Organ & Body Donations: John Oliver

Laugh through the tears with John Oliver:

Unclaimed bodies and medical school anatomy classes.

 There's a long history of unclaimed bodies being used in medical school anatomy classes. (I think the historical availability of such cadavers is one of the reasons that the Harvard Medical School is in Boston rather than Cambridge.*)  Here's an update on the practice, in Texas.

Unclaimed Bodies and Medical Education in Texas, by Eli Shupe, PhD1; Serena Karim2; Daniel Sledge, PhD, JAMA.  online August 24, 2023

"The use of unclaimed bodies (bodies not claimed by next of kin for burial or cremation) in gross anatomy education in the US has declined substantially since the middle of the 20th century owing to increases in voluntary donations and escalating ethical concerns.1-3 Nonetheless, in most US jurisdictions, counties can donate unclaimed bodies to science without consent from the deceased or their next of kin, with some medical schools still accepting such donations. The current scope and magnitude of the use of unclaimed bodies in the US is underresearched, although one 2019 study found that anatomy course leaders at 12.4% of surveyed US medical schools indicated possible use of unclaimed bodies at their institutions.4 The objective of this study was to examine the trends in use of unclaimed bodies in medical education in Texas.

...

"We found that during 2017-2021, 6 of the 14 medical schools in our sample (42.9%) either engaged in the direct procurement and use of unclaimed bodies (2 schools, 14.3%) or received transferred cadavers from schools that did (4 schools, 28.6%). The remaining 8 schools (57.1%) had no possible use of unclaimed bodies."

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*Here's a related story from the Harvard Crimson:

Harvard's Habeas Corpus: Grave Robbing at Harvard Medical School, BY NURIYA SAIFULINA, September 28, 2017

"Harvard’s corpse legacy began in late 18th century, when the newly opened Medical School began hiring grave diggers—not to bury bodies, but to exhume them. According to a 2015 history of the so-called “resurrection men” in Synthesis, an undergraduate history of science journal, the diggers snuck into Boston’s burial grounds in search of new graves, stealthily dug up some of the most “fresh” residents, and refilled the graves to avoid arousing suspicion.

...

"Around 1770, Joseph Warren founded an illicit secret society called the “Spunker Club,” also known as the “Anatomical Club.” His older brother, John Warren—the founder of Harvard Medical School—was also a member. Some of the club’s most notable members included a William Eustis, the future governor of Massachusetts, and Samuel Adams’ son.

...

"As “resurrection men” and body-snatching enthusiasts continued to ransack Boston graveyards, civil indignation incited the Act to Protect the Sepulchers of the Dead in 1815, making disturbance of buried bodies illegal and prompting a citywide patrol of graveyards and burial grounds.

"This legislature forced Harvard Medical School to “import” the cadavers from New York instead, where body snatchers were “emptying at least six hundred or seven hundred graves annually,” according to an article in the Boston Gazette.

"After the Massachusetts Medical Society published a plea in 1829 claiming that medical students had no other choice but to pursue their studies “in defiance of the law of the land,” the school’s need for illegally-obtained cadavers waned. Massachusetts passed the Anatomy Act of 1831, which allowed for dissection of the unclaimed bodies of the indigent, insane and imprisoned."

Legal and illegal sales of body parts

 U.S. law makes it illegal to sell deceased donor organs for transplant, i.e. to save a life, but it's otherwise legal to sell body parts or whole cadavers, for research, for instruction, etc.  Nevertheless, alongside the legal, regulated market, which requires consents and precautions, is an illegal black market which is occasionally prosecuted.  Here's a recent case, as reported in the NYT:

Funeral Home Operator Pleads Guilty in ‘Illegal Body Part Scheme’.  Megan Hess, who pleaded guilty to mail fraud, sold body parts without families’ consent... By Alex Traub

"The operator of a Colorado funeral home who was accused of stealing body parts and selling them to medical and scientific buyers, making hundreds of thousands of dollars in what the authorities called an “illegal body part scheme,” pleaded guilty to mail fraud on Tuesday, the Justice Department said.

...

"Here’s how prosecutors said the scheme worked: From about 2010 to 2018 Ms. Hess was in charge of Donor Services, a nonprofit “body broker service,” and Sunset Mesa Funeral Directors, which offered to arrange cremations, funerals and burials in the small western Colorado city of Montrose.

