I’ve generally believed that markets can solve most resource problems when allowed to do so. This shortage of organs is artificial. We have hundreds of millions of spare kidneys in the US. It’s like the government making farming illegal and creating a food shortage. There are plenty of healthy people who would donate a kidney, but they just have no reason to do so. If markets existed, we’d have more than enough supply to meet the present (and growing) demand. I was surprised to see so great a need contrasted to so little support for the idea. In my mind, society should try to ethically maximize the number of years its citizens are alive and well; it seems that organ markets would do that. I figured that there must be compelling ethical reasons to prohibit organ markets.
My professors brought many objections to the idea. Some of the reasons seemed minor or question-begging (e.g. “Commoditization of organs is objectionable”)(9). The two real objections to organ markets that I want to focus on are on issues of equity and undue inducement. First, would rich people benefit more than poor people? Second, would more poor people sell their organs and thus get coerced into taking bad risks?
Superficially, this seemed not utterly different from a normal trade. It’s a voluntary transaction. In general, people should be allowed to trade something they value less for something they value more. That is the essence of every Starbucks purchase, every home sale, and the foundation of our economy: trading your labor for money, and that money for stuff. And indeed, it does seem likely that if people were allowed to sell their organs, poor people would do so more than rich people. But is there a problem with that? Let’s imagine an analogous situation.
Imagine that I am the CEO of a drug company. My company invents a drug that cures breast cancer. The production cost is high and I decide to set the price near the cost of production. Nevertheless, only a tenth of those with breast cancer can afford it. As an act of corporate responsibility, I also donate free treatment to 1% of the poor with breast cancer. Also imagine part of the high cost of the drug is because it’s made out of a rare mineral found in the oceans and I have to hire a crew of 35 fishermen for a year to find enough for one cure (3). The work is non-technical, dangerous, and well-paying; thus I attract mostly poor people to do it. Is this situation unethical? Is the disparity in rich and poor so bad as to prohibit this from happening? Are the fishermen being unduly induced to do the dangerous work?
How does this connect to kidneys? If we are trying to save life, how could we do the best job at it? A kidney transplant recipient will live, on average, about 15 years longer than on dialysis. A healthy kidney donor will have minimal adverse health effects, certainly no more than 1 year of lost life on average (that is, some may die in surgery, others from later complications but almost all of them will live without complication; as far as I know, it has not been accurately measured but is presumed small). There are ~5,000 people dying on the transplant list every year. This list is thought to be biased toward the rich who can push and connive their way onto lists(7). So, every year, we’d roughly save 70,000 life-years annually if we had enough kidneys. Even assuming only 1 in 10 on the transplant list was poor, and everyone donating a kidney was poor, that would still be net 2,500 life-years saved for the poor.
This breast cancer cure story above is ethically equivalent to organ markets in terms of life-years lost by the poor and gained by the rich. 70,000 life years are saved amongst the diseased (breast cancer victims; people on the waiting list), 7,000 of which are for the poor (charity recipients; poor on the waiting list). To deliver this treatment, the poor are voluntarily exchanging risk for money and collectively losing 2,500 life years (fishermen; poor donors). The sick rich are living longer; the sick poor also are living longer. The only people who lose life years are the fishermen/donors who voluntarily take a risk for high pay.
It seems that this situation is equivalent to those which we now permit. Even without my imaginary company’s charity (that is, assuming the poor didn’t benefit in life years at all), it’s hard to argue that we should prohibit the saving of some lives by the voluntary action of others. Shall we pass laws like, “No one shall run into burning buildings to save people, especially not if one is being paid by rich people to do it?” On the contrary; we have government-run public safety systems that pay poorer people to take risks for richer people. It’s not movie stars who come to the rescue when Malibu catches fire. We permit dangerous jobs, and we permit poor people to do them. We consent to this system of risky jobs every every time we order a pizza or use a piece of paper; delivery servers and lumber workers have among the highest mortality rates (4). If allowing the poor to take risks for pay is absolutely unethical, then I ask you: how many drops of the blood of the poor are you comfortable having mixed into your pizza sauce, and how bloodstained is too bloodstained for your white paper?
What does losing 70,000 life-years mean? That means that this question is a big deal. To give you a sense of scale, in 2004, there were 42,000 life-years lost in Iraq and Afghanistan, 79,000 to fires and 86,000 to drowning (5). In other words, far more life is lost because of the government-created kidney shortage than to terrorist bullets and IEDs; the benefit of a kidney supply is about as good as preventing every lethal fire, or throwing a life preserver to every would-be drowning victim.
This is a big ethical fork in the road, and we should not change course without a compelling reason. 70,000 life-years annually is a compelling reason. It’s like someone invented a $1 cure for uterine cancer and we’ve outlawed its use for ‘ethical’ reasons (5). We’d better have a good ‘ethical’ reason to let people die. And they are dying, about 12 a day, because we’re worried about the equity of some rich people living a bit longer than they should, or poor people taking risks that they shouldn’t. If we legalize organ markets two things would happen: 1. Rich people and poor people would live longer 2. A lot of rich people’s money would end up in poor people’s pockets. Why is this bad?(8)
(3) Fisherman mortality: 71 deaths per 100,000 http://www.menatrisk.org/health/dangerousjobs.html Assuming an average US age of 36.7, and an average life expectancy of 78.2 years, and a mortality rate of fishing of 71.1 per 100,000 per year. That works out to A x (78.2-36.7)x71.1/100,000= 1 life-year (where A is the number of people exposed to this risk to equal 1 life-year). A = 33.9 fishermen working for a year together lose 1 life-year. Round to 35.
(4) Timber workers have a mortality of 117.8 per 100,000 and delivery servers have a mortality of 37.9 per 100,000.
(5) WHO BOD – 2009; US data from 2004. Breast Cancer: 612,000 DALYs. Uterine Corpus Cancer: 75,000 DALYs.
(6) The only difference, it seems to me, is not an ethical but practical. Organ donors would only get a fair price or have adequate supply in one of those two systems. Governments don't have a very good track record at setting prices.
(7) Another essay could be written on the economics of a market. With the amount that Medicare already spends on the poor for dialysis, it could probably buy the kidneys, transplant them, and have lots of money left over. There very well might not be any gap in rich and poor, at least when it comes to kidneys. In this case, the money flow would still be from rich (through taxes) to poor (after a stop in a Medicare account).
(8) This analysis is from a policy perspective, making assumptions about people acting out of self interest. Much more could be said about the virtue of self-sacrifice. I hope to write more on sacrifice, its virtue, and how medicine tends to prevent it. More on that later.
(9) The argument seemed to be of the form: 1. Commoditization is unethical 2. Selling organs is commoditization 3. Selling organs is unethical. This argument gives no actual insight into the problem, but simply confuses it with an econom-ethic word to obscure meaning. Why is premise 1 true?