Monday, December 31, 2007

Organ Donation: The "Gift" of Life?

During one's medical training, the subject of organ transplantation becomes inescapable. For myself, I've encountered it at least twice, both during my two weeks on the liver transplant team, as well during my month on the renal service during my internal medicine rotation when I went to the transplant clinic. On the surface of it, organ transplantation is one of the great successes of modern medicine as well as seemingly straightforward ethical proposition. However, after closer examination it becomes clear that organ transplantation, while still being a net positive, is not as straightforward as one would like it to be.

The article "Desperately Seeking a Kidney" in the NYTimes highlights many of the main issues. The article is written by a psychiatrist who was seeking a kidney transplant. She describes what led her to be a candidate for organ transplantation, her time on the waiting list, her quests to solicit family, friends, and eventually strangers for a donation, and how the process affected both her and her potential donors. As medical students, we often deal with science of transplation, such as the immunology behind organ rejection, and the pharmacology

Organ transplantion is encouraged by many groups, often as the "gift of life." And while I still believe that organ donation is a positive action and should occur, I must confess my own misgivings about the process, especially given the experience in the article above. In my mind, the ideal solution would involve using stem cells or some other synthetic process to provide a replacement organ, making donation virtually obsolete. Of course, this is not reality (yet, anyway). So, we are left with donation as it is. As the author discusses, in the U.S., organ donations are "gifts" by definition, as there is no other legal way to obtain an organ. However, this leads to the "tyranny of the gift," as she describes: the burden the donor feels about being obligated to make a donation, the indebtedness the recipient may feel towards the donor. It should be noted that in the majority of the cases, organ donors view the experience positively, but it still important to consider the psychological aspect of donation.

To play devil's advocate for a moment though, I wonder why we impose a system of donation that requires that organs be a gift. I understand that potential for corruption, but the U.S. has a tradition of free markets, and there is a clear market here with a well-defined demand and supply. Of course, the market could not be completely 'free,' but it perhaps could be much less 'deregulated' than it is right. Currently, my understanding of the transplant system is that organs are listed on a list on the national registry (United Network for Organ Sharing, or UNOS). Potential recipients are ranked on a list; the ranking is based on various criteria that vary by organ. When a recipient is at the top of the list, they get the first shot at an organ. The donors are anonymous unless the recipient brings their own donor (such as a sibling). Now, imagine a similar system with anonymous donor-recipient pairings, but instead of giving a 'gift,' people are allowed to bid on organs. There are several benefits to this system, especially in light of the psychological issues discussed above. First, by offering compensation for organs, this could potentially expand the pool of potential donors, leading to more lives being saved. Second, by making the donation a transaction instead of a gift, it is possible that people would have less psychological hangups, and would view their donors as merely someone who they made a deal with, such as a car salesman, instead of their 'life savior.' Lastly, by putting a price on the organ, in theory, this would help curtail the black market for organs (okay, maybe not, but in theory, it would help).

The obvious problem here is that richer recipients will be better able to purchase an organ. However, perhaps this could be mitigated by utilizing the ranking system to weight dollars of people in greater need more highly. Still, I think most people would find the system unsavory, even if it were to lead to a net increase in organ donations. Perhaps a system utilizing a Dutch auction, or even one in which there is a fixed price for organs (such as the 'market' in place for the eggs of smart, young women with a college degree from an accredited institution) may increase the amount of donation.

In the end, I think the system in place, while less than ideal, is the best compromise between ideals and practicality. However, I think the notion of the market is interesting to consider because, depending on how science advances, we may one day have to ponder what the price of a synthetic organ should be.

1 comment:

  1. Over half of the 98,000 Americans on the national transplant waiting list will die before they get a transplant. Most of these deaths are needless. Americans bury or cremate about 20,000 transplantable organs every year. Over 6,000 of our neighbors suffer and die needlessly every year as a result.

    There is a simple way to put a big dent in the organ shortage -- give organs first to people who have agreed to donate their own organs when they die.

    Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.

    Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

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