The Meat Market
Wall Street Journal. (Eastern edition). New York, N.Y.: Jan 9, 2010.
[In a race to prevent thousands of needless deaths a year, countries from Singapore to Israel are launching innovative new programs to boost organ donation. Alex Tabarrok on paying donors for kidneys, favoritism on waiting lists and the shifting line between life and death.] Harvesting human organs for sale! The idea suggests the lurid world of horror movies and 19th-century graverobbers. Yet right now, Singapore is preparing to pay donors as much as $50,000 for their organs. Iran has eliminated waiting lists for kidneys entirely by paying its citizens to donate. Israel is implementing a "no give, no take" system that puts people who opt out of the donor system at the bottom of the transplant waiting list should they ever need an organ. Millions of people suffer from kidney disease, but in 2007 there were just 64,606 kidney-transplant operations in the entire world. In the U.S. alone, 83,000 people wait on the official kidney-transplant list. But just 16,500 people received a kidney transplant in 2008, while almost 5,000 died waiting for one. To combat yet another shortfall, some American doctors are routinely removing pieces of tissue from deceased patients for transplant without their, or their families', prior consent. And the practice is perfectly legal. In a number of U.S. states, medical examiners conducting autopsies may and do harvest corneas with little or no family notification. (By the time of autopsy, it is too late to harvest organs such as kidneys.) Few people know about routine removal statutes and perhaps because of this, these laws have effectively increased cornea transplants. Routine removal is perhaps the most extreme response to the devastating shortage of organs world-wide. That shortage is leading some countries to try unusual new methods to increase donation. Innovation has occurred in the U.S. as well, but progress has been slow and not without cost or controversy. Organs can be taken from deceased donors only after they have been declared dead, but where is the line between life and death? Philosophers have been debating the dividing line between baldness and nonbaldness for over 2,000 years, so there is little hope that the dividing line between life and death will ever be agreed upon. Indeed, the great paradox of deceased donation is that we must draw the line between life and death precisely where we cannot be sure of the answer, because the line must lie where the donor is dead but the donor's organs are not. In 1968 the Journal of the American Medical Association published its criteria for brain death. But reduced crime and better automobile safety have led to fewer potential brain-dead donors than in the past. Now, greater attention is being given to donation after cardiac death: no heart beat for two to five minutes (protocols differ) after the heart stops beating spontaneously. Both standards are controversial -- the surgeon who performed the first heart transplant from a brain-dead donor in 1968 was threatened with prosecution, as have been some surgeons using donation after cardiac death. Despite the controversy, donation after cardiac death more than tripled between 2002 and 2006, when it accounted for about 8% of all deceased donors nationwide. In some regions, that figure is up to 20%. The shortage of organs has increased the use of so-called expanded-criteria organs, or organs that used to be considered unsuitable for transplant. Kidneys donated from people over the age of 60 or from people who had various medical problems are more likely to fail than organs from younger, healthier donors, but they are now being used under the pressure. At the University of Maryland's School of Medicine five patients recently received transplants of kidneys that had cancerous masses. Why would anyone risk cancer? Head surgeon Dr. Michael Phelan explained, "the ongoing shortage of organs...