The Hidden Cost of Organ Sale
* Corresponding author: David J. Rothman, email@example.com
The idea of establishing a market for organs is now the subject of unusual controversy. Proponents emphasize the concept of autonomy; opponents invoke fairness and justice. The controversy, however, has given sparse attention to what it would mean to society and medicine to establish a market in organs and to the intended and unintended consequences of such a practice. This article addresses these issues by exploring the tensions between ‘extrinsic’ and ‘intrinsic’ incentives, suggesting that donation might well decline were financial incentives introduced. It also contends that social relationship and social welfare policy would be transformed in negative ways and that a regulated market in organs would be extraordinarily difficult to achieve. Finally, it argues that organ sale would have a highly detrimental affect on medicine as a profession.
The idea of establishing a market for organs, although certainly not new, is now attracting unprecedented support. Much of the enthusiasm comes from members of the transplant community, but it is also favored by a growing number of economists and bioethicists who believe that the sale of body parts has become ‘morally imperative’. To be sure, the practice is explicitly prohibited by U.S. law, rejected by the guidelines of almost every national and international transplant society and opposed by many commentators. But never before has a market solution been so vigorously endorsed.
Almost every article advocating legalization opens by noting the shortfall in organs (over 50 000 people await a kidney), and the resulting increase in morbidity and mortality. At the same time, the number of living donors has increased dramatically (they now provide more than half of all kidneys for transplantation), to the benefit of recipients and apparently without harm to themselves. Thus, as one transplant surgeon has observed: ‘Discussing organ sales simply does not feel right, but letting candidates die on the waiting list (when this could be prevented) does not feel right either’ (1–3).
Ethics has occupied a central place in the debate over the sale of kidneys, with two key principles vying for primacy. Proponents emphasize the concept of autonomy—the right of persons to sell their body parts, free of heavy-handed paternalism. Opponents invoke standards of fairness and justice; the poor will sell their kidneys to the rich, engendering systematic exploitation. What has been relegated to the margins, however, is full consideration of the implications of such a system for medicine and for society. Proponents flatly assert that sale would increase the supply and not reduce the rate of altruistic donation. They posit that such a market could be effectively regulated and that sellers would benefit greatly from the financial windfall. But these claims are not well substantiated and may prove wrong. No less important, they fail to take into account the many other possible effects of allowing a market in organs (4,5).
Because the intended and unintended consequences of policy change cannot be easily predicted, this analysis is put forward in tentative, even speculative, terms. The aim is to raise considerations that may have been glossed over, to highlight the possibilities that have not been imagined, and to prompt second thoughts about postulates that seem obvious. The intent is not to persuade one side or the other that these projections will inevitably be realized but to encourage both sides to deepen and widen the scope of their concerns. Just as studies of the possible impact of legislation on the environment are mandated, so the likely impact of legalization of organ sale warrants consideration.
Advocates think it self-evident that market incentives will yield more organs for transplantation. ‘People are more likely to do something if they are going to get paid for it’ (6). And sellers will not drive out donors. Whatever financial incentives exist, siblings and parents will continue to donate to loved ones.
These expectations, however, may be disappointed. Since the 1970s, a group of economists and social psychologists have been analyzing the tensions between ‘extrinsic incentives’—financial compensation and monetary rewards, and ‘intrinsic incentives’—the moral commitment to do one's duty. They hypothesize that extrinsic incentives can ‘crowd out’ intrinsic incentives, that the introduction of cash payments will weaken moral obligations. As Uri Gneezy, a professor of behavioral science at the University of Chicago School of Business, observes: ‘Extrinsic motivation might change the perception of the activity and destroy the intrinsic motivation to perform it when no apparent reward apart from the activity itself is expected’ (7–12). Although the case for the ‘hidden costs of rewards’ is certainly not indisputable, it does suggest that a market in organs might reduce altruistic donation and overall supply.