"Ms. Hess and her mother sometimes obtained consent from families to donate small tissue samples or tumors of their dead relative, according to an indictment in the case. On other occasions, their request was rejected, and sometimes, they never brought up the topic at all.

"In any case, the documents say, on hundreds of occasions the funeral home operators would sell heads, torsos, arms, legs or entire human bodies. Frequently, they delivered cremated remains to families with the suggestion they were the remains of their relative when, in fact, they were not, according to the indictment.

...

"The scheme included forging paperwork, such as signatures on authorization forms for donating body parts, and misleading buyers about the results of medical tests performed on the deceased, court documents said. Ms. Hess altered lab reports so that they said that people had tested negative for diseases like H.I.V. and hepatitis when they had actually tested positive, according to the authorities."

Non-transplant tissue banks

The Brown Political Review (a student publication at Brown University) takes a look at the lightly regulated market for cadavers and body parts for uses other than transplants:

Merchants of Death: The Thriving, Unregulated Body Brokerage Industry
BY JONATHAN HUANGNOVEMBER 27, 2018

"Cadavers are irreplaceable in both the training of new medical students and medical research. Companies that make medical products also rely heavily on human tissue. Many medical schools operate their own donation programs, which provide the majority of cadavers needed for their education and research. However, many other bodies are obtained from body brokers. These body brokers, also known as non-transplant tissue banks, serve as middlemen between the recently deceased and the market for cadavers. They solicit donations from patients or their families, dismember or otherwise process the bodies as required, and sell what remains to the highest bidders. Each part has a price: a foot may sell for $250, a head might fetch $1,000. For these businesses, bodies are raw materials to be harvested and sold to other institutions for further use."

Cadavers and the slave trade

The NY Times has an article on the intersection of the slave trade in the United States with the market for cadavers for anatomy classes in medical schools:

Beyond the Slave Trade, the Cadaver Trade, By Daina Ramey Berry

"One shocking fact that’s recently come to light: Major medical schools used slave corpses, acquired through an underground market in dead bodies, for education and research.

"Yes, there was a robust body-snatching industry in which cadavers — mostly the bodies of black people, many of whom had been enslaved when they were alive — were used at Harvard, the Universities of Maryland, Pennsylvania and Virginia, and other institutions.
...
"Body snatchers like Grandison Harris of Georgia and Chris Baker of Virginia collected specimens for dissection for the benefit of medical colleges. While they received room, board and modest wages for the bodies they collected, they were also enslaved African-American men themselves, listed as “janitors” or “porters” in the medical schools’ records."
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See some of my earlier posts on the cadaver trade:

Monday, July 3, 2017

Cadavers and the teaching of anatomy

Saturday, February 18, 2012

Markets for cadavers

Thursday, June 30, 2011

Medical education in Paris in the 1830's--cheap cadavers

Buying body parts is easy, as long as you don't use them for transplants

Cashing in on the donated dead: The Body Trade
A REUTERS SERIES

Part 1: When Americans leave their bodies to science, they are also donating to commerce: Cadavers and body parts, especially those of the poor, are sold in a thriving and largely unregulated market. Grisly abuses abound.
By BRIAN GROW and JOHN SHIFFMAN
"Body brokers are also known as non-transplant tissue banks. They are distinct from the organ and tissue transplant industry, which the U.S. government closely regulates. Selling hearts, kidneys and tendons for transplant is illegal. But no federal law governs the sale of cadavers or body parts for use in research or education. Few state laws provide any oversight whatsoever, and almost anyone, regardless of expertise, can dissect and sell human body parts.
...
"Because only four states closely track donations and sales, the breadth of the market for body parts remains unknown. But data obtained under public record laws from those states – New York, Virginia, Oklahoma and Florida – provide a snapshot. Reuters calculated that from 2011 through 2015, private brokers received at least 50,000 bodies and distributed more than 182,000 body parts."


Part 2: After a few emails, a body broker sold reporter Brian Grow two heads and a cervical spine. The spine came from a young man whose parents were too poor to bury him – and they say they never knew his body would be sold.
By BRIAN GROW and JOHN SHIFFMAN


"Whether Restore Life vetted the buyer is unclear. But if workers there had verified their customer’s identity, they would have learned he was a reporter from Reuters. The news agency was seeking to determine how easy it might be to buy human body parts and whether those parts would be useful for medical research. In addition to the spine, Reuters later purchased two human heads from Restore Life, each priced at $300.

