The Ethics of National and International Organ Markets
Keywords:Human Organs, Transplantation, Organ Trafficking, Global Market in Human Organs, Ethics, kidney shortage, bioethics, medical ethics, medical anthropology, social policy, comparative religion, cultural ethnography
Ethical considerations in determining whether a human organ market could exist without causing exploitation of vulnerable populations may depend on the size of the market. Some ethical and religious considerations are culture dependent; others require legal structures to protect fundamental human rights. Both these factors suggest that an ethical market in human organs may be feasible, but not necessarily in every country or across national boarders.
D. Horvat, Salimah Z. Shariff and Amit X. Garg, “Global trends in the rate of living kidney donations,” Kidney International no. 75 (2009): 1088-1098. The authors report that there are 27,000 legal living donor kidney transplants worldwide each year, which represents 39% of all kidney transplants. However, this report includes only legally performed transplants.
The World Health Organization estimates that in 2007 there were 68,300 kidney transplants, and that 10% of all kidney transplants are done with illegally purchased kidneys. WHO EHT CPR, “GKT1 Activity and Practices,” http://www.who.int/transplantation/gkt/statistics/en. Samlee Plianbangchang, “Message from Dr Samlee Plian-bangchang, Regional Director, WHO South-East Asia Region,” WHO Guiding Principles on Organ, Tissue and Cells Transplantation, Jaipur, India, 2-5 February 2009 (2009) at http://www.searo.who.int/LinkFiles/BCT_RD_ message_2-5Feb09.pdf.
We could not find any projections for either the world or U.S. need in the future, but with the help of Alison Economy we did a regression calculation and came up with the 150,000 number based on data available through OPTN. The last 10 years: Additions to the wait list = 10932Ln(x) + 4468.3; The last 18 years: Additions to the wait list = -14.752(x^2) + 1417.2x + 15961. In both cases, x=years since 1995. So by 2025, 41,650 will be added according to the first equation or 45,200 according to the second. "Waiting List Additions By Year." OPTN: Organ Procurement and Transplantation Network. Health Resources and Services Administration, U.S. Department of Health & Human Services, 7 March 2014. Web. 28 Feb. 2014. –I assume the statistics used may change periodically, hence the access date? http://optn.transplant.hrsa.gov/latestData/rptData.asp.
Roughly two million Americans die every year, but the majority of people are too old, too sick, or were deceased too long before reaching the hospital to permit the usage of their organs. Only 10,500 to 13,000 Americans die under conditions that favor organ transplantation. Even if one were to assume the higher number, that would make only 26,000 kidneys available for transplantation. Since over 60% of Americans already agree to donate their organs, the 40 percent increase created by having everyone donate would really only result in an increase of 9,500 available kidneys for transplant, a number that could be improved slightly by improving organ retrieval and storage techniques, but not enough to provide kidneys for even a third of the 79,000 people currently waiting for a kidney. HHS, Health Resources and Services Administration, www.hrsa.gov; E. Sheehy and others, “Estimating the Number of Potential Organ Donors in the United States,” NEJM 349, no. 7 (2003): 667-74.
Arthur J. Matas, “Nondirected and Controversial Donors,” in Living Donor Organ Transplantation, Rainer W.G. Gruessner and Enrico Benedetti, eds. (New York: McGraw Hill Medical, 2008), 57-63, 59.
The data on Iran provided in this paper was collected on a six-week fact gathering trip to Iran undertaken by Sigrid Fry-Revere and Bahar Bastani, professor of internal medicine at St. Louis University in St. Louis Missouri, from 14 November to 31 December 2008.
Jeffrey P. Kahn and Francis L. Delmonicob, “Sounding Board: The Consequences of Public Policy to Buy and Sell Organs for Transplantation,” American Journal of Transplantation no. 4 (2004): 178–180.
Moazam Farhat, Riffat M. Zaman and Aamir M. Jafarey, “Conversations with Kidney Vendors in Pakistan: An Ethnographic Study,” Hastings Center Report 39, no. 3 (2009): 29-44. Mohammad A. Rai and Omer Afzal, “Organs in the Bazaar, The End of the Beginning?” Politics and the Life Sciences 26, no.1 (2007): 10-11.
Syed A. A. Naqvi and others, “A Socioeconomic Survey of Kidney Vendors in Pakistan,” Transplant International 20, no. 11 (2007): 934–939, 937.
Moazam Farhat, Riffat M. Zaman and Aamir M. Jafarey, “Conversations with Kidney Vendors in Pakistan: An Ethnographic Study,” Hastings Center Report 39, no. 3 (2009): 34-35.
