Kidney donor/sellers in Iran face social stigma--2 papers

The first of these two recently published papers is a report compiling interviews taken some time ago:

Coercion, dissatisfaction, and social stigma: an ethnographic study of compensated living kidney donation in Iran
Sigrid Fry‑Revere,  Deborah Chen,  Bahar Bastani,  Simin Golestani,  Rachana Agarwal, Howsikan Kugathasan, and Melissa Le
International Urology and Nephrology, https://doi.org/10.1007/s11255-018-1824-y, Online, February 2018

Abstract: "This article updates the qualitative research on Iran reported in the 2012 article by Tong et al. “The experiences of commercial kidney donors: thematic synthesis of qualitative research” (Tong et al. in Transpl Int 25:1138–1149, 2012). The basic approach used in the Tong et al. article is applied to a more recent and more comprehensive study of Iranian living organ donors, providing a clearer picture of what compensated organ donation is like in Iran since the national government began regulating compensated donation. Iran is the only country in the world where kidney selling is legal, regulated, and subsidized by the national government. This article focuses on three themes: (1) coercion and other pressures to donate, (2) donor satisfaction with their donation experience, and (3) whether donors fear social stigma. We found no evidence of coercion, but 68% of the paid living organ donors interviewed felt pressure to donate due to extreme poverty or other family pressures. Even though 27% of the living kidney donors interviewed said they were satisfied with their donation experience, 74% had complaints about the donation process or its results, including some of the donors who said they were satisfied. In addition, 84% of donors indicated they feared experiencing social stigma because of their kidney donation."

Here's an excerpt from the discussion of social stigma:  

"Some donors had a general sense that people had negative impressions of donors. One donor pointed out, “When people find out that you have donated, they start looking at you in a different way. They start keeping their distance.” Another donor explained what he thought was going through
people’s heads: “Oh, he sold his kidney, he’s not a good person.”
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and here's a paper with reports from an internet survey:

The Social Stigma of Selling Kidneys in Iran as a Barrier to Entry: A Social Determinant of Health
Mohammad Mehdi Nayebpour  Naoru Koizumi
World Medical and Health Policy, Volume10, Issue1, March 2018,
Pages 55-64
"Abstract
Iran is the only country in the world currently with a legalized compensated kidney donation system, in which kidney sellers are matched with end‐stage renal disease patients through a regulated process. From a practical point of view, this model provides an abundance of kidneys for transplantation as opposed to the American model that relies on altruistic donation. The major concern about adopting the Iranian model is the possibility of exploitation. A large body of literature exists on this topic, but few have focused on its cultural aspects. This paper sheds light on the cultural implications of the Iranian model by providing empirical evidence on the social stigmas against kidney sale in Iran. We claim that these stigmas act as barriers to entry to the supply market of kidneys. Due to the conditions created by social stigmas, kidney sellers are forced to consider not only monetary rewards but also cultural factors. Thus, they tend to be more cautious and try to avoid impulsive decisions. Such social stigmas act as unofficial regulatory forces to keep kidney sale as the last resort for the poor, to diversify the supply market by age, and to stretch the decision‐making process in the absence of a mandatory waiting period for transplantation."

from the discussion:
"Our survey demonstrated that an immense amount of negative stigma is directed toward kidney sellers in Iran from society. Comparison of our findings to those reported by Ghods et al. (2001), who studied the actual characteristics of kidney sellers, reveals stark differences between perception and reality. Ghods et al. interviewed 500 kidney sellers in Iran in 2001 (Ghods et al., 2001). The study reports that only 6 percent of them were actually illiterate (while 71 percent of our respondents thought kidney sellers are illiterate), 88 percent had elementary to high school degree (while only 22 percent of our respondents thought kidney sellers have a high school education), and 6 percent had university degrees and above (6 percent of our respondents thought kidney sellers have above high school education). This gap between the actual profile and the perception of kidney sellers indicates that while Iranians benefit from the current policy, they have a grave stigma against it. The other important gap between perception and reality appears in question 5. About 15 percent of people consider that kidney sellers are drug addicts and 56 percent are not sure whether kidney sellers are drug addicts or not. This particular perception is stunning, since by law kidney sellers undergo a series of strict medical tests before becoming eligible for selling. "

Cash for kidneys: letters to the editor of the WSJ

The recent Becker-Elias article, about which I blogged about my thoughts here, has drawn some letters to the editor, which the WSJ published under the headline Is a Market in Kidneys the Right Answer to Shortage? It is a tragedy when people die while waiting for a lifesaving transplant, but paying for organs isn't the answer.

One of them, by Sigrid Fry-Revere, doesn't fit the sub-headline. She advocates adopting something like the market approach in Iran. Her unedited letter, which she shared by email, is below:

Letter to the Editor of WSJ

Edited version ran Sat. Jan 2014

The Rest of the Story

I read with great interest Gary S. Becker and Julio Elias article “Cash for Kidneys: The Case for a Market for Organs” in Saturday’s WSJ.  Like so many others who have written on this subject, their article misrepresents the Iranian system of compensated donation.

Usually not much is said about Iran, because not much is known, but I went to Iran and spent nearly two months interviewing paid kidney donors for a documentary film I was planning. I visited six different regions and returned with over 200 transplant stories.  There are too many misconceptions about what is going on in Iran to explain in one letter, but the most important thing I would like to point out is that paid kidney donors are people, not commodities, and no matter what the economics of the situation, there is a human element that can’t be ignored.