"The transactions demonstrate the startling ease with which human body parts may be bought and sold in the United States. Neither the sales nor the shipments violated any laws, say lawyers, professors and government officials who follow the issue closely. Although it’s illegal to sell organs used for transplants, it’s perfectly legal in most states to sell body parts that were donated for research or education. Buying wine over the Internet is arguably more tightly controlled, generally requiring at minimum proof of age.


Part 3: Science Care reaps $27 million in annual revenue by recruiting body donors through hospices, funeral homes and online ads.

"The typical pitch to the dying and their families is two-pronged. The first is altruism: The gift of a body will benefit medical science and, by extension, others in need.

"The second is financial: Body donation saves a family money. The average funeral, including coffin, memorial service and burial, costs about $7,000, according to the National Funeral Directors Association. Simple cremation, an increasingly popular option, costs $400 to $1,000 or more.

"Body brokers like Science Care offer the cheapest option: free cremation in exchange for the body. The deal: Science Care pays for the cremation of a donor’s unused remains and for returning the ashes to the bereaved family, usually after a few weeks."


Part 4: Arthur Rathburn is accused of dismembering donated bodies with a chainsaw and renting HIV-infected parts to medical professionals. Prosecutors hailed his arrest as a crackdown. But for years, Reuters found, authorities let him do business despite signs of his bizarre practices.
By JOHN SHIFFMAN and BRIAN GROW

Cadavers and the teaching of anatomy

Hektoen International, A journal of medical humanities has several articles motivated by Rembrandt's painting of The Anatomy Lesson of Dr. Nicolaes Tulp

One of the articles is Rembrandt – The Anatomy Lesson of Dr. Nicolaes Tulp by Tan Chen. It says in part:

"Commissioned for display in the Guild Room, the painting offers a glimpse into important changes in the world of medicine. Gone are the days of public executions and dissection, and a much more subdued method has taken over. In the modern world executions are no longer public, and anatomy students no longer know the name of their corpse. Great care is taken to remain respectful of the deceased, and in doing so the hands and feet are covered so as to take away the intimacy many associate with these body parts. Today it is easy for a person to donate their body to science and allow anatomy students a real look into the human body, whereas before no choice was given.

The corpse in Rembrandt’s The Anatomy Lesson of Dr. Nicolaes Tulp gives the painting a more macabre feeling. The body being dissected is that of Aris Klindt (an alias for Adriaan Adriaanszoon), an armed robber sentenced to death by hanging. A public dissection was only a yearly event, and all bodies being dissected were that of criminals."
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Our views about cadavers have changed, and continue to change. Here's a 2016 story from the NY Times:
New York State Bans Use of Unclaimed Dead as Cadavers Without Consent
By NINA BERNSTEINAUG. 19, 2016 

"The law bans the use of unclaimed bodies as cadavers without written consent by a spouse or next of kin, or unless the deceased had registered as a body donor. It ends a 162-year-old system that has required city officials to appropriate unclaimed bodies on behalf of medical schools that teach anatomical dissection and mortuary schools that train embalmers."

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And here's the page for Stanford's Willed Body Donation Program

"Once you register to become a donor to the Willed (Whole) Body Program, Stanford’s Division of Clinical Anatomy will keep your name and contact information on file. Upon your death, a caregiver or family member must contact us right away. We take calls 24 hours/day, every day of the year. We will arrange for a funeral home to transport your body to Stanford Medical School, where it may be used to teach students about the structure of the human body and for furthering medical and scientific knowledge. 

Once study of the body is complete, we will arrange for cremation. (The study period may range from one month to two years, but it is typically about a year in duration.) At the time of donation, your family will be asked whether they wish for the cremated remains to be returned or whether they would like us to arrange for interment. Our faculty, students, and staff are very grateful for the kindness our donors have extended, and bodies are treated with the greatest respect while in our care."

Tissue transplants and tissue banks

Solid organ donation gets more press, but tissue transplants and medical devices made from human tissue are big business. Here's a profile of a Virginia organ and tissue bank:
Hearts, lungs and kidneys recovered by LifeNet Health get the most attention, but tissue is the larger player, By Elizabeth Simpson, The Virginian-Pilot

"[Tissues] are used in a wide variety of ways: to reconstruct breasts after cancer treatment. To repair joints in knees and ankles. To treat wounds of diabetics suffering from foot ulcers. To bridge bones in spinal fusion surgeries.