Perhaps the most celebrated analysis of the tension between intrinsic and extrinsic incentives is Titmuss' work in blood donation. His book, The Gift Relationship (1971), argued that the ‘commercialization of blood represses the expression of altruism (and) erodes the sense of community’. Payment undermined the altruistic motivations of would-be blood donors. Titmuss supported his hypothesis by comparing blood donation in the United States and the United Kingdom. Analyzing data from England and Wales over the period 1946–1968, where the sale of blood was prohibited, Titmuss found that the percentage of the population who donated blood and the amount of blood donated steadily increased. By comparison, in the United States, where the sale of blood was allowed, donations declined. Because U.S. data were more fragmentary, Titmuss drew as best he could on a variety of sources, including surveys, municipal statistics and comments by medical experts and blood bank officials. Nevertheless, he confidently concluded: The data, ‘when analyzed in microscopic fashion, blood bank by blood bank area by area, city by city, state by state’, revealed ‘a generally worsening situation’ (12).
Following Titmuss's lead, other studies have tried to buttress the empirical case for crowding out. One intriguing experiment turned an Israeli day care center into a research site. It was not unusual for some parents to arrive late to pick up their children; center administrators complained but levied no penalties. The researchers first took a baseline measure of the frequency of lateness and then had the center post a notice on its bulletin board: ‘The official closing time… is 1600. Since some parents have been coming late, we… have decided to impose a fine…. NIS 10 ($2.50) will be charged every time a child is collected after 1610. The fine will be calculated monthly, and is to be paid with the regular monthly payment’. Although one might have predicted that late pickups would decline, the number actually increased. And even when several weeks later the researchers had the center cancel the late charge, the higher level of lateness persisted.
To explain these outcomes, the researchers proposed that in the prefine days, parents interpreted the extra time that the teacher spent taking care of the children as ‘a generous, nonmarket activity’; they did their best to arrive on time because the teacher was considerate and should ‘not be taken advantage of’. Once the fine was levied, the added time of child care had a price and parents believed they could purchase it as often as necessary. ‘When help is offered for no compensation in a moment of need, accept it with restraint. When a service is offered for a price, buy as much as you find convenient’. Moreover, the lateness persisted after the elimination of the charge because there was no reverting to the older norm once the charge had been levied: ‘Once a commodity, always a commodity’ (10).
Another research team divided a group of teenagers who had been volunteering to collect contributions for disabled children into three different cohorts: one was not paid for their service, the second was paid a small amount, and the third was paid a more substantial amount. Using the total funds that each group collected as the outcome measure, they found that the best returns came from the volunteers, the next best from the substantially paid, and the least from the lowest paid. Financial incentives, the investigators concluded, proved less effective than moral commitments (13–15).
Still others have highlighted the potential conflict between extrinsic and intrinsic rewards by framing the following question: You see an older man hauling two boxes of bottles to the recycling center on a rainy afternoon. Knowing that the center does not reimburse for bottles, you admire his commitment to environmental concerns. Now imagine that the recycling center reimburses at a nickel a bottle and you witness the same scene. Might your admiration turn to pity and stigma replace esteem? Might you consider the older man to be very cheap or poverty stricken because he is returning bottles? Indeed, would you yourself be more or less likely to recycle where you paid for the items (11)?
None of these exercises are without important methodological weaknesses. The Israeli day care center may not have made the fine severe enough. Had the lateness penalty been $50 or $100, not $2.50, extrinsic incentives might have worked better. By the same token, had the teenagers been very well paid for their services, the reimbursed groups might have outperformed the volunteers. These points notwithstanding, the literature on the hidden cost of rewards raises the prospect of a market crowding out donation. Rather than donate and run the risks of surgery and future complications, family and friends might opt to purchase an organ; and if the market is as efficient as proponents claim, the purchased organ would be equally sound. This outcome is precisely what anthropologists have found in developing countries where organ sale is routine. In India, for example, recipients did not want to ask family members to donate and family members preferred to purchase (16).
The same dynamic might occur here were organ sale permitted. Moral incentives are now very well established in federal and state laws and an ethos of altruism is emphasized by transplant teams. A new federal act (2004) and some dozen states now allow reimbursement for donor travel, lost wages and living expenses (17). But no one permits financial gain. Altering the rules by introducing financial incentives might undermine the system, discourage donation, and reduce supply. To counter this possibility, proponents might point to the sale of sperm and egg and argue that opening a market in these body parts did not bring deleterious consequences. However, egg and sperm are not analogous to kidneys. For one, there was no tradition of altruism in sperm collection. Common practice was for students, usually medical students, to give their sperm for nominal sums. Second, clinics have not relied heavily on the altruism of family and friends for egg donation, perhaps because of reluctance among some would-be recipients to have the biological mother so prominent a figure in the child's life (18,19). Thus, the sale of egg and sperm does not directly speak to the tension between extrinsic and intrinsic reward.
