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Financial Compensation for Organ Donors is Working
Only one country in the world has eliminated the shortage of transplant kidneys. Only one country in the world has legalized financial payments to kidney donors. That country is Iran.
In an important report, transplant surgeon nephrologist Benjamin Hippen argues that the Iranian system has saved thousands of lives and it should be used if not as model then to inform America's efforts to eliminate its deadly shortage.
In the Iranian system organs are not bought and sold at the bazaar. Instead a non-profit, volunteer-run Dialysis and Transplant Patients Association (DATPA) mediates between recipients and donors. Recipients who cannot be assigned a kidney from a deceased donor and who cannot find a related living donor may apply to the DATPA. The DATPA identifies a possible donor from a pool of people who have applied to the DATPA to be donors. Donors are medically evaluated by transplant physicians, who have no connection to the DATPA, in just the same way as are non-financially compensated donors.
The government pays donors $1,200 plus limited health insurance coverage. In addition, charitable organizations also provide renumeration to impoverished donors. Thus demonstrating that Iran has something to teach the world about charity as well as about markets. Will wonders never cease? Recipients may also contribute to donor remuneration.
Hippen reports that the system works well, although better follow-up of donors would be an improvement. He concludes with a call to legalize financial compensation in the United States.
Posted by Alex Tabarrok on April 14, 2008 at 07:40 AM in Economics | Permalink
Comments
...i wish there was a way to take a snapshot of people's moral unease with 'paying for donors,' so that when this becomes the norm, we can show people "hey, you remember how much you hated this? maybe there are other things you're wrong about." Unfortunately, the change will be rather gradual, and most people will just gradually come to be okay with the idea, and hold on to their other ideas just as stubbornly.
Posted by: shawn at Apr 14, 2008 8:24:27 AM
Good point, Shawn.
I'm envisioning some kind of kidney options market for underpriviledged kids. But, of course that's what scares the heck out of the people you are talking about.
So, for a while we'll dicker around with making motorcycle riders sign donor cards and "nudging" people. Then, as you say, some day our progeny won't remember what it was like to have a kidney shortage.
Posted by: Andrew at Apr 14, 2008 8:35:35 AM
You'll notice that this is a liberal-like institution of checks and balances between many parties:
donors
recipients
evaluating physicians
DAPTA
government
charities
Mere legalization of payments will not create such an institution: it opens the door to libertarian-style abuses of all sorts.
I'd welcome laws creating such an institution adapted for our society.
Posted by: Mike Huben at Apr 14, 2008 8:49:41 AM
I haven't read the report, but assuming Alex describes it properly the program seems effective. Pragmatically, I'm fearful of the PR consequences of selling the idea to a broader audience with Iran as an example. In addition to having to get over their aversion to remunerative organ exchange, will the public now have to confront geopolitical bugaboos? How easy would it be for talking heads to take cheap shots ("Well why don't we do everything Iran does?").
Again, I love the idea and think it's awesome that there's an example somewhere. Just unfortunate that it comes from a place that comes with so much baggage.
Posted by: Daniel at Apr 14, 2008 9:07:30 AM
Dr Hippen's paper on the Iranian system is excellent.
The kind of system that would work best in the U.S. is one in which governments -- state or federal -- offer an incentive to prospective donors.
These individuals would be evaluted medically and psychologically just as altruistic donors. Their kidney would go to the next person in the queue. To avoid battles over "exploiting the poor," incentives would take the form of a health insurance, a contribution to the donor's 401k, loan forgiveness, tuition voucher for their children, etc.
If the government (a third party) procured the organ, and not the individual then worries that only the wealthy would benefit are soothed. (Nor would grey market develop as some fear.) And if no immediate cash is given then worries about the poor being "coerced" into relinquishing a kidney are also addressed. It is not low-income people that we are trying to protect from their own impulsivity but rather people who are *desperate.* And the way you handle that is by not offering what desperate people want: cash now.
More details will be forthcoming in an AEI book called When Altruism Isn't Enough - The Case for Compensating Kidney Donors (due out in Fall 08).
Also, polling data on attitudes toward donor compensation-- which I have summarized and am happy to send to anyone interested -- are encouraging.
Of course, NOTA has to be revised so that rewarding donors is no longer a felony.
Posted by: Sally Satel at Apr 14, 2008 9:26:08 AM
Alex, that it works is beside the point. You see, allowing organ sales symbolizes the wrong sorts of things. And we all know that the symbolic value of institutions matters more than the functional value, right?
Posted by: J. at Apr 14, 2008 9:37:10 AM
Wait a minute, isn't Iran an EVIL!!! place?
That's what David Frum said, and surely he can't be wrong.
Posted by: Bartman at Apr 14, 2008 9:48:37 AM
The Hippen paper is excellent. Unfortunately, it will not be read by a single policy maker in a position to actually make a difference to save lives. Its findings will still have to be filtered through the sensibilities of the majority who have proven easily demogogued(sp?) on this issue.
