. It just encourages people to make a deal that's financially rewarding rather than 'this is life and death' and showing respect for the process of health care."
There has never been a study conducted to determine the effect of compensating people for donating the organs of loved ones, said Dr. John Fung, chief of transplantation surgery at Pitt's Thomas E. Starzl Transplantation Institute.
"I suspect that it would have an impact, but I don't know, so it's definitely worth exploring," he said.
The plan's supporters include some relatives of patients who died waiting for organ donors. Rosemary Woods of Scott Township said financial incentives could have helped find a heart and liver for her son, Jonathan. The brown-eyed boy died on March 30, 1998, one day before his 10th birthday, because doctors couldn't find suitable organs.
"I firmly believe that my son's life may have been saved if anything could have been offered to a family suffering with the burden of grief," Woods said. "I think a monetary reward would definitely encourage families to give donation a closer look. Unfortunately, my Jon didn't have that chance."
To avoid giving the wrong impression, the group's plan involves a flat fee, regardless of the donor's age or number of usable organs or tissue. The money would be paid to the donor's family even if doctors are unable to use the organs.
"We want to get away from the idea of haggling," said Alexander Tabarrok, a group member and professor of economics at George Mason University in Fairfax, Va.
Relatives would likely be approached about the incentive after the potential donor dies. The group said the fee should not be less than $3,000, an amount that would help pay for the donor's funeral.
Officials at the Center for Organ Recovery and Education in Pittsburgh, the local organ soliciting agency, say the incentive could boost the number of potential donors. Only about half of those who are asked agree to donate, said spokeswoman Pat Kornick. Last year, 157 out of 311 medically eligible people donated organs locally, Kornick said.
Kyriazi said the cost of paying relatives, which the group estimates could be around $25 million a year, could be covered with money saved from medical treatment required for sick patients on organ waiting lists.
"It will end up saving money to society because right now people who need kidneys are undergoing extensive dialysis that is very costly," he said.
Kyriazi said he believes a reward would help people overcome one of the top reasons why relatives often say no to donation -- the grief caused by the thought of their relatives being disfigured.
"People understand money on a gut level, too," he said. "It would be a way of overcoming the gut level revulsion of having your loved ones cut open."
Luis Fabregas can be reached at firstname.lastname@example.org or (412) 320-7998.
Group proposes testing cash incentives for organ donations
By TODD SPANGLER The Associated Press 5/30/2003, 3:49 p.m. ET
PITTSBURGH (AP) A group of transplant surgeons, academics, religious leaders and activists wants Congress to test whether cash incentives would encourage more families to donate the organs of relatives following their deaths.
The group, based in Pittsburgh, sent a letter Wednesday to 40 U.S. senators and members of Congress, asking that a 1984 law prohibiting financial incentives for organ donations be rewritten to allow a demonstration project. The project would award $5,000 to families that authorize a deceased relative's organs to be used for transplantation.
The proposal would limit such donations to those organ procurement organizations involved in a test project developed and monitored by the federal Department of Health and Human Services. The prohibition on financial incentives for live donors would remain in place.
"It would just greatly increase the number of organs that are donated," Harold Kyriazi, a University of Pittsburgh neuroscientist who organized the group, said Friday.
About 22 people are part of the unnamed group, including Dr. John Fung, director of the Thomas E. Starzl Transplantation Institute in Pittsburgh; David Kaserman, an economics professor at Auburn University; Gregory Pence, a medical ethicist at the University of Alabama at Birmingham; and the Rev. Phillip Adams, director of Lighthouse Christian Ministries in Oklahoma City, Okla.
Under the proposal, representatives for organ procurement agencies would approach families after a relative has been pronounced brain dead and offer the $5,000 "as a way of saying thank you for giving the gift of life." The money would go to the deceased person's estate.
The coalition's letter was first reported Friday in the Pittsburgh Tribune-Review.
The United Network for Organ Sharing says more than 6,000 people died last year waiting for organs. More than 80,000 people are currently awaiting transplants.
Dr. Thomas Peters, a transplant surgeon in Jacksonville, Fla., who signed the proposal, said only about half the families approached each year about donating a deceased relative's organs agree to do so.
"Financial incentives should be studied in well-controlled and appropriately designed trials. That's all we're asking that this approach be given a try," Peters said.
Both UNOS the nonprofit organization that administers the nation's organ procurement network and the American Medical Association have called for studies of financial incentives for organ donations from cadavers.
