Compensation for donors, organ trafficking, and the Declaration of Istanbul

The American Journal of Transplantation publishes an article suggesting that organ trafficking can only be effectively ended by ending the shortage of organs, which will involve careful trials of incentives for donors.  It also publishes an editorial disagreeing with this proposal, and saying that enforcement of laws against trafficking depend on a ban on compensation to donors.

The March 2012 issue of
American Journal
of Transplantation

A Criminological Perspective: Why Prohibition of Organ Trade Is Not Effective and How the Declaration of Istanbul Can Move Forward

F. Ambagtsheer and W. Weimar
This personal viewpoint expresses the opinion of the authors on how prohibition of organ trade can be improved. See editorial by Glazier and Delmonico on page 515.

The Declaration of Istanbul Is Moving Forward by Combating Transplant Commercialism and Trafficking and by Promoting Organ Donation

A. K. Glazier and F. L. Delmonico
The authors provide a critical response to the viewpoint by Ambagtsheer and Weimar (page 571) regarding the Declaration of Istanbul and its stance toward transplant commercialism, organ trafficking and donation.

Brooklyn man pleads guilty to trafficking black market kidneys

Yesterday, in Trenton NJ, Brooklyn man pleads guilty to trafficking black market kidneys to N.J. residents

"The price was steep. As much as $160,000 to secure a donor willing to give up a human kidney for transplant.

"And Levy Itzhak Rosenbaum ... bragged on surveillance recordings that he had participated in many such black market deals.

"Today, the 60-year-old Israeli pleaded guilty in federal court to helping an FBI informant procure a kidney as part of an elaborate federal sting. At the same time, he admitted arranging transplants for three other New Jersey patients with failing kidneys — all of whom underwent surgery in out-of-state hospitals after paying Rosenbaum. None of the patients or hospitals was named, nor were they charged.

"It marked the first time in this country anyone has ever been convicted for brokering illegal kidney transplants for profit."
**********

See my earlier post on this case:

Monday, July 27, 2009

Corruption and kidneys in New Jersey and Brooklyn

***********

the Haaretz story is very good, so I'm quoting a lot of it below:
New York man pleads guilty to selling Israeli human organs

"His attorneys, Ronald Kleinberg and Richard Finkel, said in a statement that their client had performed a life-saving service for desperately ill people who had been languishing on official transplant waiting lists.

"The transplants were successful and the donors and recipients are now leading full and healthy lives," the statement said. "In fact, because of the transplants and for the first time in many years, the recipients are no longer burdened by the medical and substantial health dangers associated with dialysis and kidney failure."

"The lawyers added that Rosenbaum had never solicited clients, but that recipients had sought him out, and that the donors he arranged to give up kidneys were fully aware of what they were doing. The money involved, they argued, was for expenses associated with the procedures, which they claim were performed in prestigious American hospitals by experienced surgeons and transplant experts. The lawyers did not name the hospitals involved, nor are they named in court documents.

"Prosecutors argued that Rosenbaum was fully aware he was running an illicit and profitable operation - buying organs from vulnerable people in Israel for $10,000, and selling them to desperate, wealthy American patients.

"A black market in human organs is not only a grave threat to public health, it reserves lifesaving treatment for those who can best afford it at the expense of those who cannot," said New Jersey's U.S. Attorney, Paul Fishman. "We will not tolerate such an affront to human dignity."

"Each of the four counts carries a maximum five-year prison sentence plus a fine of up to $250,000. Rosenbaum also agreed to forfeit $420,000 in real or personal property that was derived from the illegal kidney sales.

...

"Although the hospitals where the operations Rosenbaum arranged have not been named, critics and experts on organ trafficking say many U.S. hospitals do not have vigorous enough procedures for looking into the source of the organs they transplant because such operations are lucrative.

...

"Under 1984 federal law, it is illegal for anyone to knowingly buy or sell organs for transplant. The practice is illegal just about everywhere else in the world, too.

"But demand for kidneys far outstrips the supply, with 4,540 people dying in the U.S. last year while waiting for a kidney, according to the United Network for Organ Sharing. As a result, there is a thriving black market for kidneys around the world.

"Art Caplan, the director of the Center for Bioethics at the University of Pennsylvania and a co-chairman of a United Nations task force on organ trafficking, said kidneys are the most common of all trafficked organs because they can be harvested from live donors, unlike other organs. He said Rosenbaum had pleaded guilty to one of the "most heinous crimes against another human being."

"Internationally, about one quarter of all kidneys appear to be trafficked," Caplan said. "But until this case, it had not been a crime recognized as reaching the United States."

Kosovo organ trafficking case opens

Trial Opens for 7 Kosovars in Organ-Trafficking Case

" The suspects are accused of luring victims from Turkey and former Communist countries to Pristina to sell their kidneys with false promises of payments of up to €15,000, or nearly $20,000.

"The recipients, according to the indictment, paid between €80,000 and €100,000 for the organs."

This case seems to be different from but related to the much more disturbing accusations related to war crimes:

"The case has been connected with an inquiry by the Council of Europe released this January, which found that a criminal group of Kosovo Liberation Army fighters had executed Serbian and Albanian prisoners and sold their organs on the international black market. The report said that the so-called Drenica Group was led by Hashim Thaci, the current prime minister of Kosovo."

Earlier posts:

Two faces of kidney transplantation

Illegal markets for organ transplants: Kosovo trials

If it were legal to sell organs for transplantation, what would the ads look like?

From time to time as I maintain this blog, I get a popup window from Google saying that since the blog appears to be popular I could make some money by showing ads from Google AdSense.  So far I have resisted, although an extra skim latte every week or so is tempting.

But I was recently on a site promoting deceased organ donation of transplantable organs. Apparently they are getting those lattes, since this ad appeared at the bottom of their site, giving a glimpse into an alternative universe in which organs are bought and sold:

Organ Sales & Service  We carry Lowrey & Roland Organs Service all brands 781-893-6644 www.MainStreetMusicBoston.com

And once you enter that alternative universe, you notice that even the WSJ could be there: this story (pointed out to me by Eric Budish) ran on Friday--
Trafficking in Organs, Mr. Bishop Pipes Up to Preserve a Bit of History  

""We think of ourselves, like the curator of a historical site or the park ranger at Paul Revere's house, as being stewards," says Mr. Bishop, the white-bearded, 56-year-old executive director of the Organ Clearing House, a Charlestown, Mass., company and part of a growing community of "organ rescue" operations."

