Resistance to New Ideas Kills People
When you find yourself viscerally resisting an idea, ignore your instincts and consider it anyway
There are over 100,000 people who need a kidney or liver transplant in the United States. Thousands of them will die waiting. It doesn’t have to be this way.
People hoping to receive a donation from a living or deceased donor are placed on a transplant waiting list, but many die while waiting. Many others wait on the list until they become too sick to benefit from a transplant, are removed from the waitlist, and then die. In all, the kidney shortage kills 43,000 Americans every year. This is more than the number of Americans who die in car accidents. It is also higher than the number of gun deaths in the U.S. And yet, it gets a lot less attention.
Many organizations have spent years and millions of dollars to increase organ donation efforts, but these efforts have not sharply reduced the shortage. There were a record number of donations in 2019, but many thousands still died while waiting for a transplant. The main idea here is to lobby Congress to pass a law requiring Medicare to compensate American living donors. If I could find someone to bankroll this, I’d start a 501(c)(4) organization to pay lobbyists to get this law passed.
The Problem
There are many organizations that paint a picture of the problem, so I will briefly sum it up. In the United States, someone is added to the transplant waiting list every ten minutes. At least twenty people die every day while waiting for a transplant. There are simply not enough altruistic donors. This problem affects people of all races and economic backgrounds, but disproportionately affects minorities and the poor. For example, while Black and Hispanic people make up 29% of the US population, 49% of the people on the transplant waitlist are African American or Hispanic. It is illegal to pay anyone for an organ.
The Solution
Incentivize people to donate a kidney or part of their liver while alive by having Medicare compensate them. Assuming the reimbursement amount is high enough, this will eliminate the kidney and liver shortage, as it has in Iran - the only country that allows organ donors to be paid. This would require a change in law because compensating anyone who donates organs is currently illegal.
Common Objections Refuted
“Reimbursing organ donors would commodify organs.” Everyone involved in transplants, including hospitals and doctors, are already getting paid for providing their services and that’s not commodification. The person undergoing the donation experience should also be allowed to be paid. Vague icky feelings about paying donors should not be a reason to allow tens of thousands of people to die every year. The question isn’t whether to pay living organ donors; the question is whether to pay living organ donors in order to save lives.
“Paying people to donate organs will reduce altruistic donations.” The goal in passing this proposed law would be to increase the net number of transplants. People on the waiting list would still be encouraged to reach out to family and friends to donate organs, and there is no evidence that allowing some people to be reimbursed will reduce the number of people who donate voluntarily. There is evidence that allowing reimbursement will eliminate the organ shortage: the only country that does not have an organ shortage is Iran, where compensation for organs is legal. Also, donations still take place in Iran despite the legality of paying for organs. Furthermore, the US government allows reimbursement for blood platelet donations, and that has not reduced the net supply of blood platelets. Under the proposed law, people who wanted to donate for free to a specific person could still do so. And anyone on the transplant waitlist could specify that they only want to accept organs from unpaid donors. Also, an incentive would still exist to donate for free because such donors could choose a recipient, while reimbursed donors would not be able to choose their recipient. Altruistic donations and reimbursed donations can coexist.
“Where is Medicare going to get money for this?” So, actually, Medicare would be saving money if this law passed, but first some background. Kidneys make up the vast majority of the organ shortage. 83% of the people on the organ waitlist are waiting for a kidney. Medicare largely covers costs for all kidney failure patients, including dialysis costs. Medicare spending for kidney failure patients is around $35 billion per year. Dialysis costs an average $90,000 per patient per year, and the average patient survives on dialysis for around 5 years, which comes to $450,000. Medicare already covers around 80% of kidney transplant costs, which averages around $150,000. So assuming Medicare spends $50,000 to reimburse the donor, and $150,000 to pay for the transplant, that comes to $200,000 per transplant recipient. Thus, Medicare would save an average of around $250,000 per transplant recipient, resulting in billions of dollars saved per year. In addition, the average recipient of a kidney from a living donor lives an additional fifteen years, during which the recipient could work and pay taxes. Thus, in addition to saving many lives, this proposal would also save taxpayer money.
“No one should be allowed to take risks with their own health for money.” The risk of complication from organ donation is low. Kidney donors live longer than the general population. This is probably because kidney donors are carefully screened for health, so it is possible that kidney donors might have lived even longer if they did not donate a kidney. But the point is that even if there is a risk of living a shorter life after donating a kidney, it is not significant enough to reduce the average donor’s lifespan below the average non-donor lifespan. Furthermore, we do not stop construction workers, firefighters, NFL players, and lumberjacks from getting paid for their services, even though their average lifespan is much shorter than the general population. If we allow construction workers and footballers to take risks in exchange for money, then we should not prevent organ donors from being reimbursed for lifesaving services.