Douglas Wilson, LifeNet Health’s executive vice president, puts it into perspective this way: In one month, LifeNet provides solid organs for 40 to 60 patients, most of whom live in Virginia. But in terms of tissue transplants, some 40,000 patients a month across the globe receive LifeNet bioimplants.

That branch powers the growth of LifeNet, a nonprofit in the burgeoning Princess Anne bioscience corridor with operating revenue that topped $200 million last year. Solid organ recoveries went from 385 in 2011 to 467 last year, and tissue transplants from 389,000 to 462,000.

LifeNet is one of 58 organ procurement organizations in the country, and one of more than 100 accredited tissue banks. By law, companies can’t sell human tissue, but they can charge fees for recovery, processing, storing and distributing tissue.

And LifeNet fiercely guards its techniques. In 2014, the organization took a rival tissue transplant company to court, saying it used LifeNet’s patented technology to preserve tissue grafts and bone.

A federal jury awarded nearly $35 million to LifeNet, a finding that was appealed by the New Jersey-based LifeCell Corp., but upheld by a federal appeals court last month.

Wilson expects the growth in the tissue transplant field – which includes both for-profits and nonprofits – to continue, considering a few trends:

More older people will experience worn-out knees, hips, tendons and spinal discs. Obesity rates will fuel more diabetes cases with ulcers that require tissue transplants. And there’s the explosive field of regenerative medicine, which focuses on replacing and regenerating human cells.

“We’re sending tissue to every state and 30 countries,” Wilson said. “Allografts are used in almost every hospital in the U.S.”

When technical specialist Craig Wolf came to work at LifeNet 28 years ago, he was one of 44 employees. The number now? Nearly 900. The company has 600 products, 60 patents and branch offices in Washington and Florida."

Happy 500th birthday to Vesalius

Andreas Vesalius, son of an apothecary to Emperor Maximillian and to Charles V, was born in Brussels on December 31, 1514.

and this:

"Thus, the young, inquisitive, and impetuous Vesalius began his own studies of anatomy with a single-minded determination, frequently raiding the Cemetery of the Innocents and the gibbits of Montfaucon and storing the bodies in his bedroom. When news arrived of impending war between France and the Holy Roman Empire, Vesalius relocated to Padua, where he received his medical degree in 1537 and was appointed Professor of Surgery at the university."

In any event, he made a revolution in the scientific study of anatomy...

Society for Mutual Autopsy: Nineteenth Century solution to the cadaver shortage for anatomy studies

Michael Webster directs my attention to this post about The Society of Mutual Autopsy, a society formed to supply cadavers for more, and more scientific, autopsies.(At different times and places, cadavers have been in short supply: see these previous posts.)

Here's what Wikipedia has to say:
"The Society of Mutual Autopsy (or French: la Société d'autopsie mutuelle) was established on 19 October 1876 by members of the Society of Anthropology of Paris in Paris, France.

"Its purpose was to facilitate research on any links between personality, ability and brain morphology by creating a system whereby members' bodies, upon death, would be donated to the organization for study.
Its primary tool to organize these donations was a sort of living will which accomplished two main tasks. The first was to make clear the intention of the donor to have his or her body delivered to the organization upon death. The second was to present to the organization a description of the donor: the donor's personality, skills, habits, faults, etc. to allow for more complete research by the organization on the connection between these and brain morphology."

Apparently it was active from 1876 until World War I, and conducted quite a few autopsies.

I guess that willing your body to a scientific society is logistically a lot easier for your next of kin to carry out than is willing your organs to be donated to members of a club. As of this writing, the similarly constituted Lifesharers organization (about which I have posted here) has yet to make a single donation:

Q. How many LifeSharers members have died and donated organs?
A. We have not yet had a member die in circumstances that would have permitted recovery of his or her organs.

Organs and tissue markets and black markets

NPR has a series of posts on tissue donation, which includes bones and sinews, and for which there's a regulated market, but also a black market.