Repugnant markets involving altruistic motivations

Kim Krawiec follows up on Kieran Healy's work on markets for organs, and how the distinction between gift giving and buying and selling isn't so clear.

Krawiec writes (I quote at length, but not the whole thing):

"...I agree with Kieran that financial incentives for human organs are more likely to win social acceptance if they resemble the gift-based allocation systems that have already gained social legitimacy. And the oocyte market – a clearly market-based system with the trappings of gift, including the language of donation -- is a good example of this phenomenon. 

In fact, as I’ve discussed before, this disconnect between market realities and gift narrative is an important feature of many taboo trades.  By normalizing otherwise jarring transactions, gift narratives may facilitate markets that otherwise would stagnate under the weight of social disapproval. For those, like me, who believe there is social value in enabling the infertile to reproduce or those dying from kidney failure to live – and, by corollary, allowing those who consider themselves better off by the receipt of compensation in exchange for an egg or kidney – to do so, this is a good thing. 

At the same time, though, the oocyte market example also illustrates the costs of denying market realities in favor of the pretense of gift exchange -- gifts in name only: 

(1) Legal misfit

Gift-based exchange regimes are typically governed by a different set of legal rules than are market-based exchange regimes.  We tend to recognize, for example, the possibilities for opposing interests and opportunistic behavior in a regime of market-based exchange.  And many legal rules governing market-based regimes are designed with these considerations in mind. In contrast, we often assume (incorrectly, especially when the gift is one in name only) an absence of opportunism and an alignment of interests in the case of gift-based exchange. 

(2) Social stereotypes

I do not know if, or how, this would play out in organ markets, but it has for some time concerned me with respect to reproductive markets, especially the oocyte and surrogacy markets.  Scholars have long noted the presumption that many services provided by women, including reproductive and domestic labor, should be provided altruistically, despite their high economic value.  Says Mary Anne Case, for example:

Much of what women have market power over, such as their sexual and reproductive services, they have long been expected not to commodify at all. Even when monetary compensation is allowed, it is often kept low and female providers are expected to be interested in rewards other than money.

The continued insistence that egg donors are, and should be, motivated primarily by altruism and the desire to help others, rather than by the desire for monetary compensation, threatens to reinforce gendered notions that the market activities of women are driven in large part by altruism and that women as a group are uninterested in reaping the full gains of trade from the provision of their goods and services. 

The comparison to sperm markets is especially telling. The insistence on the altruistic motivations of egg donors is in stark contrast to the presumed motivations of sperm donors, who are recruited through materials that ask, “Why not get paid for it?” and advertise, “your sperm can earn!” 

...

In the end, gifts in name only represent a trade-off.  On the one hand, the language of donation coupled with the realities of market-based exchange has the capacity to legitimate otherwise troubling exchanges, facilitating life-saving operations and parenthood for the infertile.  At the same time, gift-in-name-only exchange has consequences for the social, legal, and market structure of these industries, and for the consumers, producers, and others, including the public-at-large, affected by them."

Twelve international criminal markets

I'm not confident of the data, but numbers one and two are drugs and human trafficking, and number five is human organs.
This from Transnational Crime In The Developing World: A February 2011 Report from Global Financial Integrity. The detailed report is here.

Roughly organized in terms of overall cash flow here is their list of goods illicitly traded across borders (the ordering depends not only on highly unreliable estimates, but on how the categories are aggregated...).

1. Drugs
2. Human trafficking
3. Illicit wildlife
4. Counterfeit goods and currency ("If imitation is the sincerest form of flattery, counterfeiting is the criminal form.")
5. Human organs (my worries about data sources are compounded by noting that their figures for legal US transplants come from a 2008 article in the Economist, rather than e.g. from UNOS/OPTN data, which is easily available on the web)
6. Small arms
7. Diamonds
8. Oil
9. Timber
10. Fish
11. Art and artifacts
12. Gold

From the executive summary:
"This report analyzes the scale, flow, profit distribution, and impact of 12 different types of illicit trade: drugs, humans, wildlife, counterfeit goods and currency, human organs, small arms, diamonds and colored gemstones, oil, timber, fish, art and cultural property, and gold. Though the specific characteristics of each market vary, in general it can be said that these profitable and complex criminal operations originate primarily in developing countries, thrive in the space created by poverty, inequality, and state weakness, and contribute to forestalling economic prosperity for billions of people in countries across the world.

"The global illicit flow of goods, guns, people, and natural resources is estimated at approximately $650 billion. Though data is scarce and experts are constantly debating the relative merits and weaknesses of every new study, it is generally accepted that illicit drug trafficking and counterfeiting are the two most valuable markets. This report finds the illicit drug trade to be worth roughly $320 billion and counterfeiting $250 billion. These numbers reflect the potential for huge profits which is
the fundamental driver of criminal trade."

HT: Bettina Klaus

More on the debate over kidney sales: transcript of interview

In my earlier post, Dubner interviews me about kidney sales, I promised to link to a transcript when it became available, and now it has: there's a link at the bottom of the Freakonomics post You Say Repugnant, I Say … Let’s Do It!

Dubner interviewed me for about an hour and a half, so he and his producer Chris Neary had to do lots of editing to produce the half hour or so podcast. I recall a pair of questions, one of which made it into the show and one of which was left on the cutting room floor (or wherever unused electronic files are left).  The question that made it in was about what makes many people view kidney sales as repugnant. The question that didn't make it was, if I were asked to help design a market in which kidneys could be sold, what would be my primary concerns.