But UNOS spokeswoman Anne Paschke said her organization is not prepared to back any specific project yet, believing the details need to be carefully worked out. Some focus has been shifted back toward more traditional ways of getting people to donate organs, and Paschke said Senate Majority Leader Bill Frist currently has legislation that may allow the federal government to test whether financial incentives increase after-death donations.
"Everyone wants to make sure it's very carefully designed," Paschke said.
Dr. James Burdick, a former UNOS president and a transplant surgeon at the Johns Hopkins Medical Institutions in Baltimore, called the proposal well crafted. But he said it still may not address the issue of whether there's something intrinsically wrong with taking organ donations out of the purely altruistic realm.
Once money is introduced into the process, he said, some people willing to donate now might feel like they are selling a loved one's organs and refuse. A family might worry after accepting the money that they did it for the cash, Burdick said.
He agreed, however, that such a proposal needs to be looked at.
Kyriazi said the project would pay for itself, maintaining it costs much more to keep someone awaiting a transplant alive than it does treating someone who has received a new organ.
Kyriazi said the members of Congress selected to receive the letter were those who have introduced similar legislation in the past or who sit on committees that would consider such a proposal. One of those receiving the letter is House Energy and Commerce Committee chairman Billy Tauzin, R-La., who has scheduled a hearing on organ donation issues for Tuesday.
On the Net:
United Network for Organ Sharing: http://www.unos.org
Organgiving.com [sic]: http://www.organgiving.org
Copyright 2003 The Associated Press. All rights reserved.
June 9, 2003
Group seeks study of organ payments
Would donor compensation ease shortage or taint gifts?
By Pamela Berry email@example.com
Chuck Ivey didn't hesitate to say yes when doctors approached him years ago about allowing his brain-dead teenage stepson to be an organ donor.
"We were kind of an unusual case because we were good friends with a couple of people who had been organ recipients," said Ivey, 60, of Brookhaven.
But had the request for 19-year-old Justin Hickman's organs been followed by an offer of monetary compensation or a government death benefit for donating, Ivey said his stepson's gift of eight organs would have been tainted.
"I just think it destroys the whole spirit of what organ donation is about," said Ivey, whose stepson committed suicide.
Supporters of compensating families for organ donations admit the issue of reimbursement is one rife with controversy and emotion and could prompt claims of "organ buying."
But they say the measure is something that must be explored if the nation's shortage of transplant organs is to be addressed.
Each year, more than 6,000 Americans die while waiting for a transplant operation. About 600 Mississippians are awaiting organs.
While the number of donors has remained steady, around 5,000 to 6,000 annually, the number of people needing transplants has skyrocketed from about 20,000 to 80,000, according to the United Network for Organ Sharing.
Federal law prohibits financial incentives for organ donation, and even research requires the approval of Congress.
Last week, a group of health-care professionals, scholars, transplant surgeons and others began lobbying Congress to change the law. The group wants lawmakers to allow for a pilot study to determine if $5,000 compensations for organs would lessen the shortage.
The American Medical Association is urging the issue be studied. Last year the AMA adopted a measure to support a study even after some members called the payments unethical.
"I don't know if we have had any response from lawmakers yet, but there is some interest in Congress on both sides of the aisle," said Dr. Thomas Peters, a transplant surgeon and director of the Jacksonville Transplant Center in Florida. "I think this will happen either this year or next because nothing else has worked. Even with the enormous amount of work put into it, the rate of consent hasn't changed."
Nationally, about 50 percent of families give their consent when approached about donating their loved ones' organs, Peters said.
But James Laird, a volunteer coordinator with the Mississippi Organ Recovery Agency, said he believes the way to increase the numbers is by reaching out to families rather than reaching into government coffers.
"I know the donors' families in this state because I've worked with them over the years, and I can guarantee you 99 percent of all donor families don't want to have anything to do with compensation," Laird said. "But, naturally, you may have one or two (who) hold a different view."
Dr. Henry Barber, surgical director of renal transplantation and professor of surgery at the University of Mississippi Medical Center, said while he doesn't question the motives of the group seeking to offer a "death benefit" to donor families, he's concerned about it making the donor experience "cheap."
"There is no question about the rising number of people needing transplants, but at the same time we don't want to do the wrong thing," Barber said. "In some ways, it's unfair to those that would have liked to be organ donors and whose loved ones die under circumstances where they can't be donors. I feel strongly about that. I'm also not convinced that financial incentives of any sort will really impact the number of donors available."
