Kidney vending: the "Trojan horse" of organ transplantation

The promise of xenotransplantation: a challenge

According to many scholars, kidney xenotransplantation promises to mitigate the organ supply shortage. This claim has a certain obviousness to it: by flooding the market with a new source of kidneys, xenotransplantation promises to be a panacea. Our goal is to challenge this claim. We argue that xenotransplantation may increase rather than decrease demand for kidneys, may reduce kidney allotransplants, and may be inaccessible or otherwise unused. By offering the challenge, we hope to show deeper reflection is needed on how xenotransplantation will affect the dearth of available organs.

Unjust organ markets and why it is irrelevant that selling a kidney is the best option

An important argument against prohibiting organ sales is that it removes the best option available to individuals in dire circumstances. However, this line of reasoning fails to recognise that selling a kidney on a regulated market is only the best option in a very narrow comparison, where a regulated organ market is compared with banning organ sales. Once we acknowledge this narrowness, selling a kidney is not the best option. This paves the way for a distributive justice-based critique of the 'best option' argument for organ markets, which illuminates that organ markets should be compared with a broader set of alternatives. If providing the option of selling a kidney is not the best option, but rather the best option we are willing to provide, and one which means that many people will remain in poverty and unjust circumstances, then this reflects poorly on those societies willing to offer only this option and not a better one.

The Altruism Requirement as Moral Fiction

It is widely agreed that living kidney donation is permitted but living kidney sales are not. Call this the Received View. One way to support the Received View is to appeal to a particular understanding of the conditions under which living kidney transplantation is permissible. It is often claimed that donors must act altruistically, without the expectation of payment and for the sake of another. Call this the Altruism Requirement. On the conventional interpretation, the Altruism Requirement is a moral fact. It states a legitimate constraint on permissible transplantation and is accepted on the basis of cogent argument. The present paper offers an alternative interpretation. I suggest the Altruism Requirement is a moral fiction-a kind of motivated falsehood. It is false that transplantation requires altruism. But the Requirement serves a purpose. Accepting it allows kidney donation but not kidney sale. It, in short, rationalizes the Received View.

Efficiency and the futures market in organs

There has been considerable debate over regulated organ markets. Especially current markets, where people sell one of their kidneys while still alive, have received increased attention. Futures markets remain an interesting and under-discussed alternative specification of a market-based solution to the organ shortage. Futures markets pertain to the sale of the right to procure people's organs after they die. There is a wide range of possible specifications of the futures market. There are, however, some major unaddressed efficiency concerns. This article presents this class of concerns and discusses the implication for organ futures markets. It identifies a number of inefficiency sources pertaining to crowding out, bad organs, costs and missed opportunities, family refusals, moral hazard and strength of the provided incentive. However, a complete assessment of futures market requires better knowledge regarding the potential reaction from donors, families and health professionals.

A regulated system of incentives for living kidney donation: Clearing the way for an informed assessment

The kidney shortage continues to be a crisis for our patients. Despite numerous attempts to increase living and deceased donation, annually in the United States, thousands of candidates are removed from the kidney transplant waiting list because of either death or becoming too sick to transplant. To increase living donation, trials of a regulated system of incentives for living donation have been proposed. Such trials may show: (1) a significant increase in donation, and (2) that informed, incentivized donors, making an autonomous decision to donate, have the same medical and psychosocial outcomes as our conventional donors. Given the stakes, the proposal warrants careful consideration. However, to date, much discussion of the proposal has been unproductive. Objections commonly leveled against it: fail to engage with it; conflate it with underground, unregulated markets; speculate without evidence; and reason fallaciously, favoring rhetorical impact over logic. The present paper is a corrective. It identifies these common errors so they are not repeated, thus allowing space for an assessment of the proposal on its merits.