Regarding what is behind the repugnance of kidney sales, here's the text of my reply included in the transcript:
"Al Roth: The late Pope John Paul wrote about this and he objects strongly to the sale of kidneys but thinks the donation of kidneys is a very good thing, though if we do it for money is a very bad thing...I think his feeling is that it turns people from ends into means which is a bad thing in itself. So that’s one nature of objection. 
Another kind of objection is that it might be OK if I offered to buy your kidney because you’d be a hard guy to exploit, you’re a successful, financially solvent person, but pretty soon we’d start seeing the desperately poor and maybe they would in some sense be acting against their self interest, they would be being exploited or coerced even, by the temptation of the money in ways that if they could use their better judgement they wouldn’t want to be.  So that’s sort of a coercion argument. 
And then there’s a slippery slope argument that says if we started allowing people to sell their kidneys, it would be primarily poor people who would sell their kidneys, and pretty soon we would start hearing political discussion that said, ‘you know, we don’t really need unemployment benefits, we don’t really need aid to families with dependent children because after all, everyone’s got two kidneys and they can take care of themselves by selling a kidney if they need to’...and that makes us a much less desirable society to live in."


I don't have a transcript to consult about what I said when they asked what I would do if asked to help design a kidney market, but as I recall, my answer went something like this.
The first thing I'd want to think about is what kind of review we would want to use to judge if the market had been a success ten years (or longer) after it had been started. The criteria we'd surely want the market to be evaluated on would include:
 How had the donor/vendors fared?: were they healthy and well treated, and respected, and did they encourage new potential donor/vendors to make the same choices they had?
How had patients with kidney disease fared?: were they receiving healthy kidneys, had the waiting list for transplants largely disappeared, were kidneys being allocated in ways that were widely seen as equitable?


To focus thoughts for future debate, we might want to think about a system in which only the federal government could legally pay for a live kidney, and would have a mandate to set the price (and associated benefits like follow-up medical care) high enough so that there would be a waiting list of donor/vendors, who could e.g. be expected to undergo regular health and suitability tests (suitability being a broad term meant to include physical and mental health, deeply informed consent, etc.)  for a year before being accepted as donor/vendors, and that the kidneys obtained in this way would be allocated anonymously through some regulated procedure that might resemble the current procedures for allocating deceased-donor organs.

In terms of how I've interpreted the ongoing debate between those in favor of sales and those against, I  think that a good deal of the coercion concern can be addressed by an appropriately designed one year waiting period, although I say that without having recently talked to someone who makes that argument with conviction.
I don't see any easy way to bridge the gap between those who think that selling kidneys is a bad thing in and of itself, not to be traded off with possible benefits of other sorts (e.g. to patients and perhaps to donor/vendors), and those who don't see it that way, or who feel that the current dire circumstances of many thousands of those with kidney disease gives legitimate counterweight to this concern.
And the slippery slope concern is the one that personally gives me the most pause. I can see how appropriate legislation would prevent e.g. your bank from asking for a kidney as collateral, but I can't see any way to be sure that making kidneys a potential financial asset wouldn't make us a less sympathetic society (even though a one year waiting period and other qualification tests would limit how much kidney sales could be used as a justification for cutting unemployment insurance in particular).

My work on kidney exchange has largely avoided being enmeshed in this debate, since the "in kind" kidney exchange doesn't seem to arouse repugnance. Thus for example Debra Satz' recent book Why Some Things Should Not Be For Sale: The Moral Limits of Markets, Oxford University Press, 2010, finds little to object to about kidney exchange, but largely disapproves of kidney sales. (I expect to meet Professor Satz for the first time this weekend, at a philosophy of economics conference in Helsinki...)

Illegal markets for organ transplants: Kosovo trials

Illegal, black markets for kidneys are often cited both by opponents and proponents of legal markets: opponents look at the abuses in illegal markets and fear that legal markets would spread them, and proponents look at illegal markets and hope that legal markets would curb them.

Seven Charged in Kosovo Organ-Trafficking Ring
"At least seven people have been charged with participating in an international organ-trafficking network based in Kosovo that sold kidneys and other organs from impoverished victims for up to $200,000 to patients from as far away as Israel and Canada, police and senior European Union officials said Monday.

"According to the indictment, the traffickers lured people from slums in Istanbul, Moscow, Moldova and Kazakhstan with promises of up to $20,000 for their organs. Law enforcement officials say many never received a cent. The operations were performed at a private clinic in a run-down neighborhood on the outskirts of Pristina, the Kosovar capital.

"While the ring was first discovered two years ago, the global scale of the network and its victims is only now becoming clear.

"Officials said the ringleader was a highly regarded surgeon and professor at Pristina University Hospital, Dr. Lutfi Dervishi. The clinic was run by his son, Arban. Also charged was Ilir Rrecaj, a senior official in Kosovo’s Health Ministry when the ring was broken. They and two others are accused of crimes including trafficking in humans and body parts, unlawful medical activity, participating in organized crime, and abuse of office. All were released on bail.
...
"The trafficking network’s tentacles reached far. Warrants were issued for a Turkish doctor and an Israeli financier, and two other doctors, an Israeli and a Turk, were named as co-conspirators.

"The police said the ring had its roots at a medical conference in 2006 in Istanbul, where Dr. Dervishi met the Turkish doctor being sought, Yusuf Sonmez. Law enforcement officials describe Dr. Sonmez as a notorious international organ trafficker.

"The Medicus clinic had been founded by a European philanthropist who aided ethnic Albanian doctors during the war in Kosovo in 1999. Dr. Dervishi, police officials said, secretly transformed it into a hub for illegal organ transplants, which were performed by Dr. Sonmez.

"The indictment was first reported by The Associated Press. In it, a European Union prosecutor, Jonathan Ratel, said that in 2008, 20 foreign nationals living in “extreme poverty or acute financial distress” were “recruited with the false promises of payments.”

"The police said they broke the ring in November of that year, when a young Turkish man, Yilman Altun, was found at the Pristina airport, weak and frail. Mr. Altun told the police that his kidney had been stolen. When the police raided the Medicus clinic, they discovered an elderly Israeli man who had received Mr. Altun’s kidney.

"European Union officials said that the indictment in the case had been filed in district court in Kosovo and that a preliminary hearing was expected by the end of the year. If a judge confirms the charges, a trial will follow.
...
"Western law enforcement officials said they suspected the ring might be part of a larger criminal network whose nexus was in Israel. In September, five doctors from South Africa were charged with participating in an international kidney-trading syndicate in which dozens of poor Brazilians and Romanians were paid for kidneys for wealthy Israelis. Analysts said the organ-trafficking case was part of a disturbing global trend in which unscrupulous traffickers take advantage of the growing waiting lists of desperate patients and the vulnerability of poor people further buffeted by the international financial crisis."