Human Tissue Donation

Calculating The Value Of Human Tissue Donation(68) 

July 17, 2012 Many organ donors are unaware they've also agreed to donate their veins, bones, skin and other tissue, which can be used not only to save a life, but also to help a cosmetic surgery patient. It's a $1 billion a year industry many know little about.
Transcript

On All Things ConsideredPlaylist

Little Regulation Poses Problems Tracking Tissue(15) 

July 18, 2012 An NPR News investigation has found there's little scrutiny at key points in the tissue donation and transplant process, which could lead to serious medical mistakes.
Transcript

On Morning EditionPlaylist

Am I A Tissue Donor, Too?(23)  

July 18, 2012 NPR's Joseph Shapiro knew he had signed up to be an organ donor, but he didn't realize the red heart on his driver's license signifies that he also agreed to donate his tendons, bones, veins and other tissue.
Transcript

On All Things ConsideredPlaylist

The Seamy Side Of The Human Tissue Business(26)  

July 19, 2012 Body-stealing cases like that of Michael Mastromarino illustrate how an industry built on altruism can fall into the hands of the greedy.
Transcript

On Morning Edition

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Andrew Sullivan has a video: The Global Cadaver Trade

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In my 2007 article Repugnance as a Constraint on Markets I wrote about the case of Alistair Cooke, whose body parts were misappropriated after his death. Here's a colorful recounting of that and related stories from a 2006  New York Magazine story called The Organ Grinder.


HT: Steve Leider

Anatomist and grave robber

His biographer writes about The Beauty of Bodysnatching: Astley Cooper (1768–1841), an English surgeon and anatomist, is remembered for his contributions to vascular surgery and other specialties.

Since dissection was repugnant, cadavers were obtained illegally from grave robbers ("resurrection men").

"in those days to study anatomy required stealing corpses. Cooper went from digging them up himself in the dead of night to running an international network of men who did it for him. As king of the body snatchers he acquired human dead in every state of liquefaction and decay."

Priority for organ donation in the UK?

Britain's National Health Service is conducting a survey as part of an assessment of possible changes to its methods of acquiring and allocating organs for transplantation.

NHS considers organ donation shakeup

"The survey asks whether the UK should follow Israel's lead and say that those who are on the organ donor register should get priority if they subsequently need a transplant. "It always seemed to me that fairness is quite a fundamental British value but we have never put that in the context of organ donation," Johnson said.

"The question of presumed consent for organ donation is also raised once more. Only the Welsh assembly government has formally adopted this possibility within the UK, and it plans to legislate in 2015 if its formal consultation goes its way.

"The NHSBT survey asks about extending the recently introduced practice by which the Driver and Vehicle Licensing Centre "nudges" those renewing or updating licences into deciding whether they want to join the donor register to other documents, such as marriage applications or wills. Johnson floated using the new universal credit, the single payment for those seeking work or on low incomes."

The article also speaks of the shortage of deceased donor organs:
"About 1,000 people die in the UK each year because they do not get a transplant, according to NHSBT. Johnson said more people wanted to become donors but the transplant service could not use all the organs they donated. More than 500,000 people die in Britain each year, but only about 3,000 in circumstances where they could realistically become organ donors.
"The reality is you have to die in hospital, on a ventilator, also in the intensive care or emergency department. The number of people dying who are under the age of 75, which is where most of our donors come from, has dropped by about 15% in the last few years. The people who are dying therefore tend to be older, they tend to have more co-morbidity than the rest of the population and, like the rest of the population, they have a tendency to be fatter. Consequently there are a number of people who would like us to use their organs but their organs might not be suitable."


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Before we get too excited, note that it's a lot easier to consider changes than to enact them: see my 2008 post on attempts in Britain to move towards presumed consent for organ donation.

Regarding priority for organ donation, Judd Kessler and I have a paper coming out in the August AER:
Kessler, Judd B. and Alvin E. Roth, '' Organ Allocation Policy and the Decision to Donate,'' American Economic Review, forthcoming.

Markets for cadavers

ABC news has an 18 minute video on the market for cadavers used in recent popular anatomy exhibits. They conclude that many of these are obtained from illicit Chinese sources, and may include the bodies of executed prisoners: http://abcnews.go.com/2020/video?id=4300207

HT Itay Fainmesser

Medical education in Paris in the 1830's--cheap cadavers

Lewis Lapham discusses David McCullough's “The Greater Journey: Americans in Paris."

Cadavers at $2.50 Lured Americans to 1830s Paris

"At noon, the cadavers were delivered to the dissecting rooms at the Amphitheatre d’Anatomie -- carts had arrived earlier and dumped the bodies of naked men and women on the pavement outside. Corpses came cheap: An adult cost 6 francs or about $2.50; a child could be had for less.

"The amphitheater was big enough for 600 students. They smoked cigars to offset the nauseating smell of putrefaction and walked gingerly to avoid slipping on the fragments of flesh littering the floor. Larger pieces were fed to caged dogs.

