MANAGED CARE December 2004. ©MediMedia USA
You can buy just about anything on the Internet these days — including lifesaving body parts. Where do we draw the line?
A recent incident has brought a twist to the issue of commercial transactions involving human organs.
This October, we were spectators of a case in which a 58 year-old candidate solicited a kidney donor on an Internet site (MatchingDonors.com). The Web site put him in touch with a 32 year-old who wanted to do "something big" for someone else. This first "Internet-brokered" transplant ignited a dialog that promises to keep organ donation policymakers warm this winter.
Transplant candidates, providers, and payers should watch for possible new ethical guidelines from UNOS (the United Network for Organ Sharing, which administers transplants in the U.S.), addressing this unprecedented situation.
Some alarm
One issue inciting alarm was that MatchingDonors.com charges $295 per month to transplant solicitors. The press treated this aspect of the story indignantly, because this fee is several times higher than those charged by traditional, not-for-profit organizations, but the main focus of media scrutiny was the $4,500 paid by the recipient to the donor as reimbursement for travel and lost income. Federal law prohibits payment for organs.
However, it is vague whether reimbursement for expenses constitutes payment. The press reported this aspect of the story as a scandalous — and possibly illegal — case of organ selling.
At least two questions spring from this incident. First, what should our attitude be toward transplant matchmaking arranged by for-profit entities via the Internet? Second, regardless of whether the Denver transplant actually constituted organ selling, what exactly is ethically problematic about an arrangement between two consenting adults for the purchase of a kidney?
Current public policy is firmly against organ selling. However, there has been an ongoing dialog among ethicists about what aspects of this practice are unethical, and whether this is simply because of unwanted consequences (which might be managed somehow), or whether some fundamental principle makes organ selling inherently immoral.
The list
The problem of finding a donor can dominate the life of a transplant candidate. There are about 31,000 people currently waiting for kidneys. Each day, 63 people on the list receive a transplant, but another 16 die because organs aren't available.
UNOS rigorously oversees the process that assigns priorities for available organs according to a complex formula that differs for each organ type. Extraordinary effort is taken to neutralize the effects of wealth, celebrity, race, age (to an extent), and other biases that do not bear directly on the medical success of the procedure.
Counselors often advise candidates to "talk to your extended family," "tell your friends at work," and "post a notice on your church bulletin board." Directed donations are a small portion of the pool, compared to cadavers and anonymous donations.
A no-brainer?
Of course, simply finding a willing donor does not mean that there will be a tissue match. But, having a designated donor — even if the match does not work out for the designated recipient — may advance the recipient's position on the list.
In this light, using the Internet to bring potential donors and candidates together sounds like a no-brainer. What's the difference between the Internet and a church bulletin board — or billboards and newspaper ads? For one thing, cost. Candidates lacking funds for advertising are at a disadvantage. But does this inequality forbid all advertising? What about people without a family, a church, or employment? Does their plight mean that those who are connected to networks may not avail themselves of them? This would be a cruel imposition of "fairness."
Potential for misunderstanding
We should be mindful of the potential for misunderstanding, confusion, and abuse in marketing. It's guaranteed that advertising would produce some tasteless commercials, assuming that the same folks who work on political campaigns are available during nonelection years.
However, if it increased the pool of donors, wider advertising would be justified. Even those without the means to arrange private listings still move up the list when somebody ahead gets a match. Those who don't advertise still benefit from the success of those who do.
Regardless of the path that brings a donor and a recipient together, they must still satisfy screening criteria that include medical, psychological, financial, and ethical standards, a-nd resolve conflicts of interest on all sides.
This triage function and the actual provision of transplant services need to remain the purview of qualified facilities, under expert supervision, to provide a check upon wildcat or impulsive eBay organ swappers.
Sticky question
The question of payment for organs is stickier. On the one hand, the image of a homeless indigent signing up at the storefront kidney bank causes a pang of empathic anguish, and there are practical problems with organs from socially disadvantaged donors, including real medical risks from unhealthy lifestyles.
On the other hand, some would say it is presumptuous and paternalistic to forbid a starving Bombay street beggar to collect money to feed himself and his family for a couple of years, in return for sacrificing an organ he won't need anyway, if he dies.
In fact, this exact transaction is reported to be increasingly common in India. Is it exploitation — or capitalism? What if a mining company offered that beggar a job digging coal, which might carry an even greater chance of death? Or a job as a firefighter — arguably even more risky? How do we define the moral limits of what a person can earn by maiming his or her own body?
We pay millions to watch pugilists cause each other permanent brain damage, and thousands of high school athletes sacrifice their knee ligaments every year, with the enthusiastic approval of their parents.
All the issues
Why prohibit the sale of a kidney? True, there is potential for coercion that may color the voluntariness of the decision. We might want to protect the Bombay beggar (or the college student paying off a loan) from making a choice to be regretted later.
Yet economic pressure is simple compared to the issues involved with donations between family members.
Imagine learning that you are the only possible match for your mother-in-law, abusive uncle, or delinquent daughter. Conflicts of interest among altruistic donors span the full human spectrum, yet current policy considers these ethically acceptable while monetary transactions are not.
I bet we'll find a way to allow compensation for organ donors that preserves the ethical values important to us while we're waiting for the stem cell gang to make this whole stressful business fade into the history of medicine.