If the Price is Right: The Ethics and Efficiency of Market Solutions to the Organ Shortage

Due to the shortage of organs, it has been proposed that the ban on organ sales is lifted and a market-based procurement system introduced. This paper assesses four prominent proposals for how such a market could be arranged: unregulated current market, regulated current market, payment-for-consent futures market, and the family-reward futures market. These are assessed in terms of how applicable prominent concerns with organ sales are for each model. The concerns evaluated are that organ markets will crowd out altruistic donation, that consent to sell organs is invalid, that sellers will be harmed, and that commodification of organs will affect human relationships in a negative way. The paper concludes that the family-reward futures market fares best in this comparison but also that it provides the weakest incentive to potential buyers. There is an inverse relationship between how applicable prominent critiques are to organ market models and the increase in available organs they can be expected to provide.

Would government compensation of living kidney donors exploit the poor? An empirical analysis

Government compensation of kidney donors would likely increase the supply of kidneys and prevent the premature deaths of tens of thousands of patients with kidney failure each year. The major argument against it is that it would exploit the poor who would be more likely to accept the offers of compensation. This overlooks the fact that many poor patients desperately need a kidney transplant and would greatly benefit from an increased supply of kidneys. The objective of this study is to empirically test the hypothesis that government compensation of kidney donors would exploit the poor. Exploitation is defined by economists and several noted ethicists as paying donors less than the fair market value of their kidney. Exploitation is expressed in monetary terms and compared with the economic benefit recipients receive from a transplant. Data are from the Scientific Registry of Transplant Recipients and the United States Renal Data System annual data reports. Educational attainment is used as a proxy for income. We estimate that if the government rewards living donors with a package of non-cash benefits worth $75,000 per kidney, donors would not be exploited. Much more important, this compensation would likely end the kidney shortage, enabling many more patients with kidney failure to obtain transplants and live longer and healthier lives. The value of kidney transplantation to a U.S. recipient is about $1,330,000, which is an order of magnitude greater than any purported exploitation of a living donor (zero to $75,000). Consequently, the aggregate net benefit to the poor alone from kidney transplantation would increase to about $12 billion per year from $1 billion per year currently. Most of the benefit would accrue to poor kidney recipients. But poor donors would receive the fair market value of their kidney, and hence would not be exploited. If the government wanted to ensure that donors also received a net benefit, it could easily do so by increasing the compensation above $75,000 per donor.

Deemed consent: assessing the new opt-out approach to organ procurement in Wales

In December 2015, Wales became the first country in the UK to move away from an opt-in system in organ procurement. The new legislation introduces the concept of deemed consent whereby a person who neither opt in nor opt out is deemed to have consented to donation. The data released by the National Health Service (NHS) in July 2017 provide an excellent opportunity to assess this legislation in light of concerns that it would decrease procurement rates for living and deceased donation, as well as sparking an increase in family refusals. None of these concerns have come to pass, with Wales experiencing more registered donors, fewer family refusals and more living donations. However, as the number of actual donors has dropped slightly from a high level, the situation must be monitored closely in the years to come.

Kidney Sales and Market Regulation: A Reply to Semrau

Luke Semrau argues that the documented harms of existing organ markets do not undermine the case for establishing regulated systems of paid kidney donation. He offers two arguments in support of this conclusion. First, Semrau argues that the harms of kidney selling are straightforwardly amenable to regulatory solution. Second, Semrau argues that even in existing black markets, sellers would likely have experienced greater harm if the option of selling a kidney were not available. This commentary challenges both of Semrau's claims. I argue that there is no reason to believe that kidney sellers benefit from the current black market trade in organs, and highlight a number of potential issues regarding the effectiveness and feasibility of Semrau's proposed market regulations.

Policy options for increasing the supply of transplantable kidneys in Singapore

Kidney transplantation is the preferred treatment for eligible end-stage renal disease patients. However, the supply of donated kidneys has been consistently insufficient to meet the transplantation requirements of the population. In this paper, I discuss the feasibility of several policy options that engage potential donors or key individuals in a Singapore context, including financial and non-financial incentives for deceased/living organ donors and their families, improving actualisation rates of both donation after brain death, donation after cardiac death through quality improvement programmes and remuneration schemes, and a media platform for directed organ donation. I conclude by highlighting the most feasible policies to be considered.