"It was a scene that in the 1830s drew students from all over to Paris, the medical capital of the world. Oliver Wendell Holmes, one of the first Americans trained in the new clinical methods, wrote that to understand anatomy, he’d cut his subject “into inch pieces.” He could not have done so anywhere else, he added.

"Upon returning to the U.S., Holmes taught at Harvard Medical School until 1882, expounding the benefits of dissection, the microscope and the stethoscope, all of which were largely unknown in the U.S."
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The situation in Britain (and the U.S.) was much less freewheeling. I wrote about cadavers for anatomy study in my article  Repugnance as a Constraint on Markets "


"When the British medical journal The Lancet published its first volume in 1824, its pages reflected a concern that too few cadavers were available for anatomy classes. The main source of cadavers was an illegal black market supplied by so-called “resurrection men,” and an editorial by that name opens with the news that a reliable resurrection man had recently been arrested and sentenced. The editorial goes on to suggest—in an early observation that how issues are framed may influence how they are perceived—that the government policy of only allowing the bodies of executed murderers to be used for anatomy studies “tends to keep up . . . the prejudice which is at present so strong against the obtaining of bodies for dissection” (Lancet, 1824).
... In Britain, the Anatomy Act of 1832 considerably expanded the source of legal cadavers for dissection.

Organ Allocation Policy and the Decision to Donate

That's the title of a paper that Judd Kessler and I recently finished, motivated by one aspect of organ donation in Singapore (and recently also in Israel), namely that registered donors receive priority for organs should they need a transplant themselves:
Kessler, Judd B. and Alvin E. Roth, Organ Allocation Policy and the Decision to Donate," June 2010.  (As an added bonus, Judd is on the jobmarket this year.)

Here's the abstract: "Organ donations from deceased donors (cadavers) provide the majority of transplanted organs in the United States, and one deceased donor can save numerous lives by providing multiple organs. Nevertheless, most Americans are not registered organ donors despite the relative ease of becoming one. We study in the laboratory an experimental game modeled on the decision to register as an organ donor, and investigate a variety of strategies for increasing the donation rate. We find that an organ allocation policy giving priority on waiting lists to those who previously registered as donors has a significant positive impact on registration.

And this is from the concluding section
"Before further considering the benefits of the priority rule, it is worth noting that there are other ways to change policy that could positively affect the number of registered organ donors. For example, one proposal that has received a good deal of attention would change the current “opt in” registration method used in the United States to an “opt out” system in which everyone is presumed to be a donor unless he or she actively indicates otherwiseAnother proposal, “mandated choice” would require everyone (e.g. who applies for a driver’s license) to specifically indicate whether they wished to be a donor or not. We want to briefly argue here that the priority rule that we consider may create a more direct link between registration as an organ donor and subsequent successful organ recovery and transplantation than policies that change the procedure by which individuals register as organ donors.

Attempts to increase organ donation rates by changing the default organ registration status (and adopting an “opt out” policy) would surely generate more registered organ donors since those who do not take any explicit action would automatically be registered as donors (see Johnson and Goldstein 2003, 2004, who find direct evidence that registration rates are higher with an “opt out” system).[2] However, such a policy may weaken the link between the registration decision and the legal clarity of the potential donors’ last wishes. Under current United States gift law, changing the default status is likely to have legal consequences that could be detrimental to organ retrieval.

Since the Uniform Anatomical Gift Act of 1968 (UAGA), an individual can make his or her own legally binding decision to be an organ donor after death, which does not require the consent of next of kin (Glazier 2009). However, a donor symbol on a driver’s license has not been considered sufficient evidence of the deceased’s intent to donate in order to proceed without permission from the next of kin. Aside from the fact that the driver’s license is often not available in a timely way, the law allowed that a registered donor could have changed his or her mind about donation subsequent to the issuance of the driver’s license (Glazier 2006).

