TCS Daily

Dying to See the Outcome

By David L. Kaserman - July 26, 2002 12:00 AM

As most people are now aware, there is in this country a severe and growing shortage of cadaveric human organs available for transplantation. Every year, for at least the past 30 years, the number of patients needing an organ transplant - such as a kidney, heart, or liver - has consistently exceeded the number of organs supplied. As a result, more than 50,000 of these patients have died, and it is estimated that less than half of the almost 80,000 people currently on waiting lists will live to receive the needed transplants.

Troubling as those figures are, what is even more disturbing is the fact that most of those deaths could have been avoided by adopting a more intelligent public policy for cadaveric organ procurement. Specifically, the organ shortage is the direct consequence of a longstanding policy that proscribes any payment to families of recently deceased individuals. That is, our organ procurement policy, which was codified into law in 1984, requires that all organ donations (acquisitions) occur at a price of zero. All other suppliers of inputs in the transplantation process - surgeons, nurses, organ procurement officials, and so on - are paid for their services. But the family of the donor, without whose consent a transplant operation cannot occur, must go uncompensated.

As anyone with basic economic literacy knows, a straightforward solution to any shortage is to allow price to rise to its equilibrium, market-clearing level. The organ shortage is no exception. It is the zero-price policy, and that policy alone, that is responsible for the organ shortage and its associate suffering and death. Consequently, a simple policy change that eliminates the legal constraint on cadaveric organ prices would lead to a substantial increase in the number of organs collected. Waiting lists would decline, waiting times would shorten, and many lives would be saved.

Toward that end, the American Medical Association (AMA) and the United Network for Organ Sharing (UNOS) recently approved resolutions condoning trials in which financial incentives will, for the first time, be used to encourage increased cadaveric organ donation. To conduct these trials, a legislative exemption from the legal ban on donor compensation will be required. It is imperative that such an exemption be provided as soon as possible, as the data obtained from these trials will provide the information needed to formulate a more effective organ procurement policy. If properly designed and conducted, the proposed experiments hold the promise of ultimately removing the legal ban on organ purchases altogether and, thereby, resolving the number one problem confronting transplant patients - the shortage of transplantable organs.

When such trials do begin, it is important that they be carefully designed and executed. In particular, it is likely that the results obtained will be quite sensitive to how the experiments are carried out. In this regard, at least six concerns exist:

  • Compassion -- Potential donor families should be approached with the same concern and consideration currently afforded them. That is, current protocols for requesting organ donations should continue to be followed. The financial incentive should be seen as a benefit that is provided in addition to (not instead of) the sense of helping others by making needed organs available. Money is no substitute for compassion.

  • Payment -- The payments offered should include a direct monetary award. Any constraints placed on the recipients' use of the funds (e.g., a requirement that they be used for funeral expenses, donated to charity, and so on) can reduce the value of the award. And, importantly, such restrictions may reduce it by different and unobservable amounts for different recipients. Thus, sole reliance on in-kind payments will bias the experiment's results in unknown ways. A menu of alternative forms of compensation could be used, but it should include direct payments as an option.

  • Variety -- The size of the payments offered in these trials should vary considerably in order to measure the responsiveness of supply across a wide range of prices. Payments form $500 to $5,000 per donor would seem a reasonable range to begin the trials. Such payments would represent a miniscule portion of overall transplant costs but are, nonetheless, likely to elicit a substantial supply response. Depending upon the responses obtained, payments outside that range could become necessary, although that outcome seems unlikely.

  • Geography -- Trials should be conducted in as many regions of the country as feasible. Currently, organ donation rates vary substantially across geographic areas for reasons we do not fully understand. Thus, results observed in one region may not carry over to other regions, and a wide geographic coverage becomes important.

  • Time -- Paying for organs represents a dramatic shift in organ procurement policy. It has not been done before. Consequently, both those requesting organ donation and the families they approach may need some time to adjust to this significant alteration in how these transactions have previously been conducted. The trials will need to proceed over a sufficiently long period of time to allow such adjustments to occur. At the same time, however, we must remember that, while we are experimenting, people are dying.

  • Monitoring -- Any change in public policy always affects some interest groups adversely, and organ procurement policy will be no exception. Some care will need to be taken in how the trials are conducted, and the process should be monitored as it proceeds. There are still people strongly opposed to the use of financial incentives to encourage organ donation, and (not surprisingly) many of them work in the current system of procurement and allocation. In all likelihood, the contemplated trials will have to be implemented concurrent with these groups' ongoing organ acquisition activities. While outright sabotage is unlikely, those in this business know that very subtle changes in how families are approached can have dramatic effects on rates of consent. Therefore, careful monitoring of the process by unbiased third parties may be needed.

Finally, it should by pointed out that, while a policy that allows organ procurement organizations (OPOs) to offer financial incentives to potential donors is unquestionably an important step in the right direction, it is not equivalent to a policy that would allow competitive organ markets to form. With compensation, the trials will necessarily be conducted within the existing institutional setting, in which organ acquisition is carried out by government-franchised OPOs at controlled prices. Importantly, these organizations are: (1) nonprofit; and (2) granted exclusive territories within which they each enjoy monopsony status. With organ markets, however, for-profit firms would compete aggressively to acquire the needed organs at market-clearing prices. The performance achieved under these alternative organizational structures is likely to differ, perhaps substantially. In particular, the organ markets approach is far more likely to resolve the shortage. But, for now, the proposed trails should proceed as quickly as possible. Many patients are dying to see the outcome.



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