Organ transplantation is a life-saving treatment option for patients with organ failure. It is also cost-effective compared to alternatives such as dialysis. However, the current organ supply in the United States (US) does not meet the demand, resulting in excess mortality and disability. Over 100,000 were waiting for organ transplants in 2020, and about 40,000 Americans are added to the waitlist every year (Astier, 2020). Due to organ shortage, about 7,000 Americans die while waiting for transplantation (DeRoos et al., 2019). Organ shortage, particularly kidney, is expected to worsen in the next ten years because the US population is aging. End-stage kidney disease (ESKD) is more prevalent in older people than younger adults. These issues indicate the need for effective policy options to expand the donor pool. Legalizing the sale of organs in a regulated market is one policy option suggested to increase organ supply, particularly kidney and liver.
Technical Aspects
Healthy living donors can safely donate one of their kidneys or part of the liver to their relatives or biologically unrelated persons. Living organ donation, particularly kidney and part of the liver, carries minimal risk provided the donor is healthy (Siddique et al., 2020). Although the health risks are minimal, living organ donation carries significant financial costs that create barriers. Living donors incur expenses such as travel and medical costs and lost wages during recovery that, if not reimbursed, can adversely impact living donors’ financial and social well-being (Siddique et al., 2020). Current law permits recipients or the government to cover donors’ expenses, such as travel, medical, recovery, and lost wages (Health Resources and Services Administration, (HRSA), 2020). Compensating a living donor beyond the actual expenses of donating amounts to a sale or profiting, which is currently illegal in the US.
Public Policy
This section discusses public policy options proposed to address the current organ shortage and associated mortality. Current policy debates surrounding organ transplantation have primarily focused on incentivizing living organ donations. Several stakeholders have pushed for increased reimbursement of living organ donors to incentive donation. In 2020, the HRSA expanded the scope of reimbursable expenses for living organ donors to include lost wages and child/elder care (HRSA, 2020). Reimbursement for living donors was previously limited to transportation, surgery, healthcare, and recovery costs. Organ donation based on presumed consent is another public policy proposal to address the organ shortage in the US. A presumed consent policy would consider everyone a cadaveric donor unless they explicitly opt out before death (DeRoos et al., 2019). Presumed consent policy has been leveraged to increase organ supply in many European countries, including Spain, Belgium, and France. Lastly, other stakeholders have proposed amending the National Organ Transplantation Act (NOTA) to legalize organ sales in a regulated market (Astier, 2020; Elías et al., 2019; Jones, 2020). This is the most controversial policy proposal for increasing organ supply in the US. It extends the existing living donor reimbursement policy that only pays donation expenses, such as travel, medical, recovery, and lost wages. In a legal organ market, donors would profit from the sale of kidneys, part of liver, and any other parts that can be harvested from living persons.
This essay discusses the pros and cons of the third policy proposal, legalizing organ sales. Legalizing organ sales will address the current shortage, save lives, and lower healthcare costs. Supporters of a legal organ market argue that paying living donors above donation, healthcare, and recovery costs would motivate more donations and increase supply (Astier, 2020; Parada-Contzen & Vásquez-Lavín, 2019). This argument is supported by research showing that past donor reimbursement initiatives have increased living organ donations (HRSA, 2020). Therefore, it is valid to argue that paying living donors beyond the costs of donation, healthcare, and recovery should motivate organ donations further. From an ethical perspective, proponents of a legal organ market argue that increasing organ supply through financial incentives saves lives that would otherwise be lost due to shortage (Elías et al., 2019; McCormick et al., 2022). This is the core ethical argument of the pro side. Saving lives is a moral good (beneficence). In addition to saving lives, expanding access to kidneys through a legal organ market would save the healthcare system millions (McCormick et al., 2022). Successful kidney transplants reduce the need for costly dialysis.