Philosophy of organ donation: Review of ethical facets

Transplantation ethics is a philosophy that incorporates systematizing, defending and advocating concepts of right and wrong conduct related to organ donation. As the demand for organs increases, it is essential to ensure that new and innovative laws, policies and strategies of increasing organ supply are bioethical and are founded on the principles of altruism and utilitarianism. In the field of organ transplantation, role of altruism and medical ethics values are significant to the welfare of the society. This article reviews several fundamental ethical principles, prevailing organ donation consent laws, incentives and policies related to the field of transplantation. The Ethical and Policy Considerations in Organ Donation after Circulatory Determination of Death outline criteria for death and organ retrieval. Presumed consent laws prevalent mostly in European countries maintain that the default choice of an individual would be to donate organs unless opted otherwise. Explicit consent laws require organ donation to be proactively affirmed with state registries. The Declaration of Istanbul outlines principles against organ trafficking and transplant tourism. World Health Organization's Guiding Principles on Human Cell, Tissue and Organ Transplantation aim at ensuring transparency in organ procurement and allocation. The ethics of financial incentives and non-financial incentives such as incorporation of non-medical criteria in organ priority allocation have also been reviewed in detail.

From blood donation to kidney sales: the gift relationship and transplant commercialism

In The Gift Relationship, Richard Titmuss argued that the practice of altruistic blood donation fosters social solidarity while markets in blood erode it. This paper considers the implications of this line of argument for the organ market debate. I defend Titmuss' arguments against a number of criticisms and respond to claims that Titmuss' work is not relevant to the context of live donor organ transplantation. I conclude that Titmuss' arguments are more resilient than many advocates of organ markets suggest, and more relevant to the debate than is commonly appreciated.

Transplant tourism: the ethics and regulation of international markets for organs

"Medical Tourism" is the travel of residents of one country to another country for treatment. In this article I focus on travel abroad to purchase organs for transplant, what I will call "Transplant Tourism." With the exception of Iran, organ sale is illegal across the globe, but many destination countries have thriving black markets, either due to their willful failure to police the practice or more good faith lack of resources to detect it. I focus on the sale of kidneys, the most common subject of transplant tourism, though much of what I say could be applied to other organs as well. Part I briefly reviews some data on sellers, recipients, and brokers. Part II discusses the bioethical issues posed by the trade, and Part III focuses on potential regulation to deal with these issues.

Transplant tourism: a modern iteration of an ancient problem

PURPOSE OF REVIEW

To explore the scope and implications of emerging global problem of transplant tourism, a practice in which patients seek transplant services (most commonly kidney allografts) in countries other than their permanent residence. Potential remedies that must be implemented if abuses are to be curbed are also offered.

RECENT FINDINGS

Although traveling abroad for medical services may not be problematic from a number of perspectives, what makes transplant tourism so troubling is its link with organ trafficking and transplant commercialism. Unlike many illegal markets, however, this one is driven by the need of patients with irreversible kidney failure, who, along with kidney vendors, are the most vulnerable participants in the process in terms of medical and financial outcomes.

SUMMARY

This review explores the scope and implications of transplant tourism, and offers potential remedies that must be implemented if abuses are to be curbed.

The prohibition of kidney sales and organ markets should remain

PURPOSE OF REVIEW

There is an ongoing vigorous debate regarding the wisdom of the current prohibition of organ sales in the United States. We argue that this prohibition must remain in place. We discuss the current international realities regarding organ vending in order to show that even a so-called 'regulated' market brings with it danger to the welfare of transplant donors, their recipients, and potential recipients of nonrenal organs. We counter the specific arguments made in favor of organ sales while recommending multiple measures that can serve to remove disincentives to noncommercial organ donation. We encourage the investment in innovative healthy transplant practice for the benefit of all.