Update: Dec 15. The Telegraph follows the beginning of the trial: Kosovo physicians accused of organ trafficking racket -- A gang of Kosovan organ traffickers operated an elaborate international network that traded in the organs of people living in extreme poverty, a court heard.

Organs for sale? Repugnance as controversy to sell magazines

Mohammad Mahdian points out this ad for the Economist magazine, entitled
"Trading Human Organs Should Be Allowed"

Organ sales in China

MSNBC reports Organ trafficking trial exposes grisly trade: Chinese man accused of selling black market body parts
"China in 2007 banned organ transplants from living donors, except spouses, blood relatives and step or adopted family members, but only launched a national system to coordinate donation after death last year.
Its efficiency has yet to be proved. Nearly 1.5 million people in China need organ transplants each year, but only 10,000 can get one, according to the Health Ministry.
The defendants in the two Beijing trials face up to five years for their role as go-betweens between donors and buyers, which could "damage society and moral values", the Procuratorial Daily reported. They are still waiting for their verdict.
But at least two of them say they are being unfairly hounded for playing a vital role in helping both the sick and poor.
"I believe I was helping people, not harming others," the paper quoted defendant Liu Qiangsheng as saying.
Liu says he got into the business after selling half his own liver in 2008 to help pay for this father's medical bill. A friend of the recipient, who was waiting in despair for a liver, asked him to find another organ provider.
"I saved the life of the person who received my liver. He was only in his 30s. I do not regret it," he said.
His partner, Yang Shihai, had also sold one of his own kidneys, the paper reported.
"The donors were free. They were not controlled by us. They sold their organs voluntarily," it quoted Yang saying.
Middlemen specialized in faking documents allowing donations between strangers have helped raise transplants from living donors to 40 percent of donations, from 15 percent in 2006, the official China Daily reported last year.
However the majority of organs for transplant are still harvested from executed criminals, the paper said. Beijing hopes the new system will end both live transplants and taking organs from prisoners, which makes senior officials uncomfortable.
"(Executed prisoners) are definitely not a proper source for organ transplants," Vice Minister Huang Jiefu told China Daily."

An incongruous note: In the middle of the story was an ad saying "Buy 1 Get 1 Free." (It turned out to be an ad for eyeglasses...)

Books about markets for body parts (for and against)

Below are a mix of books, some scholarly some popular, mostly harvested by clicking on the Amazon links "people who bought this book also bought," from one book to the next. The descriptions are from Amazon:

Body Shopping: Converting Body Parts to Profit by Donna Dickenson
Product Description
According to law, you don't actually own your own body, and you might be shocked by the cunning ways everyone from researchers and entrepreneurs to doctors, insurers, and governments are using that fact to their advantage. Thanks to developments in biotechnology and medicine, cells, tissues, and organs are now viewed as both a valuable source of information and as the raw material for new commercial products.This 'currency of the future' might be fueling the new biotechnology industry, but the former owners of that flesh and bone aren't entitled to one fraction of the proceeds. In "Body Shopping", award-winning writer Donna Dickenson makes a case against the newfound rights of businesses to harvest body parts and gain exclusive profit from the resulting products and processes. To illustrate her case, she presents a series of compelling stories of individuals injured or abused by the increasingly rapacious biotechnology industry. Some cases have become public scandals, such as the illicit selling of the late broadcaster Alastair Cooke's bones by a body parts ring involving surgeons and undertakers.Others are hardly known at all, including the way in which for-profit umbilical cord blood banks target pregnant women with offers of a 'service' that professional obstetrics bodies view as dangerous, the leukemia patient who tried and failed to claim property rights in a $3 billion cell line created from his tissue, and the real risks facing women who provide eggs for the global market in baby-making. "Body Shopping" offers a fresh, international, and completely up-to-date take on the evolving legal position, the historical long view, and the latest biomedical research - an approach that goes beyond a mere recital of horror stories to suggest a range of new strategies to bring the biotechnology industry to heel. The result is a gripping, powerful book that is essential reading for everyone from parents to philosophers, and from scientists to lawmakers - everyone who believes that no human should ever be reduced to the sum of their body parts.


Black Markets: The Supply and Demand of Body Parts by Michele Goodwin, 2006
From Publishers Weekly
Law professor and bioethicist Goodwin sheds much needed light in this disturbing examination of yet another failure of the American health care system: an organ donation process that leads to the sale of human organs. Despite some highly technical sections, the author artfully uses case law and tragic stories of people caught in the machinery of an organ marketplace that favors the well connected. Even readers well versed in current events are likely to be shocked by the prevalence of "presumed consent" legislation in 28 states that shifts the choice to donate away from potential donors —corneas, for instance, are routinely harvested by local coroners unless a specific prior refusal has been communicated (and sometimes even despite such a directive). The author does a good job of linking this country's history of medical scandals that victimized African-Americans to that community's misgivings about serving as either donors or seekers of a spot on the coveted transplant waiting lists. Her controversial recommendations, which include lifting the taboo on selling cadaveric organs to address the organ deficit, should spark much discussion. (Mar.)


Tissue Economies: Blood, Organs, and Cell Lines in Late Capitalism (Science and Cultural Theory) ~ Catherine Waldby (Author), Robert Mitchell (Author)
Product Description
As new medical technologies are developed, more and more human tissues—such as skin, bones, heart valves, embryos, and stem cell lines—are stored and distributed for therapeutic and research purposes. The accelerating circulation of human tissue fragments raises profound social and ethical concerns related to who donates or sells bodily tissue, who receives it, and who profits—or does not—from the transaction. Catherine Waldby and Robert Mitchell survey the rapidly expanding economies of exchange in human tissue, explaining the complex questions raised and suggesting likely developments. Comparing contemporary tissue economies in the United Kingdom and United States, they explore and complicate the distinction that has dominated practice and policy for several decades: the distinction between tissue as a gift to be exchanged in a transaction separate from the commercial market and tissue as a commodity to be traded for profit.
Waldby and Mitchell pull together a prodigious amount of research—involving policy reports and scientific papers, operating manuals, legal decisions, interviews, journalism, and Congressional testimony—to offer a series of case studies based on particular forms of tissue exchange. They examine the effect of threats of contamination—from HIV and other pathogens—on blood banks’ understandings of the gift/commodity relationship; the growth of autologous economies, in which individuals bank their tissues for their own use; the creation of the United Kingdom’s Stem Cell bank, which facilitates the donation of embryos for stem cell development; and the legal and financial repercussions of designating some tissues “hospital waste.” They also consider the impact of different models of biotechnology patents on tissue economies and the relationship between experimental therapies to regenerate damaged or degenerated tissues and calls for a legal, for-profit market in organs. Ultimately, Waldby and Mitchell conclude that scientific technologies, the globalization of tissue exchange, and recent anthropological, sociological, and legal thinking have blurred any strict line separating donations from the incursion of market values into tissue economies.


