The Coming Market in Body Parts?

The current supply of donated hearts, kidneys and livers for transplants is far too little to meet demand. So economists have a simple solution: create a market. Let people sell their organs and let donors buy them. It’s a case of balancing supply and demand. Today’s Wall Street Journal gives fresh attention to the perennial idea of establishing an organ market as a way to decrease the growing waiting list for kidneys. Organ sales have been banned in the U.S. since 1984 under a bill introduced by then-Rep. Al Gore.

WSJ reporter Laura Meckler describes the crusade by transplant surgeon Arthur Matas of the University of Minnesota, to create a trial market as a way to supply kidneys to the 70,000 people now waiting for transplants. Meckler also describes the objections of Francis Delmonico, another prominent kidney surgeon who until recently was the president of the United Network for Organ Sharing, which runs the nation’s organ-distribution system. “The sale of bodies or body parts would undermine the fundamental values of our society,” Dr. Delmonico has testified to Congress.

This whole issue is so fraught because it reveals the ethical and social implications of commodifying something. To put a price on a human organ implies that it is a fungible thing without social or personal meaning. And what, if not bodies, should have social and personal meaning? Markets can also induce people to regard their own organs — and themselves — as objects for sale: the ultimate in legalized dehumanization. But critics reply that, with some 4,400 people dying while waiting for a kidney, what’s so bad about inducing a larger supply of kidneys through payments? Lives could be saved!

What makes Dr. Matas’ argument so beguiling is that it partially addresses objections. He does not call for a pure, unregulated market. The government would set the price of kidneys, and insurers and Medicare would pay that price for transplant organs. Kidneys would go to whomever is at the top of the waiting list, rich or poor, not to the highest bidder. And potential sellers would have to be screened in advance, and their medical conditions monitored after the transplant.

In theory, it all sounds somewhat reasonable. But stop for a moment and ask how effective environmental or product safety regulation is. We all know that regulation is an inherently flawed oversight mechanism. It is often corrupt, in fact, and it can disguise and legitimate egregious harms. It can be gamed. Why would organ regulation be any different? Moreover, even an excellent regulatory system would not deal with the built-in inequities and value shifts that would occur if organs were bought and sold. The most obvious one is that the poor would be the most likely sellers of organs. Already, people in developing countries are the prime sellers of kidneys in international black markets. Do we really want to open those floodgates and turn the South into a living warehouse of human organs for the wealthy folks of the North?

From a strict economic perspective, of course, this makes perfect sense — just as it make perfect economic sense for the U.S. to dump its toxic wastes in developing countries, an argument once made by Lawerence Summers. The point is, such scenarios are ethically repugnant. But few economists are eager to see their discourse trumped by anything so squishy and subjective as “social ethics.”

Once we get into a straight cost-benefit analysis, we lose any perspective on social equity. For example, Dr. Matas published a paper that calculated that getting kidney transplants for people currently on dialysis treatment — which is often paid by Medicare — could save the government $95,000 per patient. Why not compensate donors and let the government break even, or save money?

But the thing about market transactions is that they don’t really take account of the larger circumstances, beyond the transaction. Kidney sellers in India often suffer from post-operation complications, and the cash payments don’t necessarily improve their finances. Worse, the kidney market could poison the whole doctor-patient relationship. Can we trust what the doctor is advising, or does he or she have a vested interest in making the sale? And what would happen to the organ donation system if suddenly money were being paid for healthy organs? The market could easily crowd out voluntarism and altruism, a dynamic that has been seen in open software communities into which money is introduced as an inducement for work.

In some ways, the whole controversy over organ sales is being propelled by new medical technologies that make transplants feasible on a global scale, and by our own fantasies of developing “spare parts” for a body that can be indefinitely regenerated. This theme is explored in a terrific book by Catherine Waldby and Robert Mitchell, Tissue Economies.

Ultimately, I think Dr. Delmonico has the stronger case. Organ sales cannot be effectively regulated. And regulation doesn’t even begin to address the troubling social and ethical precedents that would be set. Here’s one area of human life were markets simply do not belong. But check out the WSJ debate of economists on this issue.