::: Shailendra Nair :::

Imagine your little girl needs a heart transplant. If she gets it in time, she’ll live a long, healthy life. Without it, your child has, at most, one year to live. You put her on a heart donor waiting list, full of hope. A year – surely that’s plenty of time. But then, the days bleed into weeks, the weeks into months and you watch your child slowly lose her valiant battle. Time is running out. You don’t want to believe it. You tell yourself a donor will be found, has to be found.

But suddenly, the 365 days that, at first, seemed like all the time in the world, has run out. Your little girl draws her last breath. You hold her lifeless body in your arms, wondering how it could be that in all this time, no donor could be found.

Tragically, this saddest of endings is all too common

According to the government site organdonor.gov, “An average of 18 people die each day waiting for transplants that can’t take place because of the shortage of donated organs.” And that number is on the rise. The graph on the government’s organ donor website shows we are falling further and further behind.

Is there anything we can do about it? Under the current system, probably not. But there are alternatives. Each has its own moral and legal issues.

One alternative is to institute a presumed consent system. You know that decal on your driver’s license that says you want your organs to be donated upon death? Under this system, that decal wouldn’t be necessary. You’d be presumed to consent unless you specified that you do not consent to having your organs donated after death. Spain has instituted this program with significant success. In addition to presumed consent, Spain uses dispatching donor networks that monitor emergency rooms around the country. The networks ask families of the recently deceased for permission to harvest organs. So far, the networks have seen only a 15% national rate of refusal. To be fair, Spain is a standout. Of the 24 countries in the EU that have this system, Spain and Belgium are the greatest success stories.

And the U.S. does have a version of this system, but it’s limited. In the U.S., hospitals have the right to presume consent when no family member can be found and no declaration has been made. Obviously, those conditions mean presumed consent doesn’t apply in many cases.

Coordination and government funding issues aside, a universal presumed consent system like that in effect in Spain and Belgium could be an important step toward solving the donor problem in this country.

But even presumed consent won’t entirely solve the problem. Presumed consent only harvests organs after the donor is deceased. And the fact of the matter is, we have an ever-increasing aging population that will consistently outstrip those supplies.

If we are to get out ahead of the problem, there has to be an increase in live donations as well. This is where the more libertarian minded argue that if our bodies are ours to manage, it should follow that we are also able to sell our organs. They argue that the financial incentive will increase the supply of live donors so significantly, it will eliminate the market shortage. The libertarians argue that organ sales – not presumed consent, which they claim not only violates personal freedom, but also is ineffectual over the long run – is the answer.

There’s a certain logic to their thinking. We don’t expect altruism to drive markets in most other aspects of our daily lives. Ralph’s Markets, Macy’s, BMW dealers, you name it – they’d all go out of business in a New York minute if they had to rely on the altruism of farmers, garment manufacturers, or auto parts manufacturers. The same can be said of the organ market. As long as it relies upon altruism, there will always be a shortage of organ donors.

In fact, there is some evidence that the financial incentive works. Organ sales are permitted in the Philippines as long as the donor recipients are natives. A Filipina organ recipient describes the domestic market: “Nobody in these parts,” she said, “would donate a kidney without getting paid.” And the market is thriving. This recipient stated that the prices for organs are going up.

Iran uses a hybrid system of free market and government control. There, vendors sell their organs to the government, which acts as an intermediary. It pays them and gives them free health insurance for one year. Donor recipients must be Iranian and they are required to work to pay for the cost of their organs. The system has virtually wiped out the waiting lists for donors.

But there are dissenters, some of whom even object to Iran’s hybrid model. One dissenting group says that any market based system will necessarily be exploitative of the poor since they’re the ones who’ll be most tempted to take the risks in order to get the rewards. The poor of Pakistan and China have shown willingness to sell corneas on the black market for money. A market system – black or otherwise – exploits such abject poverty.

There is, however, a blind spot to that thinking. Who works in coal mines? Who enlists in the military? It is the working poor, to a large extent. The coal mines, the military are unquestionably high risk occupations. If we’re so worried about exploiting the poor, why do we allow them to do these dangerous jobs? Because we know it’s their right to assume the risk of a dangerous job if they deem the reward worthwhile. By parity of reasoning, if the poor are allowed to choose these high risk jobs, then doesn’t it logically follow that they should be able to decide whether to take the risk of selling their own organs? It’s an interesting, albeit somewhat chilling argument.

This leads to the second group of dissenters, whose viewpoint is described by the Hastings Center on Bioethics: “In a market—even a regulated one—doctors and nurses still would be using their skills to help people harm themselves solely for money. The resulting distrust and loss of professional standards is too a high price to pay to gamble on the hope that a market may secure more organs for those in need.”

Indeed the oath to do no harm certainly is ethically and morally important to doctors. But if by donating a kidney, a destitute person can not only help the recipient, but also use the proceeds to start a business and thereby lift himself out of poverty, isn’t it a win-win? Who is really harmed?

The solution to the organ donor shortage problem poses a fundamental moral question: who has sovereignty and of what? If a person owns his own body, then rich or poor, shouldn’t he have the right sell his organs if he so chooses?

On the other hand, is the sale of organs the commoditization of the poor? Is such a market system the thing that lies at the bottom of the slippery slope of moral decay? If so, is it possible that the donor shortage can be cured without such controversial measures as organ sales? Can the current system be fixed, or is it set up for failure?

There is hope that scientific advances may eventually allow us to “grow” organs in the laboratory. When that day arrives, none of the above questions will matter. But that day is long in the future. In the meantime, the death rate of patients on donor waiting lists will continue to rise.

As of now there is no legal market for organ transplants in the U.S., nor do we have the presumed consent statute that’s working so well in Spain. With demand growing exponentially due to the new medical advances that keep us alive so much longer, the problem will only get worse. Ultimately, some kind of change will have to come. Here’s to hoping that day arrives sooner rather than later.

As published on http://www.forbes.com/sites/marciaclark/2013/06/13/selling-your-organs-should-it-be-legal-do-you-own-yourself/2/