Ethical, Legal and Psychological Aspects of Organ Transplantation, “The Declaration of Istanbul on Organ Trafficking and Transplant Tourism” (2008), Internet, http://www.esot.org/Elpat/Content.aspx?item=59. South African Renal Society, “Istanbul Declaration: [List of] Organizations Endorsing As of February 22, 2009,” Internet, http://www.sa-renalsociety.org/.
Sigrid Fry-Revere, THE KIDNEY SELLERS: A JOURNEY OF DISCOVERY IN IRAN, Carolina Academic Press, 2014.
Saudi Arabia passed a law in October 2006 providing for a much more generous donor compensation package than that which currently exists in Iran. The Saudi initiative includes a monetary “reward” of SR 50,000 (about USD $13,000), and lifetime health insurance for donors and their families as well as the possible option of as much as SR 110,000 (about USD $27,000) distributed on a monthly basis for ten years. P. Garwood, “Dilemma over Live-donor Transplantation,” Bulletin of the World Health Organization 85, no. 1 (2007): 1-5; F. A. M. Shaheen and M. Z. Souqiyyeh, “Current Status of Renal Transplantation in the Kingdom of Saudi Arabia,” Transplantation Proceedings 36 (2004): 125-127. Note we have some hesitation about the trustworthiness of this article because we found a news report about deceased kidney transplantation in Saudi Arabia that sheds some doubt on the degree of success expressed in the above article. See Khadija Habib Jeddah, “Organ donation gaining wide acceptance among Saudis,” Arab News (14 April 2013) http://www.arabnews.com/news/448090. Also see Alex He Jingwei, Allen Lai Yu-Hung, and Leong Ching, “Living Organ Transplantation Policy Transition in Asia: towards Adaptive Policy Changes,” Global Health Governance, Vol. III, no. 2 (Spring 2010). Note I have some hesitation about the trustworthiness of this article because I found a news report about deceased kidney transplantation in Saudi Arabia that sheds some doubt on the degree of success expressed in the above article. See Khadija Habib Jeddah, “Organ donation gaining wide acceptance among Saudis,” Arab News (14 April 2013) http://www.arabnews.com/ news/448090.
Sigrid Fry-Revere, THE KIDNEY SELLERS: A JOURNEY OF DISCOVERY IN IRAN, Carolina Academic Press, 2014.
U.S. Bureau of Labor Statistics, www.bls.gov.
Djavad, “Tyranny of numbers: Stagnant rural incomes,” in Inequality, Macroeconomy, Poverty (May 22, 2009 http://djavadsalehi.com/2009/05/22/the-rural-complaint/.
Note that using Dr. Ghods’ estimate that the average living kidney donor in in 2008 was compensated the equivalence of six months salary for a registered nurse (Personal communication with Ahad J. Ghods, M.D., F.A.C.P., Chief, Division of Nephrology, Department of Medicine, Iran University of Medical Sciences (1979 to the present), then that amount would be approximately $32,000 (see note 18). But, that only accounts for the monetary part of the compensation package, donors also receive at least one year health insurance and sometimes much more. In the United States the Kaiser Foundation estimated that in 2009 one year of health insurance premiums for a single healthy individual averaged $4824. So, that brings the average Iranian donor package up to a value of 36,824. But for over 80% of our donors for whom we have data there were additional non-monetary benefits: years more of health insurance for the donor and/or the donors family, dental care, and donated material goods such as household items and food. It was very hard to put a dollar amount on the added benefits received by donors. But even just coverage of one year of health insurance premiums for the whole family according to a Kaiser Foundation 2009 estimate would bring the value of the package up to $45,375, and a few of the donors we interviewed had health insurance for themselves and/or their families that they could renew annually through the Anjoman. Not to mention all the other benefits it is much harder to value monetarily: dental care, and other material goods and services. We believe $45,000 is probably a conservative estimate of the average total value of the Iranian donor benefits package in terms of purchasing power equivalence for the U.S.
Pius XII, “Address to the delegates of the Italian Association for Cornea Donors and the Italian Union for the Blind,” on May 14, 1956, Acta Apostolicae Sedis 48 (1956): 465, at http://www.ewtn.com/library/curia/ pcpaheal.htm
Richard V. Grazi and Joel B. Wolowesky, “Jewish Medical Ethics: Monetary Compensation for Donating Kidneys,” IMAJ 6 (2004): 185-188, Internet, http://www.hods.org/pdf/Grazi%20and%20Wolo.pdf.
