Far more people need kidneys than the supply of available organs. The current U.S. waitlist for a kidney has reached nearly 100,000 people, but only between 16,000 and 17,000 kidneys are transplanted each year, according to recent data from the Health Resources & Services Administration. Economists have long pondered whether offering people financial incentives to donate kidneys might be the best way to address this huge mismatch between supply and demand. Now, growing evidence from trials in other areas of medicine suggests that financial incentives are a potent way to improve national health.
“There is a huge gap between deceased donation and existing demand. This gap will never be filled by deceased donation,” says Dorry Segev, an associate professor of surgery at Johns Hopkins University School of Medicine. He adds that people are living longer and increasingly suffering from diseases such as high blood pressure that make kidney donation impossible. “So you have to try to get living donors to meet the demand that is out there.”
Kidneys are among the few organs where living donation is feasible: Many people are healthy enough to live problem-free with only one kidney. Currently, around a third of kidney transplants come from living donors. Such kidneys lead to better health outcomes, with living donations lasting roughly twice as long as those that come from deceased donors, according to the National Kidney Registry.
The vast majority of these donations go to family members; people are less willing to donate to strangers. They might be tempted by financial compensation, but the National Organ Transplant Act of 1984, outlawed the sale of human organs. Economists and health policy experts, however, argue that the time has come to reconsider financial incentives for kidney donation.
“Despite many and multifaceted methods to get people to donate kidneys, various approaches to increase organ procurement have not succeeded,” says Benjamin Hippen, a nephrologist at Metrolina Nephrology Associates and a clinical associate professor at the University of North Carolina, Chapel Hill. That, in turn, drives desperate patients to turn to medical tourism and the organ black market. “It’s a dangerous and unjust system,” he says.
Cash for Kidneys?
Bolstering the case are positive outcomes from various clinical trials of financial incentives for reducing smoking, obesity, and other unhealthy behaviors. “Current trends regarding the use of financial incentives in medicine suggest that the time is ripe for new consideration of payments for living kidney donation,” write Matthew B. Allen and Peter P. Reese of the University of Pennsylvania’s Perelman School of Medicine in a recent editorial in the Clinical Journal of the American Society of Nephrology.
Such incentives need not necessarily involve cash payments. Some proposals call for less controversial measures, such as providing donors with free lifetime health coverage. “Reducing disincentives to donation — such as covering lost work and medical insurance for people who have donated — has value,” Segev says. Hippen adds that such provisions could “accomplish larger public policy objectives” by helping track the health of kidney donors over decades or longer. Currently, donors are only followed for two years, so many questions remain unanswered about the longterm health impacts of kidney donation.
Meanwhile, estimates of the social cost of the organ waitlist are enormous. Dialysis — the most common form of treatment for end-stage renal disease — requires multiple lengthy sessions per week, leading to poor quality of life. Transplant recipients also tend to live 10 to 15 years longer than those on dialysis, and more than 4,000 people die each year while on the kidney waitlist, according to the Organ Procurement and Transplantation Network. The average wait time of six years is also a problem, as researchers have found that the longer a person is on dialysis, the shorter their transplanted organ tends to last.
“We estimate a $500,000 per-person value in getting access to kidneys,” says Gary S. Becker, a professor of economics and sociology at the University of Chicago, who recently co-wrote an economic analysis of a potential kidney market. This would place the total cost of the wait list at approximately $50 billion.
In contrast, rough estimates place the monetary value of a kidney at “somewhere between $10,000 and $25,000,” says Becker, who is also a professor at the University of Chicago’s Booth School of Business and who won the 1992 Nobel Prize in Economics for extending economic analysis to “a wide range of human behavior and interaction, including nonmarket behavior.” This estimate includes lost time from work due to recovery and other health complications as well as the risk of death from surgery and a diminished quality of life. (Kidney transplants are considered very safe, with only roughly a 0.03% risk of death.) “The purchase and sale of kidneys would fully eliminate waiting lists and the shortage of kidneys,” Becker says.
Moreover, unlike the current system, you “can time surgery around the situation of the giver and recipient. Instead of missing your turn if you are too sick, you can wait a while until you recover,” Becker adds.
A Slippery Slope
Even proponents of kidney markets, however, acknowledge the visceral reaction that the idea incites. “It touches on a horror that is sometimes difficult to express adequately,” Hippen says. “But that will dissipate, just as it did for sale of blood products.” The U.S., he says, represents the largest supplier of these products, such as plasma and clotting factors, while European countries forbid any compensation for blood donation. “They won’t buy it from their citizens, but they will buy it from the U.S.,” Hippen says.
Others worry about the “slippery slope” that offering financial compensation provides. “The problem is that when you offer money to people for an item, but that item has eligibility criterion, it becomes difficult to assess those criteria, putting both the donor and recipient at risk,” Segev says. For example, patients will be more likely to hide or disguise high blood pressure to ensure they could donate.
Another obstacle is the medical community. “There has to be a tremendous degree of trust between donor and recipient, and donor and provider for a market to work,” Segev adds. “Only a minority of physicians, however, favor financial incentives for donation.”
Hippen, however, points out that financial compensation for kidneys is already happening — in perhaps its most dangerous form. While there is no comprehensive data on the organ black market, he says, a recent World Health Organization memorandum estimated that underground trafficking comprises 10% of all transplanted organs. Such illicit markets offer fewer protections for both donor and recipient and disproportionately harm the extremely poor in countries such as China and India.
“Demand for illegal organs is primarily driven by wealthy people,” Hippen says. “If demand is sated in people’s home countries, there won’t be significant economic return to support an illegal market. We can cut off the head of the snake.”