“A poor person might be in desperate financial straits, such as facing eviction, and therefore not really consent.” There could be safeguards for this as well. For example, the law could impose a six-month waiting period for anyone to be added to the list, so that no one volunteers on impulse or during an emergency. (In theory, the law could also require donors to be above a certain income level, though I don’t think this is a good idea because it would discriminate against poor people.) Additionally, the law could require doctors and hospitals to ask potential donors whether they are volunteering to donate out of desperation, followed by specific follow up questions such as: are you in a desperate financial situation? Are you facing eviction, unemployment, bankruptcy, etc.? Transplants should only go forward if the hospital and doctors are satisfied that the donor consented and isn’t doing it out of desperation.
“Paying people for donating organs would lead to exploitation of the poor.” Given that Medicare is a government agency that helps the poor, it seems unlikely that they will want to exploit the poor. Organ donations would go to the next in line, not the richest person in line. Also, the law could include restrictions on who can donate (for example, only U.S. citizens who are employed) to prevent exploitation. The proposed law could add further safeguards, such as having hospitals screen potential donors for stability (emotional, financial, physical) before allowing transplants to proceed. Moreover, to be compensated, donors would have to apply to be added to a donor list. The transplant recipient would not be able to choose which person on the donor list should be the donor. This “blind matching” reduces the likelihood that a donor will seek out someone to exploit; even if someone was manipulated into being added to the donor list, there is no way of ensuring that the manipulator would benefit from this. Finally, it is currently mostly the poor who are most likely to die while waiting for an organ transplant. Wealthy Americans have larger networks of potential donors, can move to states where there are more donors (as Steve Jobs did, when he moved to Memphis), and can pay a lot of money to a “donor” under the table. Thus, it does not make sense to prevent reforms that might hurt poor people, when the current system definitely harms poor people, especially because the theoretical harms can be mitigated.
“Why only allow compensation via Medicare at a set price? A free market would be better at calculating how much to pay donors.” The law could inject some market mechanisms to ensure a sufficient supply of donors. For example, the law could set the reimbursement amount at $30,000, but after 3 years, the number rises by $10,000 every year during which there has been 100 more people on the kidney and liver waitlist than on the donor list. Furthermore, prohibiting private citizens from paying donors preempts the objection that a law allowing donor compensation would further advantage rich people. Setting the price and only allowing the government to pay reduces potential for exploitation and inequality in organ transplants, thus increasing the odds of bipartisan support for this law.
“A much less controversial way to accomplish the same goal is to switch from an opt-in system to an opt-out system. If the default is that people who die donate their kidneys, the organ shortage is solved.” An opt-out system would be great, but reimbursement for living donors is still necessary for a few reasons. First, it should not be assumed that moving to an opt-out system would completely solve the organ shortage problem. In France and Brazil, some form of an opt-out system led to a decline in organ donations. Nobel prize winning economist Alvin Roth wrote that “mandated choice may be counterproductive.” Second, it is not necessarily true that an opt-out system would be less controversial than the system proposed here. An opt-out system would be very controversial to several religious groups. Finally, kidneys from living donors function years longer than kidneys from deceased donors. Kidneys from living donors last about 12–20 years, while kidneys from deceased donors last 8–12 years. Therefore, the goal is to increase organ donations from living donors. Opting in to donating organs upon death helps with deceased donor organs, not organs from living donors.
“More people are signing up to donate their organs when they die, and 3D-printed kidneys are around the corner. This shortage should go away in a decade or so.” Even assuming this is true, we cannot wait for the shortage to go away. If 1,000 people die this year due to an organ shortage, that is already too many lives lost. The actual numbers are much higher than that.
“If you pay people to donate organs, they may hide disqualifying medical information.” People are specifically asked questions that can disqualify them from donating organs. The proposed law should make it a crime to lie when answering these questions, with the penalty being large fines or even jail time. And the law should give transplant doctors access to all volunteer donors’ medical records do they can check for disqualifying diagnoses. And again, we need to weigh the possibility of some people lying and causing some harm against the harm of definitely allowing 43,000 people to die every year. This proposed law is not utopian; it is the least bad option.
“What we need is more education and outreach, not reimbursement.” This argument has literally been made for decades. Tens of millions of dollars have been spent on education and outreach. Doubtless, more can be done, but we should not let thousands more die while we keep waiting for results.
“I’m squeamish about allowing people to get paid for donating organs.” That is understandable, but squeamishness should not be a reason to allow tens of thousands of Americans — mostly minorities and the poor — to die every year.
Conclusion
The law needs to change. The law that prohibits compensation is known as NOTA, and it was passed in 1984 in response to testimony from a person who was planning to bring poor people from developing countries to sell their organs. Congress decided to ban organ markets, and expressed the belief that altruistic donations would prevent an organ shortage. Turns out Congress was wrong and there is a shortage. In any event, we don’t want to create a market; we want the government to pay a set price. Lobbying Congress seems to be the most effective way to change the law to allow this. For example, it took years of lobbying to bring the First Step Act to fruition. I think I’d need a few hundred thousand dollars to pay specific lobbyists with records of success. I would like to set up a 501(c)(4) nonprofit to allow people to bankroll this if they are so inclined.