Confronting these potential negative outcomes, yet other proponents have suggested that organ sale be introduced on an experimental basis so its impact could be closely monitored. Select several states or a region to serve as laboratories and were the total number of organs to decline, the experiment in sale would be ended. But even this approach would not be free of risk. As suggested in the Israeli day care center research, there may be no going back. Once a commodity, always a commodity.
Social Relations and Kidney Sale
What impact might organ sale have on day-to-day social interactions? Let us make a few preliminary assumptions. The purchase price for an organ would have to be nontrivial. One calculation, based on cost savings were transplantation to more completely replace dialysis, sets the figure at $275 000 per kidney (20). For sake of argument, let us divide that number by a little more than half and use a price of $125 000. Because government policy would have to strongly favor such an arrangement, let us also presume that the sum would be tax free.
Would sellers be attracted? Undoubtedly. They would likely come from the lower class and lower-middle class, although at this price some in the middle class might participate as well. It is doubtful that anyone with significant means would sell a kidney even for a substantial sum.
The removal of the kidney would leave an indelible mark in the form of a scar. Were the procedure done laparoscopically, it would be small and not easily distinguished from other surgical interventions. Still, it would be visible, if not to strangers then to intimates. Evidence of the sale would thus be written on the body and speak to moral character. It would point not to heroism and generosity of spirit (intrinsic reward) but to desperation and avariciousness (extrinsic reward). In fact, a study conducted in Iran found that kidney sellers suffered extreme shame in their community (21). In the United States, the opprobrium might be even greater. Historians of punishment, for example, have proposed that the practice of public torture was abandoned in the 18th century not because the punishments were ineffective, but because citizens shared new and acute sensibilities about bodily integrity, which the spectacle of dismemberment violated (22). Although a surgical scar does not rise to this level, it may still be asked whether we are ready to countenance the signs of kidney sale.
The everyday consequences of an organ market might create other problems. If kidney sale brought a payment of $125 000 tax free, it would make financial sense to undergo the procedure sooner rather than later. For someone at age 21, investing $125 000, perhaps in a mutual fund, would likely double the sum by age 30. Should one then boast of the sale to a prospective partner? At what point in a relationship would one relate the fact? Would it be presented as having the means for a down payment on a starter home? Would the partner be obliged to sell a kidney in the future to enable a move to a still larger home? Should one anticipate inquiries from prospective in-laws on whether you have yet sold your kidney? Should one anticipate such questions from bill collectors (in India this is not hypothetical), or from welfare or unemployment officers or from attorneys in bankruptcy proceedings? Should one also anticipate parents asking an 18-year-old to sell a kidney to offset substantial college tuition costs, or later, wedding costs?
In sum, the implications for social relationships of transforming body parts into commodities are unknown and might bring unintended negative consequences. As Margret Radin, a professor of law, has astutely observed: ‘The law both expresses and works to form and evolve cultural characteristics and commitments…. “Preferences” bring law into being, but law also makes and changes “preferences”’. Because there is feedback between law and culture, we might come to regret the legalization of kidney sale (23).
The Myth of the Regulated Market
Proponents offer very different models for a market in organs, making it difficult to know precisely what is being advocated. Some would restrict compensation to cadaveric organs and give credits to families who agree to the removal. Others, including a committee of the American Medical Association, endorse a futures market in organs: they would compensate would-be donors for agreeing to organ removal upon death (24–29). Still others urge a regulated market among living vendors but provide almost no details (1,6,20). Mostly everyone rejects a public auction with the kidney going to the highest bidder; the preference is for distribution by a central, UNOS-like organization, permitting individuals to sell but not to purchase an organ (30–32). Such compromises, it should be noted, are inconsistent with proponents' attachment to the market. After all, people are even more likely to do something if they are very well paid for it—so why not permit auctions?