I agree with Andrew that one day civilization will get there. Unfortunately we're a long way off.
Posted by: M. Hodak at Apr 14, 2008 9:55:18 AM
marc...for spelling, you've got to work with firefox: automatically spell checks and red-underlines misspelled words in any form.
It can't stop me from writing stupid things...but at least they're spelled correctly.
Posted by: shawn at Apr 14, 2008 10:08:17 AM
does the market for human eggs have any relevance to this discussion? has there been any economic analysis?
Posted by: ptk at Apr 14, 2008 10:12:59 AM
Bartman´s sarcastic remarks are exactly the sort of snark that endangers this sort of program. The fact that Frum might or might not be right on Iranían "evilness" says nothing about how good this program is. Though he may not have meant it this way, his suggestion that the soundness of this program in any way undermines the moral geopolitical critique of Iran works wonders in discouraging potential allies in favor of a more liberal market in transplant organs.
Posted by: hojak at Apr 14, 2008 10:35:44 AM
Hojak,
Bartman's connection between the U.S. transplant policy and the "moral geopolitical critique" of Iran is not all that fleeting. Both are based on false assumptions and and both prey on people's unsubstantiated fears.
Posted by: Chairman Mao at Apr 14, 2008 10:52:55 AM
Chairman:
I'm glad you got it. When I worked in the Gulf I got to know many real, live, actual Iranians. Despite the mad mullahs, Iran is a place where thought and introspection are still viewed as positive attributes, and not limp-wristed leftish afflictions, like in certain segments of certain other countries.
I'm not at all surprised that the Iranians were able to come up with a sensible, nuanced and balanced policy and procedural framework, that effectively meets the net underlying goal of extending and improving human life.
Posted by: Bartman at Apr 14, 2008 11:17:08 AM
Moral qualms about such a program evaporate once you've seen someone die for lack of a donor organ. Incidentally the Iranians have also legalized (and subsidized) gender change operations, and have instituted the practice of "temporary marriages" where the couple determines the length of their arrangement and which legally ensure that any children born are considered legitimate and entitled to inheritance/support.
Had a Scandanavian country done any of this, we'd be congratulating them on how advanced they were.
Posted by: hass at Apr 14, 2008 12:22:11 PM
That would be "remuneration". I'm sure people prefer to be paid, and not just counted.
Posted by: foo at Apr 14, 2008 12:25:56 PM
Eh. I would've thought that Iran executed enough people for homosexuality or jaywalking that they would have a good supply of kidneys.
(The U.S. is better at sentencing people to death than actually executing them, but when we *do* execute them, we are distressingly likely to do so by either poison or electrocution, neither of which can be good for potentially lifesaving organs.)
Of course, then there's "The Jigsaw Man" by Larry Niven.
Posted by: Anderson at Apr 14, 2008 12:44:24 PM
That would be "remuneration". I'm sure people prefer to be paid, and not just counted.
Ah, but it's worth a little more if you're being counted again. Still not as good as being paid, though.
Posted by: sidereal at Apr 14, 2008 1:40:11 PM
Fixed. By the way, I know it's more fun to post my spelling errors for all the world to note but you could just email me! :)
Thanks
Alex
Posted by: Alex Tabarrok at Apr 14, 2008 2:42:27 PM
Daniel says: " Again, I love the idea and think it's awesome that there's an example somewhere. Just unfortunate that it comes from a place that comes with so much baggage."
What baggage? Where? Says who? Does the whole of humanity -- all 3,000 million of us -- consist solely of Washington DC policy nutcases?
Posted by: Sudha Shenoy at Apr 15, 2008 7:17:19 AM
Sudha: Isn't that more like 6,500 million?
Anderson: How many people does Iran execute per year? Wikipedia's article on Capital Punishment said about 317, which probably isn't enough jaywalkers and gays to supply many kidneys.
There's plenty to hate about Iran's government, but that doesn't negate the fact that they are doing something very sensible and humane w.r.t. organ transplants.
Posted by: albatross at Apr 15, 2008 9:27:00 AM
Ive read some disturbing news about the Iranian system that basically confirms the worst fears of opponents of organs sales in the United States.
My hunch is that Hippen's paper describes the system as it should be, rather than as it is--according to the column that ran in the Wall Street Journal earlier this year, Iran has problems getting the recipients who most need a transplant to the top of the list. Equally disturbing are reports that impoverished families pressure their children to sell their kidneys, and that middlemen often take most or all of the money.
Advocates of legalized organs sales in the United States claim that our government could regulate this sort of thing. Im not so sure.
Posted by: Ryan at Apr 15, 2008 1:34:37 PM
the practice of "temporary marriages"
I believe that is actually a loophole so it is possible to practice prostitution.
Posted by: class-factotum at Apr 16, 2008 9:17:25 AM