In both countries rewarded gifting is legal and sanctioned by religious authorities. Mohammad M. Golmakani, Mohammad H. Niknam and Kamyar M. Hedayat, “Transplantation Ethics from the Islamic Point of View,” Medical Science Monitor 11, no. 4 (2005): 105-109; Author’s conversation with Ayatollah M. Damad, Tehran, Iran, 9 December 2008.
Mohammad M. Golmakani, Mohammad H. Niknam and Kamyar M. Hedayat, “Transplantation Ethics from the Islamic Point of View,” Medical Science Monitor 11, no. 4 (2005): 105-109; and Author’s conversation with Ayatollah M. Damad, Tehran, Iran, 9 December 2008.
See Ron Athey, Internet, http://hackingthefuture.blogspot.com/2009/02/ron-athey-at-abode-of-chaos.html;Franco B, Internet, http://www.franko-b.com/gallery/g_performance4.htm.; Orlan, Internet, http://www.orlan.net; Stalking Cat, Internet, http://www.stalkingcat.net.
See R. R. Faden and T. L. Beauchamp, A History and Theory of Informed Consent (New York: Oxford University Press, 1986), and T. L. Beauchamp and J. F. Childress, Principles of Biomedical Ethics, 6th ed. (New York: Oxford University Press, 2009).
Sanjay Nagral, "The Indian Kidney Bazaar," Combat Law 4, no. 4. (2005), Internet, http://www.indiatogether. org/combatlaw/vol4/issue4/organ.htm; Thomas Schmitt, “A Pound of Flesh: Organ Trade Thrives in Indian Slums,” Spiegel Online, (14 June 2007), Internet, http://www.spiegel.de/international/world/0,1518,488281,00.html;. Amihan V. Abueva, “The Philippines: Fifth Organ Trafficking Hotspot!” Power point presentation (2007). Yosuke Shimazono, “The state of the international organ trade: a provisional picture based on integration of available information,” Bulletin of the World Health Organization (BLT) 85, no. 12, (2007): 965-962.
Sanjay Nagral (2005).
D. A.Budiani-Saberi and F. L. Delmonico, “A Commentary on the Global Realities,” American Journal of Transplantation, no. 8 (2008): 925–929. Leigh Turner, “Let’s wave goodbye to ‘transplant tourism,’” British Medical Journal, no. 336 (2008): 1377.
Amihan V. Abueva, “The Philippines: Fifth Organ Trafficking Hotspot!” Power point presentation (2007). Yosuke Shimazono, “The state of the international organ trade: a provisional picture based on integration of available information,” Bulletin of the World Health Organization (BLT) 85, no. 12, (2007): 965-962; Fernan Marasigan, “Tighter controls on organ donations pushed,” Business Mirror, Internet, Sunday, 12 July 2009 at http://businessmirror.com.ph/home/nation/13038-tighter-controls-on-organ-donationspushed.html?tmpl=component &print=1&page=.
D. A. Budiani-Saberi and F. L. Delmonico, “Organ Trafficking and Transplant Tourism: A Commentary on Global Realities,” American Journal of Transplantation, no. 8 (2008): 925–929.
D. M. Tober, “Kidneys and Controversies in the Islamic Republic of Iran: The Case of Organ Sale,” Body and Society (2007), v.13(3): 151-170.
Rai and Afzal argue that the Bonded Labor Abolition Act of 1992 has not stopped bonded labor in Pakistan, and that because of the loopholes in the 2007 Human Organs and Tissues Ordinances, the legal prohibition on organ sales may prove equally ineffective. Mohammad A. Rai and Omer Afzal, (2007): 10-11.
National Organ Transplant Act: Hearings on H.R. 4080 Before the Subcommittee on Health and Environment of the House Committee on Energy and Commerce, 98th Congress, 1st Session 224 (1983).
Approved 19 October 1984 and amended in 1988, 1990, and 2008: “The National Organ Transplant Act,” (1984 Pub.L. 98-507), Internet, http://www.unos.org/SharedContentDocuments/NOTA_as_amended_-_Jan_2008.pdf.
Communications with Ahad J. Ghods, M.D., F.A.C.P., Chief, Division of Nephrology, Department of Medicine, Iran University of Medical Sciences (1979 to the present); Dr. Ali Nobakht Haghighi, permanent member of the Iranian Academy of Medical Sciences (http://www.ams.ac.ir/), former Deputy of Treatment, Finance and Administration of Ministry of Health (1986-1993), and others the author met and interviewed on her research trip to Iran, Nov.14, 2008-Dec. 31, 2008.