RECENT FINDINGS

In 'natural experiments' performed in developing countries the outcome for kidney vendors, in terms of both their medical and psychosocial health, has been shown to be poor. A high incidence of serious infections has been reported in recipients of vended organs.

SUMMARY

Commercialization of living kidney donation does not serve the interests of the donors, endangers the health of recipients, and undermines the healthy development of the international transplant endeavor.

Key issues in transplant tourism

Access to organ transplantation depends on national circumstances, and is partly determined by the cost of health care, availability of transplant services, the level of technical capacity and the availability of organs. Commercial transplantation is estimated to account for 5%-10% (3500-7000) of kidney transplants performed annually throughout the world. This review is to determine the state and outcome of renal transplantation associated with transplant tourism (TT) and the key challenges with such transplantation. The stakeholders of commercial transplantation include: patients on the waiting lists in developed countries or not on any list in developing countries; dialysis funding bodies; middlemen, hosting transplant centres; organ-exporting countries; and organ vendors. TT and commercial kidney transplants are associated with a high incidence of surgical complications, acute rejection and invasive infection which cause major morbidity and mortality. There are ethical and medical concerns regarding the management of recipients of organs from vendors. The growing demand for transplantation, the perceived failure of altruistic donation in providing enough organs has led to calls for a legalised market in organ procurement or regulated trial in incentives for donation. Developing transplant services worldwide has many benefits - improving results of transplantation as they would be performed legally, increasing the donor pool and making TT unnecessary. Meanwhile there is a need to re-examine intrinsic attitudes to TT bearing in mind the cultural and economic realities of globalisation. Perhaps the World Health Organization in conjunction with The Transplantation Society would set up a working party of stakeholders to study this matter in greater detail and make recommendations.

Sociological and ethical issues in transplant commercialism

PURPOSE OF REVIEW

'Global transplant commercialism' (practices and policies involving international trade in organs from living vendors, e.g., 'transplant tourism') is currently subjected to unprecedented criticism. In parallel, the debate around 'local transplant commercialism' (practices and policies that confine trade in organs from living vendors to national markets or economic unions) is heating up. In an attempt to assess the potential outcomes of these trends, this article reviews and discusses some sociological and ethical issues, ending with a proposal for a reinvigorated anticommercialist strategy.

RECENT FINDINGS

The current international campaign against global transplant commercialism is conducted by an ad hoc alliance between strange bedfellows, proponents of local transplant commercialism on the one hand and opponents of any transplant commercialism on the other. Disparities in the rigor of the respective ethical discourses, the expanding list of precedents of legitimized commerce in the human body, and the political economy of transplantation, all suggest that the former have the upper hand.

SUMMARY

Recent achievements in the struggle against international organ trafficking may not herald the abolition of transplant commercialism but rather presage its reconfiguration in deglobalized forms. In light of such a prospect, those who wish to prevent the pervasive commodification of the human body from entering the gates of transplant medicine should consider devising a new, perhaps more radical, strategy.

Incentivizing living organ donation

PURPOSE OF REVIEW

The number of organs available for the patients on the transplant waitlist remains at a disproportionate low. All possible methods to curtail this shortage, including providing donors with incentives, have been proposed. This article reviews recent publications addressing the benefits and risks involved in incentivizing living donation.

RECENT FINDINGS

The debate about the ethics, feasibility, and possible models for compensating organ donors has been prominent in recent literature. As certain countries take lead on this initiative, others are cautiously weighing in on the impact implementations of such policies may have on the society, especially on the underprivileged.

SUMMARY

The shortage of organs has resulted in proposal of strategies that encroach on certain moral and ethical principles. Providing incentives to donors is one such strategy that is likely to receive a lot of attention in the next few years.

The international realities of live donor kidney transplantation

Horvat and coauthors report on trends in living kidney transplantation in 69 countries, having assembled the data from registries, national societies, the medical literature, and direct contact with transplant centers. Assembling worldwide data on live-donor kidney transplants is a commendable accomplishment that serves the international transplant community well.