Body Brokers: Inside America's Underground Trade in Human Remains (Paperback)~ Annie Cheney 2006
From Booklist
*Starred Review* Here's one with the potential to keep folks up nights, wondering whether the urn on the mantel contains 100-percent Uncle Fred or a blend. Before journalist Cheney began an assignment for My Generation magazine, she had never suspected there might be diverse career opportunities for cadavers, that whatever one wants to be when one grows up, options continue to exist postmortem. But consider the ever-popular organ donor program. And then there's the option of donating one's body to a medical school for the betterment of mankind through science. Once that latter choice is made, Cheney learned, alternatives multiply, and a corpse can follow one of several roads. On a lower thoroughfare, big bucks are waiting for the cold-blooded entrepreneur ready to carve human bodies up like chickens and parcel them out to the highest bidder for such uses as military bomb test dummies, lifelike operative subjects for medical seminars, and resource troves for the machine-tooling of bones into orthopedic apparatus. Even if one never willingly donates one's body, there are enough unscrupulous morticians and morgue workers who will surreptitiously carve out an ulna or a femur and replace it with a PVC pipe, then sell the goods on the not-so-open open market. This is a chilling expose of the grisly industry of body trading. Donna ChavezCopyright © American Library Association. All rights reserved --This text refers to the Hardcover edition.


Kidney for Sale by Owner: Human Organs, Transplantation, and the Market )~ Mark J Cherry, 2005
Product Description
Over the past decade in the United States, nearly 6,000 people a year have died waiting for organ transplants. In 2003 alone, only 20,000 out of the 83,000 waiting for transplants received them - in anyone's eyes, a tragedy. Many of these deaths could have been prevented, and many more lives saved, were it not for the almost universal moral hand wringing over the concept of selling human organs. Bioethicist Mark Cherry explores the why of these well-intentioned misperceptions and legislation and boldly deconstructs the roadblocks that are standing in the way of restoring health to thousands of people. If most Americans accept the notion that the market is the most efficient means to distribute resources, why should body parts be excluded? Kidney for Sale by Owner contends that the market is indeed a legitimate - and humane - way to procure and distribute human organs. Cherry stakes the claim that it may be even more just, and more compatible with many Western religious and philosophical traditions, than the current charity-based system now in place. He carefully examines arguments against a market for body parts, including assertions based on the moral views of John Locke, Immanuel Kant, and Thomas Aquinas, and shows these claims to be steeped in myth, oversimplification, and contorted logic. Rather than focusing on purported human exploitation and the irrational "moral repugnance" of selling organs, Cherry argues that we should focus on saving lives. Following on the thinking of the philosopher Robert Nozick, he demonstrates that, with regard to body parts, the important core humanitarian values of equality, liberty, altruism, social solidarity, human dignity, and, ultimately, improved health care are more successfully supported by a regulated market rather than by well meant but misguided, prohibitions.


The Ethics of Organ Transplants: The Current Debate (Contemporary Issues (Buffalo, N.Y.).) (Paperback 1999)~ Arthur L. Caplan (Author, Editor), Daniel H. Coelho (Editor)
From Library Journal
Renowned bioethicist Caplan (Ctr. for Bioethics, Univ. of Pennsylvania) and medical writer Coelho have selected 35 articles that are representative of the ethical issues surrounding organ transplantation. Scarcity of organs and the high costs involved in these procedures force difficult legal, philosophical, scientific, and economic choices. What are the sources of organs used in transplantation? How can we make the procurement system more efficient? Should we pay for organs? Should someone who has already received one transplant be allowed a second? Should alcoholics be given liver transplants? Are transplants really worth the tremendous costs? These are just a few of the questions discussed here. In many cases, the editors have selected companion articles that illustrate contrasting viewpoints on a particular issue. Although some articles are slightly dated, the issues are still relevant. This well-balanced, reasonably priced compilation is recommended for all libraries.ATina Neville, Univ. of South Florida at St. Petersburg Lib.Copyright 1999 Reed Business Information, Inc.


The U.S. Organ Procurement System: A Prescription for Reform (AEI Evaluative Studies.) (Hardcover) by David L. Kaserman and A. H. Barnett
Product Description
Experts make a compelling and persuasive case for markets in human organs.

Kieran Healy, Last Best Gift. Altruism and the Market for Human Blood and Organs. Chicago University Press, 2006


The Baby Business: How Money, Science, and Politics Drive the Commerce of Conception (Hardcover)~ Debora L. Spar
From Publishers Weekly
Among the troubling aspects of new reproductive technologies is the takeover of reproduction by the marketplace. This probing study accepts the free market process while casting a discerning and skeptical eye at its pitfalls. Harvard business prof Spar (The Cooperative Edge: The Internal Politics of International Cartels) explores many aspects of the high-tech commodification of procreation: the fabulous revenues commercial fertility clinics earn from couples' desperate desire for children and the ensuing conflicts between medical ethics and the profit motive; the premiums paid for sperm and eggs from genetically desirable donors; the possible exploitation of poor, nonwhite and Third World surrogate mothers paid to gestate the spawn of wealthy Westerners; the fine line between modern adoption practices and outright baby selling; and the new entrepreneurial paradigm of maternity, in which the official "mother" simply finances the assemblage of sperm, purchased egg and hired womb and lays contractual claim to the finished infant. Spar considers most of these developments inevitable and not undesirable (they provide kids to parents who want them), but calls for government regulation to curb excesses and protect the interests of all involved. Her sanguinity will not satisfy all critics, but she offers a lucid, nuanced guide to this brave new world. (Feb. 14) Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

