There seems to be quite a lot of debate around the subject of organ donation at the moment. The Herald today warns people off looking for “bootleg kidneys“. The university of Victoria ran a conference yesterday on the issue and Eric Crampton at Offsetting Behaviour has run a series of articles here, here and here. At one point in Eric’s comments, Andy Tookey of LifeSharers joins in the discussion. Eric’s posts and their comments are an interesting read.
New Zealand does indeed have an appalling rate of organ donation. Eric thinks this could be solved by allowing some commercialisation of the organ market. In terms of cadaver donations, I have no real issue with the agreed sale of a deceased person’s organs – particularly if it is a pre-mortem agreement with the deceased, to provide for his estate. The notion of relatives auctioning off uncle Merv’s kidneys, post-mortem, to make a buck is somewhat distasteful to me, but that is purely personal. To me, the central issue here is whether the deceased has clearly indicated his/her intentions to be a donor and, if so, whether they wish to gift their body or not. That requires just two ticks on an organ donor card. Pre-mortem sales would have to be carefully constructed so that both parties are quite clear on the conditions. Certainly, it should be drafted legally as part of a will.
Eric does an able job of pointing out that this sort of bypassing of the queue has advantages to all – in that others on the list will now be bumped one forward. He is also correct in saying that commercialisation of organ donation appears to attract new donors rather than reduce charitable donation. What he does not stress is that there is no reason at all why the public health service should not bid for the same organs. Bear in mind that, for instance, haemodialysis is an extremely expensive business costing at least $100,000 per annum. Bidding $20,000 for a kidney (if bidding actually went that high) would seem a good deal in comparison, even omitting the greatly increased quality of life a transplant patient receives.
Live donors are another matter entirely. I have an enormous amount of misgiving about purchasing a kidney from a living person. This goes against the ethic of first do no harm (actively harming the donor) but this is not a severe consideration. After all, we use family volunteers all the time, do we not? Should my children or my wife even need a renal transplant, there is no doubt in my mind that I would be willing to donate one of my kidneys and I am certain that most of my readers would be like-minded towards their families. There is no issue with this, so the imperative of first do no harm can be waived, simply because the donor wishes it so.
No, Hippocrates is not the problem here. The real reason that I have misgivings about live commercial donors is the issue of exploitation. The free market principle relies on everyone being free to make voluntary transactions. Unfortunately, when the transaction becomes asymmetrical, it potentially becomes unethical. The more asymmetry, the greater the potential. How ethical is it to offer a starving African $100 for his kidney, knowing he has little idea of the consequences and no access to any sort of medical monitoring or follow up? How ethical would it be to take part of the liver of a man with a gambling addiction in return for wiping his debt? Or how about offering $100,000 to that same man’s widow if he puts a gun to his head and donates his heart to you? How long will it be before we arrive at the nightmarish scenes of Michael Crichton’s Coma?
This is one can of worms we should not be opening.
And there is no need. I often hear that the reason New Zealand has a poor donation rate is that family members can veto the wishes of the deceased and that Maori consider the removal of organs tapu. While I agree that family members should not be able to counteract the wishes of the deceased, I think that this has very little to do with the lack of organ donation. I think that the lack of organ donation is almost entirely do to with the complete apathy of Organ Donation New Zealand. Organ donation is barely promoted. And there is no donation register which, to my mind , is a fatal flaw. In order to solve New Zealand’s organ donation problem, I would immediately promote an organ donation register (via media and mail) to which potential donors could sign up to online. This would be a legal transaction and would supersede the family veto. The same service could be promoted in general practices and hospitals with a free tissue typing service (allowing faster access to organs in an emergency). Each donor would be matched up to potential recipients on the transplant list. Should organs become available from a donor a list of potential recipients, their tissue typing and their level of need should be available at the press of a button.
There are hundred of organs from the suddenly deceased which are wasted every year, not because the family object to their use, but because it is just impossible to finalise matters of permission when someone dies suddenly. The vast majority of these cases are in the community and in the ED, not in the ICU. A proper binding register would enable the ED doctor/police/ambulance crew to immediately know that this person who has just died has harvestable organs. the transplant team could be calling in the recipient before the body has even arrived at the hospital. This might seem a little macabre, but it would give hundreds of people a year a new lease on life.
Surely that is worth a little effort.