Although legalizing the sale of organs would expand supply and save lives, critics have raised several ethical concerns. Opponents of legal organ market argue that legalization would commodify the human body, widen existing health inequalities, and exploit people experiencing poverty. Opponents fear that paying for organs commodifies the human body and violates our inherent dignity and value (Reese & Pies, 2023; Sever et al., 2022). Human value cannot be quantified, but legalizing organ sales would turn body parts into commodities that can be priced. In addition to this ethical concern, opponents believe that an organ market would widen existing gaps in access to organ transplant (Sever et al., 2022; Reese & Pies, 2023). Opponents fear that legalizing organ trade means that access would be based on ability to pay rather than need, hence only high-income people will benefit. Lastly , opponents argue that legalizing organ sales would result in exploitation of poor and low-income people (Jones, 2020). Only those with low incomes will have the financial motivation to participate in the organ market as vendors. Consequently, low-income people, those experiencing homelessness, and some racial groups will be overrepresented as organ vendors.
Opinion and Conclusion
In conclusion, both sides of the debate on legalizing organ sales to increase supply and access offer valid arguments. I, however, feel the critics’ ethical argument that legalizing organ sales will commodify the human body and degrade our inherent dignity is weak because we are already paying people for sperm and ova donations, surrogacy, and lost body parts in work-related cases. From the care ethics perspective, legalizing the sale of organs would increase their supply and save thousands of people who would rather die prematurely from organ failure. Increased organ supply through legal sales would also save the healthcare system millions of dollars due to reduced frequency of dialysis and other costly interventions. Ethical concerns that legalizing organ sales would widen the organ access inequity and exploit low-income people can be addressed through a regulated market arrangement. For example, the legal organ market can be designed such that the government is the sole buyer. The government, through a designated agency, would then allocate the procured organs based on need and adjust prices to reflect recipient’s income. The government would also consider paying living donors in installments or cashless options such as tuition. Such payment models would discourage organ donors who are primarily motivated by cash benefits. Researchers, economists, and policymakers should assess the feasibility of such a tightly regulated organ market.
References
Astier, H. (2020, February 18). Should organ donors be paid? The heavy toll of US kidney shortage. BBC News. https://www.bbc.com/news/world-us-canada-51266959
DeRoos, L. J., Marrero, W. J., Tapper, E. B., Sonnenday, C. J., Lavieri, M. S., Hutton, D. W., & Parikh, N. D. (2019). Estimated association between organ availability and presumed consent in solid organ transplant. JAMA Network Open, 2(10), e1912431. https://doi.org/10.1001/jamanetworkopen.2019.12431
Elías, J. J., Lacetera, N., & Macis, M. (2019). Paying for kidneys? A randomized survey and choice experiment. American Economic Review, 109(8), 2855–2888. https://doi.org/10.1257/aer.20180568
Health Resources and Services Administration (HRSA). (2020). Removing financial disincentives to living organ donation. Federal Register. https://www.federalregister.gov/documents/2020/09/22/2020-20804/removing-financial-disincentives-to-living-organ-donation
Jones, S.-A. (2020. December 16). A legal organ market: Should it exist?. UAB Institute for Human Rights. https://sites.uab.edu/humanrights/2020/12/16/a-legal-organ-market-should-it-exist/
Lentine, K. L., Lam, N. N., & Segev, D. L. (2019). Risks of living kidney donation: Current state of knowledge on outcomes important to donors. Clinical Journal of the American Society of Nephrology: CJASN, 14(4), 597–608. https://doi.org/10.2215/CJN.11220918
McCormick, F., Held, P. J., Chertow, G. M., Peters, T. G., & Roberts, J. P. (2022). Projecting the economic impact of compensating living kidney donors in the United States: Cost-Benefit analysis demonstrates substantial patient and societal gains. Value in Health, 25(12). https://doi.org/10.1016/j.jval.2022.04.1732
Parada-Contzen, M., & Vásquez-Lavín, F. (2019). An analysis of economic incentives to encourage organ donation: Evidence from Chile. Latin American Economic Review, 28(1). https://doi.org/10.1186/s40503-019-0068-2
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