RepoMen (the movie)

Joshua Gans points me to the trailer for the upcoming movie RepoMen. It touches on both repugnance and organ transplantation:

Synopsis
In the futuristic action-thriller Repo Men, humans have extended and improved our lives through highly sophisticated and expensive mechanical organs created by a company called The Union. The dark side of these medical breakthroughs is that if you don’t pay your bill, The Union sends its highly skilled repo men to take back its property…with no concern for your comfort or survival. Jude Law plays Remy, one of the best organ repo men in the business. When he suffers a cardiac failure on the job, he awakens to find himself fitted with the company’s top-of-the-line heart-replacement…as well as a hefty debt. But a side effect of the procedure is that his heart’s no longer in the job. When he can’t make the payments, The Union sends its toughest enforcer, Remy’s former partner Jake (Academy Award® winner Forest Whitaker), to track him down. Now that the hunter has become the hunted, Remy joins Beth (Alice Braga), another debtor who teaches him how to vanish from the system. And as he and Jake embark on a chase across a landscape populated by maniacal friends and foes, one man will become a reluctant champion for thousands on the run.

Incentives for organ donors at MR and the WSJ

Alex Tabarrok writes at MR about Innovative Solutions to the Shortage of Transplant Organs, and at the WSJ: The Meat Market.

He discusses recent developments in transplantation policy in Israel and Singapore, among other things.

Declaration of Istanbul update

I received an email regarding the 2008 Declaration of Istanbul, intended to slow/halt/reverse transplant tourism and black markets for organs. It states in part:

"On September 30, 2009, the Steering Committee of the Declaration of Istanbul met in Beirut, Lebanon, in conjunction with the Congress of the Asian Society of Transplantation, to formulate a strategy and plans for the continued implemention of the Declaration."

"Updates:
· Since the November 2008 Steering Committee meeting, there has been a reduction in organ trafficking and transplant tourism in China, the Philippines, and Pakistan. Israel has enacted legislation that impedes Israeli citizens from receiving insurance coverage for transplants performed outside of Isreal if the destination country prohibits foreign patients from undergoing transplantation. There has been a recorded reduction in foreign transplants in Colombia from 12 % to 1 % of transplants performed.

· More than 80 professional organizations and societies have endorsed the Declaration of Istanbul.

· On October 13, 2009 a Joint Report by the Council of Europe and the United Nations will be presented in New York at the United Nations to launch a global effort in combating human organ trafficking.

· In March 2010, the WHO will hold its 3rd Global Consultation on transplantation in Madrid, Spain (in collaboration with TTS and ONT) to foster the development of self sufficiency in each nation in providing organ transplants for its residents. "

"Mission Statement:
The Mission of the Declaration of Istanbul Custodian Group (DICG) is to promote, implement and uphold the Declaration of Istanbul so as to combat organ trafficking, transplant tourism and transplant commercialism and to encourage adoption of effective and ethical transplantation practices around the world. "


"The following GOALS have been identified for these revised Task Forces:

I. Professional Organizations:
· Professional Organizations require that speakers at scientific and educational meetings on clinical organ transplantation disclose whether the clinical and research activities being reported have complied with the Principles of the Declaration of Istanbul.
· Professional Organizations have an established mechanism for determining the appropriateness of accepting presentations on clinical organ transplantation based on the disclosure of their compliance with the Principles of the Declaration of Istanbul.
· Organizations that endorse the Declaration of Istanbul establish mechanisms to promote, implement and uphold the Declaration (for example, through their ethics committees, awards and membership criteria).

II. Medical and Scientific Journals:
Medical and scientific journals require that authors of articles relating to clinical organ transplantation disclose whether the clinical and research activities being reported have complied with the Principles of the Declaration of Istanbul.
Medical and scientific journals have an established mechanism for determining the appropriateness of accepting presentations on clinical organ transplantation based on the disclosure of their compliance with the Principles of the Declaration of Istanbul.

III. Pharmaceutical Companies and Other Research Sponsors:
· Pharmaceutical companies establish a mechanism to ensure that the clinical studies of organ transplantation they support comply with the Principles of the Declaration of Istanbul.
· Pharmaceutical companies disclose whether the clinical studies of organ transplantation they support comply with the Principles of the Declaration of Istanbul.
· All organizations and individuals that fund clinical studies of organ transplantation establish a mechanism to ensure that these studies comply with the Principles of the Declaration of Istanbul.
· All organizations and individuals that fund clinical studies of organ transplantation disclose whether these studies comply with the Principles of the Declaration of Istanbul.

IV. Violations of the Declaration:
· Violations of the Principles of the Declaration are drawn to the attention of relevant healthcare authorities and institutions and medical societies as well as to the World Health Organization and other relevant intergovernmental organizations.

V. Government and Healthcare Institutions:
· Governments and responsible national authorities adopt and implement policies, laws and regulations in accordance with the Principles of the Declaration of Istanbul and the WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation.
· Hospitals and other healthcare institutions engaged in organ transplantation services adopt and implement policies in accordance with the Principles of the Declaration.
· National and institutional ethics committees develop policies concerning organ transplantation which are in accordance with the Principles of the Declaration."

In related news, the United Nations and the Council of Europe have launched a study on "Trafficking in organs, tissues and cells and trafficking in human beings for the purpose of the removal of organs". (Here's a brief news report.)

Peter Singer on compensating kidney donors

Kidneys for Sale? by Peter Singer

The distinguished Princeton philosopher of bioethics takes a nuanced view of the matter of compensation for donors, in a discussion of organ sales that touches on New York, Singapore, and Iran.

HT: Joshua Gans

Thaler on mandated choice

In the NY Times, Dick Thaler considers how the way people are asked whether they would like to be deceased organ donors might influence the donation rate: Opting in vs. Opting Out .

Thaler thinks organ sales are too widely viewed as repugnant to be politically feasible. And despite the headline, he comes out in favor not of opt in or opt out as defaults, but rather mandated choice, a nudge of the kind he and Cass Sunstein celebrate in their best selling book of that name.