Whatever the proposed system, regulation may not be readily accomplished. Once a market is lawful, half-way measures that allow for sellers but not for buyers might prove inoperative. Effectively regulated markets typically involve so-called ‘natural monopolies’ wherein entry points can be effectively policed. (Think of electric power, telephone service and railroads.) By contrast, in kidney sale, with almost everyone eligible to enter the market, oversight will not be easily established or maintained. So too, as most students of regulated markets are quick to admit, change almost inevitably carries unintended consequences. Deregulate the market in energy trading and Enron scandals occur; deregulate the telephone market and the communications industry is transformed; deregulate the savings and loan business and corruption breaks out. Hence, the question must be asked: since practices may develop in ways that cannot be predicted or controlled, are we ready to live with a system that makes kidneys a commodity?
Who May Sell?
With significant sums available to kidney vendors, the question of eligibility assumes new importance. Medical selection criteria for sellers would almost certainly come under intense pressure, with physicians urged to discount potentially disqualifying characteristics (from hypertension to a history of substance abuse). Would-be sellers might also withhold information on present habits or past personal and family medical histories, following the market maxim of let the buyer beware.
Some proponents would restrict sale to U.S. citizens (31,32), but the limitation seems neither logical nor appropriate. Why penalize green card holders or long-term residents? Or for that matter, tourists or illegal immigrants? Since the goal is to maximize the number of organs and since kidney sale ostensibly benefits the vendor, why exclude anyone? Why should not the poor of Bombay enjoy an option given to the poor of Appalachia? Why deprive a patient of a kidney because the seller must travel? The end result, however, might give new meaning to the lines of Emma Lazarus engraved on the Statute of Liberty: ‘Give me your tired, your poor….the wretched refuse of your teeming shore’.
The Impact on Medical Professionalism
Allowing kidney sale would pose fundamental challenges to professional medical ethics and doctor-patient relationships (33). Currently, in the practice of living organ donation, donor altruism mitigates, although does not entirely eliminate, the principle of ‘do no harm’. In the pioneering days of living donation, surgeons like Joseph Murray were deeply troubled about the morality of ‘maiming’ one person (in his case, one twin) for the benefit of another (34–36). This concern was overcome only by emphasizing the deep emotional ties between donor and recipient. The psychological damage to a twin, proscribed from saving his brother's life, reset the risk-benefit calculus and justified the surgeon's intervention. But a strictly commercial transaction offers no mitigating circumstances. The physician unavoidably becomes an accessory to a patient's income-generating activity, a circumstance almost without precedent. Although surgical techniques have improved, risks still remain, so medicine would have to qualify the principle of ‘do no harm’ because of a dollar amount.
Upward Mobility through Kidney Sale
One claim frequently made to justify kidney markets is that the sums paid to vendors will redound to their economic benefit. The bioethicist Robert Veatch recently retracted his long-held opposition to sale, arguing that because American society has so neglected the poor, objections must be put aside. Social welfare programs are so inadequate that it is wrong to oppose a measure that might assist them (37). The empirical question, however, is whether organ sale would actually benefit the poor or, to the contrary, bring even more deleterious effects.
The best data comes from the third world. In India, as Goyal et al. have documented, 87% of kidney sellers reported a deterioration of health status and one third, a decrease in family income. Of 292 persons who sold a kidney to pay off debts, 74% still had debts 6 years later, and those in poverty increased from 54% prior to the sale to 71% after the sale (38). These findings are reinforced by Cohen's in-depth interviews with 30 sellers and their families in Madras. Although they were attempting to pay off debts, he found that ‘sellers are frequently back in debt in a few years’. He also discovered that debt collectors became more aggressive in ‘kidney selling zones’, making a system of sale self-reinforcing (16).
To be sure, the American experience might be different, with the economic returns from sale promoting property mobility. But kidney sale might also have a negative impact on social welfare policy. Some proponents have argued, for example, that kidney sellers should receive lifetime health insurance, and in this way move the country closer to national health insurance. But legalized kidney sale might have the very opposite effect. If you want health insurance, sell your organ. Surely this is not the most promising method for accomplishing a more just distribution of health-care benefits. Were there no organ shortage, no one would propose kidney sale as a way of equalizing economic conditions.
However lamentable the consequences of the shortage of organs, kidney sale might turn out to be counterproductive. It might not produce the increase in organs that proponents anticipate. More, it might engender conditions inimical to professional medical practice and social cohesion.
This work was supported by a Robert wood Johnson Foundation Investigator Award in Health Policy Research to the authors and by the Samuel and May Rudin Foundation. The views expressed are those of the authors and imply no endorsement by either foundation. We are especially grateful to Natassia Rozario for her outstanding research assistance.