In recent years, computer registries have allowed for fast checks of organ registration status. They also provide individuals with a way to easily change their organ donor status online, which allows the presence in the registry to be interpreted as intent to donate. The legal status of the anatomical gift has meant doctors can recover donated organs without receiving explicit permission the next of kin (see Glazier 2006). In contrast, a donor registration that does not reflect a positive decision to donate (as under an “opt out” policy) may not be taken as evidence of the deceased’s intent in the legally compelling way that registration does currently. Under an opt out policy, approval from next of kin might again become necessary for an organ to be transplanted.[3]

A "mandated choice" system would also change the way in which individuals became registered donors (see Thaler and Sunstein 2008 and Thaler 2009). Under “mandated choice,” every individual who registered for a driver’s license (or potentially other state or federal documentation) would be required to indicate that he will be an organ donor or that he will not. While there is evidence that a “mandated choice” policy would (like “opt out”) generate more registration of organ donors (Johnson and Goldstein 2003, 2004), similar concerns arise about whether a change to mandated choice would lead to more donated organs and transplants. While the UAGA makes registering to be a donor legally binding under an “opt in” policy, failing to register as an organ donor is not a legally binding decision, whereas registering as a person who declines to donate would likely be legally binding on the next of kin. Discussions with the staff at the New England Organ Bank suggests that they are able to recover organs from about half of all non-registered potential donors in New England by approaching next of kin. This means that more than half of the people who are not currently registered under “opt in” would need to choose “yes” in mandated choice to increase the recovery rate.[4] Consequently, it remains an empirical question whether a change to “mandated choice” would generate more organ transplants.

Even though registration under “opt out” and “mandated choice” systems may raise legal concerns about the intent of registrants under the UAGA, changing the procedure by which individuals register as donors may still be a fruitful avenue to pursue to increase organ donation and recovery.[5] Gift laws can also potentially be changed to address any legal concerns that might arise from new policies. We simply see these legal issues as additional hurdles to monitor and overcome in successfully implementing a change in registration policy. One attraction of the priority rule is that it seems to avoid these additional hurdles since it preserves the current donor registration process as is (and thus is consistent with current United States law regarding donor intent at time of death).

While comparing the different mechanisms in our experiment, the priority rule, rebate, and discount all generate an incentive to donate that offsets the costs of donation. But the priority rule has two advantages over the rebate and discount both inside and outside of the laboratory. First, the simplicity and elegance of the priority rule (as suggested by its outperformance of the rebate and discount at the start of the game) suggests that its benefits are particularly clear and salient. Second, and more importantly, the priority rule is feasible to implement and can be implemented without any additional costs to the system. In contrast, decreasing the costs of registering to be an organ donor is difficult (it is difficult to both understand the costs and to decrease them) and providing a rebate through the form of monetary incentives is not currently allowed by the U.S. National Organ Transplant Act and by similar legislation in many countries.

...

The priority rule used in Singapore appears to be a powerful policy tool. Results from this experiment suggest that it performs as well as or better than discounts and rebates that are of a similar magnitude to the benefits of priority. It is a plausible mechanism to increase rates of registration, and policy makers should consider allocation policy along with other policies to generate more organ transplants."

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The regulated market for cemeteries

The NY Times reports, City Cemeteries Face Gridlock.

"More than 50 years have passed since a major cemetery was established within the city, and no new burial grounds are planned. But New Yorkers continue to die, some 60,000 a year.

"Accordingly, per square foot, burial plots in centrally located cemeteries rival the most expensive real estate in the city. A private mausoleum at Woodlawn Cemetery in the Bronx can easily cost more than $1,000 per square foot.

"“We have people who would like to disinter Mom and Dad and sell the graves back to make some money,” said Richard Fishman, the director of the New York State Division of Cemeteries.


"There are state laws limiting the profits on resold graves, but the fact that people would be willing to go to such lengths, Mr. Fishman said, illustrates just how valuable burial plots have become."
...
"Other major urban areas have taken measures to alleviate similar space crunches. London allows people to be buried upright, while cemeteries in Singapore and Sydney, among others, offer “limited tenure,” cemetery-speak for digging up bodies after a certain amount of time so that the plot can be reused."
...
"It might seem that an enterprising developer could find a way to make a lucrative business out of providing burial space.

"But that has not happened.

"First, by law, cemeteries in New York State must be nonprofit institutions. There are 35 privately owned cemeteries in the city and several dozen with religious affiliations. The closer to Manhattan and major transportation, the more crowded and expensive a burial ground will be. Farther away, particularly in Staten Island and parts of the Bronx, space is available. The indigent of New York City are buried on Hart Island in Long Island Sound.

"Woodlawn, which was part of Westchester County when it was founded in 1863 but was later incorporated into the Bronx, still has burial room. It hopes to be able to offer graves for another 40 to 50 years, but that relative abundance hasn’t kept its prices down.