"Here is how it works: When you go to renew your driver’s license and update your photograph, you are required to answer this question: “Do you wish to be an organ donor?” The state now has a 60 percent donor signup rate, according to Donate Life Illinois, a coalition of agencies. That is much higher than the national rate of 38 percent reported by Donate Life America
The Illinois system has another advantage. There can be legal conflicts over whether registering intent is enough to qualify you as an organ donor or whether a doctor must still ask your family’s permission. In France, for example, although there is technically a presumed-consent law, in practice doctors still seek relatives’ approval. In Illinois, the First-Person Consent Law, which created this system, makes one’s wishes to be a donor legally binding. Thus, mandated choice may achieve a higher rate of donations than presumed consent, and avoid upsetting those who object to presumed consent for whatever reasons. This is a winning combination.
THE key, however, is to make signup easy, and requiring people to make a choice is just one way to accomplish it. The private sector could help create other simple methods. Here is a challenge to Mr. Jobs: Why not create a Web site — and a free app for the iPhone — that lets people sign up as organ donors in their home states? "

(Note from my earlier post on Steve Jobs' liver transplant that Massachusetts is one of the few states that allows you to sign up to be a donor online, and see also Thaler's remarks at the bottom of this other earlier post.)

One of the things I like about signing up online is that it allows people to think about organ donation at places other than the Department of Motor Vehicles. I wonder if that's the only place we should be asking people about donation; or whether that location invites you to think too much about fatal car crashes (which are far from the only way to become an organ donor, and which you might prefer not to think about).

On the DMV form at the top of the page you can see that here in Massachusetts we have "opt in" for organ donation, but mandated choice for voter registration. (You can enlarge the photo by clicking on it, if you're reading this on a small screen.) So Thaler's good suggestion would be easy to implement, a very gentle nudge in the right direction.

Kidney donations, incentives, sales, legislation

An interview including Alex Tabarrok, Sally Satel, and Frank Delmonico, covering the range of viewpoints on the subject.

"Last year Pennsylvania Senator Arlen Specter floated a draft bill that could have cleared the way for states to offer non-cash incentives. ...
But groups including the National Kidney Foundation rejected Specter's proposal, now a spokeswoman for the Senator says he has no plans to introduce the bill."

Here is one draft of Senator Specter's proposed bill (on the site of the American Society of Transplant Surgeons--it was never introduced into the formal legislative process): Organ Donation Clarification Act of 2008 - Proposed Specter Bill

The current issue of the American Journal of Transplantation contains a survey of the ASTS membership, which finds that a majority of the surgeons responding support various income tax credits, insurance, and reimbursement for funeral expenses and lost wages, but oppose cash payments to the donor, donor's family or estate. (Rodrigue et al., "Stimulus for Organ Donation: A Survey of the American Society of Transplant Surgeons Membership," AJT, 2009, 9, 2172-2176.

Misc. organ transplant links

The links below, which I collected over some time but never turned into blog posts, all have something interesting to say about transplantation.

Should We Legalize the Market for Human Organs? An NPR debate among Sally Satel, Amy Friedman, and Lloyd Cohen (arguing for), and James Childress, Frank Delmonico, and David Rothman (arguing against).

Lingering myths discourage organ donation from American Medical News:
"Only 38% of licensed drivers have joined their states' organ donor registries, with many deterred by long-held misconceptions about how the transplant system works, according to poll results released in April."

Organ donations decline with economy from the Miami Herald.
The numbers of organ donors is down, and experts say one reason may be the recession. But "Because of legislative action, Floridians starting in July will be able to register online to be an organ donor at donatelifeflorida.org ."

In the Kidney Trade: Seller Beware
"Need a kidney? You may be able to buy one in Pakistan, which has become one of the world’s largest “kidney bazaars,” according to an article published in the May-June issue of The Hastings Center Report, a bioethics journal.
But who sells their kidneys, and what becomes of these people afterwards? The article, by two doctors and a psychologist from Karachi, paints an ugly picture of the kidney business and challenges the argument made by some that selling organs is a great financial boon to the poor and that they are grateful for the chance to do it. "

A Better Way to Get a Kidney Daniel Rose in a NY Times OpEd proposes we shift to "opt out" for deceased donors.

National Paired Donation Network (Steve Woodle) does an exchange in Pittsburgh: Kidney exchange benefits boy, 5, and woman

Larissa MacFarquhar: Paying for Kidneys
Megan McArdle: Department of Bizarre Arguments

"Exploitation" of the Poor is a Poor Reason to Ban Organ Markets from the Volokh Conspiracy

Milford men take part in four-way kidney swap (when we helped start NEPKE, only pairwise exchanges were initially feasible, but NEPKE became a pioneer in including 3- and 4-way exchanges in its optimization algorithm...)


Britain's only saviour sibling twins: At the age of two, little do they know it but Amy and Anthony Maguire are Britain's only 'saviour sibling' twins, created to be donors for their sick older brother.
Bone marrow donation requires a perfect match.
"The twins were born after IVF treatment was used to select embryos which are a match for their brother Connor so that blood taken from their umbilical cord at birth may one day be used to offer him life-saving treatment."

Organ donation to get halachic approval
A uniquely Israeli obstacle to organ donation wends its way towards resolution:
"Chief Rabbinate tries to encourage religious public to become organ donors by resolving halachic quandaries surrounding process, issuing special donor card "

Public call for organ donations (China Daily), and
China Announces Voluntary Organ Donor System (NY Times)
CD: "China launched a national organ donation system yesterday in a bid to gradually shake off its long-time dependence on executed prisoners as a major source of organs for transplants and as part of efforts to crack down on organ trafficking."...
"Currently about one million people in China need organ transplants each year while only 1 percent receive one, official statistics show.
Only about 130 people on the mainland have signed up to donate their organs since 2003, according to research on the promotion of organ donation after death by professor Chen Zhonghua with the Institute of Organ Transplantation of Tongji Hospital."...
"China issued an organ transplant law in 2007 that bans organ trafficking and only allows donations from living people to blood relatives and spouses, plus someone considered "emotionally connected."
However, organ middlemen have been faking documents in order to make a person who is desperately in need of money be considered "emotionally connected" to the recipients, reports said.
Living transplants increased to 40 percent of total transplants from 15 percent in 2006, Chen Zhonghua said.
"That's one of the daunting tasks facing us as we try to end the organ trade by establishing this system," Huang noted.
Other goals include preventing organ tourism, improving transplant quality, better defining donors' rights and satisfying patients' needs for transplants in an ethical manner."

