Thursday, August 23, 2007

Selling Kidneys: Part I - Cadaveric Options

End-Stage Renal Disease (ESRD) has only two viable medical options to date: regular dialysis or kidney retransplantation. Dialysis is more expensive, less effective and limits certain lifestyles choices. Transplants, then, are a superior option to handling ESRD, but as it has already been said there is a severe shortage of kidneys. So three questions come to the fore: 1) What might increase the supply of kidneys? 2) Will that option be ethical? 3) Will that option be effective?

What might increase the supply of kidneys?

The good news is that there are a surprising number and a variety of ways to increase the number of transplantable kidneys. The bad news is that many of them are either questionably ethical or marginally effective or both.

One broad way to increase the kidney supply is to increase the number of cadaveric organ donations. Currently this country runs under an 'opt-in' system for cadaveric organ donation. In contrast Belgium, inter alia, runs on a 'opt-out' model, where everyone is presumed to be an organ donor unless they choose specifically and explicitly to not participate. Also, though no country is currently under a 'salvage' model it has been discussed by ethicists. Here citizen preference is completely disregarded - essentially the state has ownership of the body of deceased citizens for medical purposes: organ donation conscription. Of course, this final model has obvious ethical dilemmas.

There are two options with both ethical and effective promise.
1) Offer a 'required response' model. This is the blend between the 'opt-in' and 'opt-out' models. It would require citizens to make choice between being or not being an organ donor - most likely it would manifest as a question on yearly IRS tax forms. Polls have suggested that many people want or are willing to be organ donors, but have been deterred in the process to 'opt-in.' The hopes of this method would be to reduce the possible deterrence in becoming a organ donor, which is currently done through the DMV while registering/updating licenses. The downside of the model is that on its own it does introduce an incentive for donating.

2) The government offers a non-direct pecuniary incentive for those willing to be organ donors. This incentive could take many forms. Mostly likely it would be some type of premium reduction in the cost of health insurance (subsidized by the government or run through medicare), a one-time tax reduction, or subsidizing funeral costs. This would almost surely increase the number of donors, but there are ethical qualms about the introduction of any form of pecuniary incentives (this will be discussed at length - perhaps even ad nauseam - in future posts).

Both of these options are ethically innocuous enough to be at least conceivable options in the United States. However, the fact is they just won't be able to satiate the need for kidneys. (Though these measures should still be seriously considered because of the inability to do living transplantations on other organs, most poignantly hearts.

Even if some financial incentive is introduced to increase the number of citizens to enroll as organ donors it will not be able to adequately reduce the number of patients on the kidney waiting-list. Even if everyone was a donor there would likely still be need for kidneys because so few people die in a way compatible with donating.

So, while cadaveric options to increase the supply of organs may be a worthwhile venture, it will not be suitable to address the shortage for kidneys. That is why living kidney transplantations must be considered. In the next post I will address the medical issues surrounding living donation (LD) and what incentives might be introduced to increase such operations.

1 comment:

Dave Undis said...

There is a simple way to put a big dent in the organ shortage -- give organs first to people who have agreed to donate their own organs when they die.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.

Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.