Barber said he's not against studying the matter but adds, "I wouldn't want there to be any public backlash on this issue. I think this has the potential to make it worse and bring up the issue that organs are for sale."
Laird said he understands the emotional desperation that would cause some families to push for compensating donors.
Laird's son, Jonathan, now 12, received a liver transplant in 1992 when he was 7 months old. The organ came from a year-old boy who died from a brain tumor.
"When you are waiting for an organ, you will do everything you can possibly do to help your child," said Laird. "A lot of times, you have to accept that this is the way it will be. But most people will do anything. At that time, even if it would have taken me to come up with several thousand, I would have done that. It's a tremendous roller coaster. One day, you're doing great and the next, they are on death's doorstep and you can only wait for a donor to be found."
Laird said he knows getting more organ donors is possible without paying families because he's seen Mississippi turn its numbers around. Nationally, Mississippi is second only to Florida for its organ donor rate.
"In 1998, Mississippi had the lowest rate in the nation," Laird said. "But we pushed for public education. Last year, we had 60 donors, and already this year we have had 30 to 32. The key to that has been educating hospitals and staff so that they are willing to work with us."
Kevin Stump, executive director of the Mississippi Organ Recovery, said he's willing to see the measure studied but fears what payments would do to the system.
"If this is what the government feels will help donations, then so be it," Stump said. "But we've only had one family in 10 years decline to donate because we wouldn't pay them. Giving a family an honorarium to help defray the cost of a funeral is one thing. But giving them money is something I'm not OK with."
Stump said he also fears offering compensation would harm the quality of the donated organs by encouraging people to lie about family medical histories so they would be eligible to donate.
Peters said if the study were approved, six to 10 organ donor organizations across the United States would participate and funding would come from the U.S. Department of Health and Human Services, which has an office dedicated to increasing organ donations.
"A crucial aspect of the proposal is that the gift be a set amount that is given to the estates of all brain-dead patients who are judged to be good donor candidates and whose families do indeed donate," Peters said. "There should be no possibility of unseemly haggling. Neither should there be any reduction of the amount of gift if a presumptively good donor turns out to have a few or no usable vital organs."
Ivey said even in light of the lives that could be saved, he's hopeful the measure will fail.
"There are too many possibilities of the whole system being contaminated and ruined," he said. "This is a life-and-death matter like anything else. Eventually, we all have to meet our maker, and I just truly believe in the bottom of my heart that this is not right."
Palm Beach Post column
Chicago Tribune Editorial
Time to pay for organs?
Should Americans die waiting for organs while most usable organs go into coffins? Every year over the past decade, 4,000 Americans died waiting for an organ that never came. At the same time, thousands of families chose not to donate organs of a brain-dead relative.
Is there nothing we can do about this continuing tragedy?
Recently, a few national leaders organized to advocate a trial of paying families for consent to donate. The coalition includes transplant surgeons Tom Peters and John Fung, University of Chicago law professor Richard Epstein, several economists, a medical ethicist (myself) and several others.
Earlier this month, we sent a letter to 40 members of Congress proposing a trial project in which families that agreed to donate organs of deceased loved ones would receive $5,000. Harold Kyriazi, a neuroscientist at the University of Pittsburgh, led this project.
The basic idea is not to start a market where rich people buy the organs of poor people, but rather to nudge ambivalent families toward consent. (The current system of distribution, where organs go to those most in need, would not change.) Why not test the idea on a small scale and see if it increases consent?
In a congressional hearing on June 3 before a subcommittee chaired by Rep. James Greenwood, R-Pa., the basic ideas of the proposal met a sympathetic response. Surgeon Robert M. Sade of the Medical University of South Carolina testified, on behalf of the American Medical Association that, "In June 2002, the AMA adopted a policy encouraging the medical community to support the re-examination of motivation for cadaveric organ donation. In particular, the report explored financial incentives as a possible strategy to increase organ donation, and recommended that the impact of these incentives on donation rates be studied."
First, how does it "cheapen life" to save life? The source of the organs is already dead and the only ones really affected are those anxious patients and their families waiting for organs. If anything, perpetuating the current system and doing nothing cheapen the lives of those waiting.
Would such a system lead down the slippery slope to a commercial market for organs? I doubt it. We have had a dual system for blood for many years (now usually just plasma), where people can both donate altruistically or be paid, and it has not led to auctions for rare plasma. Nor does the fact that some people get paid seem to discourage people from altruistically donating blood, probably because people sell or donate blood for very different reasons.