NYT: "At least one million people in China need organ transplants each year, but only about 10,000 receive them, according to government statistics. Dr. Huang said that most of those organs — as high as 65 percent, by some estimates — are taken from death row inmates after their executions."...
"The practice of harvesting organs from executed Chinese convicts has been widely reported in the past, although it was only confirmed in 2005, by Dr. Huang, at a medical conference in Manila. The government has routinely denied other allegations that prisoners’ organs regularly found their way to the black market, often for sale to wealthy foreigners, and that executions were sometimes scheduled to coincide with the need for a specific organ.
At a news conference in Shanghai held Wednesday to unveil the new organ-donation system, one transplant surgeon was quoted by the newspaper as saying that the taking of organs from convicts was sometimes subject to corruption. "

Corruption and kidneys in New Jersey and Brooklyn

The NY Times reports on a corruption investigation resulting in 44 arrests in New Jersey and Brooklyn: In New Jersey Case, Nervous Jokes and a Cereal Box of Cash

Almost as an aside, the story reports that a broker for transplant kidneys was caught in the net:

"Another man in Brooklyn, Levy-Izhak Rosenbaum, was accused of enticing vulnerable people to give up a kidney for $10,000 and then selling the organ for $160,000. Mr. Dwek pretended to be soliciting a kidney on behalf of someone and Mr. Rosenbaum said that he had been in business of buying organs for years, according to the complaint."

Part of the repugnance to the transaction seems to be the buying and selling prices. (Would we/should we feel differently if the kidneys were bought for $100,000 and sold for $115,000?)

Steve Leider points me to an Indiana Jones connection: Anthropologist's 'Dick Tracy moment' plays role in arrest of suspected kidney trafficker. (The anthropologist in question, Nancy Scheper-Hughes, writes frequently about black markets for kidneys, and apparently indentified Mr Rosenbaum some years ago, although the story doesn't suggest to me an immediate connection to the recent arrest.)

Parag Pathak points me towards Benyamin Cohen's story in Slate, following up on the Jewish connection: The arrests of rabbis who trafficked body parts uncover more complicated issues, that suggests some of the nuances of Jewish religious jurisprudence about organ donation and sales.

Trying to figure out Jewish law directly from the Bible skips a couple of centuries of subsequent interpretation. Here's what I wrote about kidney sales in a footnote of my paper Repugnance as a constraint on markets:

3 While there is no central authority on the application of Jewish law to modern concerns such as transplantation, the most authoritative opinions are contained in various “responsa” or answers to particular questions by rabbis acting as legal “deciders” (poskim), whose authority arises from the respect of their peers. The consensus on the matter of live kidney donation, for example, seems to be that live donation is allowed (since it saves lives), but it is not required (since the donor becomes wounded and takes some risk to his own life), and hence it falls into the category of things for which compensation could be offered and accepted (unlike actions that are either forbidden or required). See, for example, Eisenberg (2006), Grazi and Wolowelsky (2004), Kunin (2005), and Israeli (1997) who cite eminent modern poskim such as Rabbi Shlomo Zalman Auerbach and Rabbi Moshe Feinstein."

"For example, Avraham (2004, p. 271–2) reports the opinion of the eminent Rabbi Shlomo Zalman Auerbach that someone who sells a kidney with the intention of saving a life does a good deed “even if he would not have donated his kidney only to save life.” But he goes on to note, “[I ]n spite of all that has been said above, it seems to me that it is the community that needs soul-searching for allowing a person to reach such a depth of despair that he must sell a kidney, either because of poverty, debts, or the inability to pay for a relative’s medical expenses.”

Although mainstream Jewish authorities support organ donation, some streams of ultra-orthodox Judaism do not: here's a disturbing article brought to my attention by Miran Epstein, from Yediot: Heart recipient's father: We'll never donate organs
It goes on to note
"The father's words angered Prof. Yaacov Lavee, director of the Heart Transplantation Unit at the Sheba Medical Center. "This is outrageous," he said. "I've heard such statements from many of my candidates (for a transplant), who weren't ashamed to admit they wouldn't donate organs.
"Such statements led me to initiate the bill that prioritizes transplants for people who have signed an organ donor card. This is clearly immoral behavior," he added.
The new transplant law, which will go into effect in May, states that any person in need of a transplant and who has had an organ donor card for at least three years will be given priority on the organ transplant waiting list. "

This makes some aspects of Israeli transplant law resemble parts of Singapore's transplant law, which also gives priority for organs to those who are registered as donors. (I wrote about this near the end of an earlier post.)

Update: Sally Satel's take is in the WSJ: About That New Jersey Organ Scandal It’s not surprising when 80,000 Americans are waiting for kidneys, and a background piece from Time magazine: How Does Kidney-Trafficking Work?

Markets for organs

In Reward Organ Donors , Sally Satel writes in the Asian WSJ about the recent changes in Singapore law regarding compensation for donors (see my previous posts here and here). She goes on to outline the design of the kind of market she would like to see, and ways in which perceived repugnance might be addressed.

"My colleagues and I suggest a system in which a donor can accept a reward for saving the life of a stranger. A third party (the government, a charity or insurer) would provide the benefit and newly available organs would be distributed to the next in line -- not just to the wealthy. Donors would be carefully screened for physical and emotional impediments to safe donation, as is currently done for all volunteer living kidney donors. Moreover, they would be guaranteed follow-up medical care for any complications.
Many people are uneasy about offering lump-sum cash payments. A solution is to provide in-kind rewards, such as a down payment on a house, a contribution to a retirement fund or lifetime health insurance, so the program would not be attractive to people who might otherwise rush to donate on the promise of a large sum of instant cash.
Not only will more lives be saved through legal means of donor rewards, but fewer people will haunt the black-market organ bazaars of places like China, Pakistan, Egypt, Colombia and Eastern Europe. The World Health Organization estimates that 5% to 10% of all transplants performed annually -- perhaps 63,000 in all -- take place in these clinical netherworlds."