“We want to have enough saved so that the income from the trust, once we are closed and have nothing left to sell, is enough to maintain the cemetery,” said John P. Toale Jr., the president of Woodlawn.

"While there is a space crunch in the city, there is more space in the suburbs, and cemeteries in upstate New York can barely give away plots, state officials said. Many New Yorkers who struggled and saved to live in the city end up buried elsewhere.

"Even as the broader real estate market languished in the recession, prices for graves in the city continued skyward. The state regulates the fees a cemetery can charge for services like excavation, but graves sell at market price. So burial plots are a cemetery’s revenue-generator.
...
"Now that an end to plot sales is in sight, Green-Wood is seeking to transform its image, according to Richard J. Moylan, its president. The graveyard charges admission for guided tours, giving people a chance to saunter through time among the tombstones of the notable and the notorious. The hope is that it will become much like Père Lachaise cemetery in Paris, a magnet for tourists."

See also this earlier post.

BBC on Suppliers of Human Bodies

The BBC has aired a 20 minute piece on Suppliers of Human Bodies . You can listen to it here. The first interviewee is my HBS colleague Michel Anteby, largely about his article A Market for Human Cadavers in All but Name?

The second interviewee is Brent Bardsley, of Anatomy Gifts Registry, part of the not-for-profit Anatomic Gift Foundation.

The interviewer is largely horrified ("trading in human flesh..." "money shouldn't be involved here..." "an unsavory business..."), but the interviewees help put the issues in perspective (and the law regards human tissues as an "anatomical gift").

Presumed consent and deceased donor organ donation

Kim Krawiec writes: "Duke sociologist (and Crooked Timber blogger) Kieran Healy visited my Taboo Trades and Forbidden Markets seminar this week to discuss his book, Last Best Gifts (University of Chicago Press, 2006) -- a study of the social organization of exchange in human blood and organs – as well as his research on presumed consent laws (See, Do Presumed Consent Laws Raise Organ Procurement Rates? DePaul Law Review, 55:1017–1043 (2006)) (PDF). Healy has also written several other articles about gift and market exchange in human blood and organs and, in addition, studies the moral order of market society (See, for example, Marion Fourcade and Kieran Healy, Moral Views of Market Society. Annual Review of Sociology 33:285–311 (2007) (PDF.))"
...
[The article on presumed consent] "is a comparative study of rates of cadaveric organ procurement in seventeen OECD countries between 1990 and 2002. Those in the United States (and other countries, including the UK) concerned with insufficient cadaveric donor rates frequently advocate a switch to a presumed-consent legal regime (as opposed to the US informed consent regime), as a quick fix to the problem of under-supply. This seems logical enough – in other contexts we have reason to believe that alterations to the default rule, and particularly from an opt-in to an opt-out regime, may meaningfully impact behavior. This is especially plausible when the law functions as some sort of signaling device about societal norms or when, as in the case of organ donation, choosing involves scenarios – death – that one prefers not to contemplate, perhaps causing inertia.
But in the case of cadaveric organ donation an additional argument is typically put forward in favor of presumed consent: the removal of next of kin from the decision-making process. Though the Revised Uniform Anatomical Gift Act specifies that family consent or concurrence is not required, the reluctance of procurement organizations in the U.S. to proceed with organ retrieval against next-of-kin wishes has been generally recognized.
Yet Healey finds that presumed consent laws do not make a material difference to the procurement rate. Importantly, presumed consent laws typically do not remove the next of kin from the procurement process. Although presumed-consent countries have somewhat better procurement rates on average than informed-consent countries, Healy concludes that this is not because of any direct effect of the law on individual choices. Instead, improved donation rates appear driven by substantial investment in the logistics of organ procurement – better training, clear delegation of responsibility, and a strong presence in hospitals, for example. "

Commodification of the body, in Economic Sociology

The November 2009 issue of Economic Sociology, The European Electronic Newsletter, is largely devoted to discussion of "commodification of the body." Here are the articles, which concern cadavers, organs for transplantation, blood, and eggs and sperm.

A Market for Human Cadavers in All but Name by Michel Anteby

The Tyranny and the Terror of the Gift by Nancy Scheper-Hughes

Honestly Embracing Markets in Human Organs for Transplantation by Mark J. Cherry

Between Gift and Commodity: Blood Products in France by Sophie Chauveau

Debt and Gratitude by Lea Karpel