A year ago, I wrote an op-ed for the Los Angeles Times urging the same kind of trial. At that time, 4,000 Americans died each year waiting for organs. According to the United Network for Organ Sharing, the number last year jumped to 6,000. It also says that 80,000 Americans currently wait for organs.
Five thousand dollars is about the right amount to offer families. Of course, no matter what amount is proposed, some critics will see it as coercively too much; others, as exploitatively not enough. Five thousand dollars would help with funeral expenses, a child's education or unpaid medical bills. But it's not like a half-million dollars, which really might be coercive to some families.
Another strange thing has recently happened: The number of organs from living donors has surpassed those from brain-dead patients. So desperate is the need that, more and more, families and friends of dying patients donate their organs.
This is admirable, but it also brings problems. At least two living donors have died, and others have experienced long-term problems from donation. It also started to create a norm where relatives are expected to donate. What happened to the ancient idea in medical ethics, "First, do no harm"? The person who gives up the organ is certainly made worse off by the surgeon than he was before.
On the other hand, if we had doubled the numbers of donations from cadaveric sources, few of these living donations would have been necessary.
It is not as if offering incentives doesn't have ethical complications. It certainly does. But the question is whether those complications are so weighty that 6,000 American lives every year should be sacrificed to avoid them. Surely if we care about life, we should care about the lives of these dying Americans who await an organ.
Families don't consent for many reasons: distrust of the medical system, desires for closure, fear of criticism of other family members. Oftentimes, the easy route is not to donate, to get it over with. Our proposal would give them a reason to think otherwise. (Our Proposal to Congress may be viewed at www.organgiving.org.)
The 1984 law that prohibits cash incentives to families for organ donation was originated in reaction to a Jack Kevorkian of the time (H. Barry Jacobs) who planned to establish a commercial market for organs from living adults. Sometimes, in attempting to stop an aberrant individual, laws are passed too quickly that hurt other people.
All Congress needs to do now is authorize an exception to the 1984 law permitting an experimental trial of cash incentives. What has it got to lose?
Certainly, the patients who now wait in anonymity with their families need new hope. Why not give it to them?
Americal Medical News (official organ of the American Medical Association)
The organ shortage: Financial incentives
For two years, Melissa Alexander of South Waymouth, Mass., waited for a transplant to replace her lungs, which were diseased from cystic fibrosis. Finally, in a desperate attempt to save the 32-year-old woman's life, doctors performed partial transplants on Oct. 3. But her body was so weakened from the long wait that she died the next day.
Medical advances offer the potential to save growing numbers of lives such as Alexander's through transplants of livers, hearts, lungs and other organs. Yet 6,900 patients on waiting lists died last year because of a critical shortage of donors. Currently, more than 82,000 people in the USA are waiting for transplants. That contrasts with 7,500 living and deceased donors so far this year.
The donor shortage persists in spite of numerous education campaigns aimed at persuading healthy Americans to donate their organs after they die. Medical studies estimate that organs could be obtained from 10,500 to 26,000 brain-dead victims each year if more people consented to the donations. And polls conducted for organ-procurement groups show 75% say they would be donors. Yet fewer than 30% have formally consented. In nearly half the cases, relatives step in and veto the wishes of the deceased.
The resistance to donating organs raises doubts about the nation's ability to meet the need for replacement organs without a change in strategy. Even medical groups long opposed to modest payments to donors, including the American Medical Association, now endorse the idea of testing some reward programs. But progress is stymied by an outdated federal ban on financial incentives for organ donations.
The medical community's shifting mind-set and the growing need for organs suggest the timing is right to test whether sensible ways exist to encourage donations without creating a for-profit industry.
Some possibilities include:
Before such ideas can be tested, Congress would need to ease its 19-year ban on compensation for organs. Senate Majority Leader Bill Frist, R-Tenn., a transplant surgeon, backs a proposal moving in that direction. A more direct approach has been offered in the House.
Critics argue that financial incentives will lead to a black market of organs auctioned off to the highest bidder. They say offers of money are an affront to human dignity and donors who give for altruistic reasons.
To avoid a black market, incentive programs would need close monitoring. But physicians, scholars, clergy and civic leaders who worked together this year to consider solutions to the organ shortage concluded that carefully limited financial incentives would motivate those already inclined to be donors to carry through with their plans.
Melissa Alexander and the other thousands who die annually while waiting for organs provide tragic evidence of the need for a new national policy. Test runs of incentive programs are a good place to start.