You might think I’m going to say we should not pay kidney donors, or that I’m going to rage about how exploitive kidney selling is. Not so. I learned many things on my trip to Iran, but the most important was sometimes money is what makes helping others possible.

The issue isn’t how much a kidney is worth, but how to make helping economically feasible and how best to show appreciation. I disagree with economists who say you can put value on someone giving up part of their body to save another person’s life. A conscious, informed decision, to risk oneself for another is an invaluable gift both to the person and to society.

Iran is the only country in the world that has solved its kidney shortage, and it has done so by legalizing and regulating compensated donation.  In the rest of the world there are two options:  Altruistic donation and the black market. The third option only exists in Iran where the rule of law protects donors and recipients alike. Paid donors are not treated like criminals, as is the case when the underprivileged are exploited for their kidneys on the black market. 

The Iranian system has developed over 30 years and continues to improve.  Today, paid donors are secure in their knowledge that the system works to protect their rights as much as the rights of recipients. Their money is put in escrow, the middlemen who arrange kidney matches are NGO volunteers, not black market profiteers, and they are treated on the same medical wards and in the same post-operative clinics as kidney recipients.  

How much are Iranian kidney donors paid for their service to humanity? Much more than the thank you, travel expenses, and occasional lost wages, paid altruistic donors in the United States. Iranian kidney donors receive the equivalent to six month’s salary for a registered nurse in Iran, or approximately $32,000 in the United States. But in addition to monetary compensation, they receive many goods and services that are hard to quantify in dollars.  All receive at least one year of health insurance, not just care related to their nephrectomy, as is the case in the United States. They also receive automatic exemption from Iran’s two-year mandatory military service.

Furthermore, Kidney donors often receive extra health insurance, sometimes for their whole family and often under terms where it can be renewed annually. They receive dental care at the NGO dental clinics that serve diabetes patients and kidney recipients. They receive job services, small business loans, and household goods.  I estimate the total average package paid donors receive in Iran is close to $45,000 in value. 

Most importantly, these paid donors know the government supports them for having done something honorable, like a paid firefighter or a paid emergency medical professional. They have saved a life -- and their contribution to society is invaluable.  Mohaghegh Damad, the ethicist for the Iranian Academy of Medical Sciences told me no payment could ever be enough. But, the payment Iranian kidney donors get, makes doing the right thing easier. 

In the United States 20-30 people die every day because they can’t get a kidney. Iran is the only country in the world where almost everyone who medically qualifies to get a kidney gets one, and in many regions of the country there is a waiting list for people who want to donate.  Maybe its time we learn something from their experience.

Sigrid Fry-Revere, J.D., PhD, is a bioethicist and founder and president of the non-profit organization Stop Organ Trafficking Now and author of The Kidney Sellers (Carolina Academic Press, 2014).

An anthropologist (Dr. Elham Mireshghi) looks at the market for kidneys in Iran

Elham Mireshghi completed her Ph.D. in Anthropology at UC Irvine in 2016. Her dissertation is
Kidneys on Sale? An Ethnography of Policy, Exchange, and Uncertainty in Iran

Here's the abstract:
"Since 1997, Iran has implemented the world’s only program for living paid kidney donation. The program has been developed and administered by a non-profit NGO – the Kidney Patient Foundation (KPF). Though sanctioned by Shi‘a Muslim jurists and celebrated in the West as the “Iranian Model,” the program has been rife with moral unease and uncertainty in Iran. While organ donation after death is valorized, undergoing transplantation for cash is stigmatized. Furthermore, there is little agreement among policy actors that facilitating paid organ giving is a good idea. In this dissertation, I examine kidney “selling” both at the level of the exchange – where I analyze the experiences of kidney givers and recipients – and at the level of institutional and bureaucratic process, legal and scientific reasoning, and practical and ethical negotiation, to explain how Iran came to uniquely sanction and bureaucratically routinize kidney selling. I disentangle the dense threads of moral reasoning and experience among a range of actors - from donors and recipients to doctors, policy activists, and Islamic jurists – that undergird the policy’s development and implementation. I have conducted ethnographic field research (2011-2013), including observation inside medical and Islamic institutions in Tehran and Qom, and indepth interviews of kidney givers and patients, KPF personnel, doctors and legal scholars and jurists. I have also analyzed Islamic legal texts, as well as visual and textual media.

"My analysis brings together analytic approaches within the anthropology of public policy, medicine, morality, and exchange, while also contributing to a growing interest in Iranian Studies to venture beyond themes of repression and resistance. I consider Iran’s living kidney giving program within the context of Iran’s post-revolution medical modernization projects, its haphazard economic liberalization, and ongoing commitment to social welfare, alongside an examination of the role of Islamic jurists and other “experts” in policy making. I elucidate the socio-economic conditions and aspirations that motivate kidney givers, and the “medical imaginary” that facilitates their decision as well as the legal reasoning of jurists. Lastly, I offer an alternative to the “commodity paradigm” in examining exchanges involving money that can contribute to bioethical discussions of organ sales."



Here's a paragraph describing the reduction in waiting time for a kidney transplant resulting from the market:

"The culmination of these regulations has resulted in a much shorter wait for kidney transplants in Iran than is the case in, for example, the United States, where paid donation is prohibited and most organs from unrelated donors come from cadavers and brain-dead individuals. This has often been touted as one of the most important outcomes of permitting kidney sales. In the US, if one does not find a donor among family or friends or an “altruist” living stranger, then the wait can take nearly four if not more years. In Iran, the wait can be a little over a year, if not less; though celebratory reports on what is now called the “Iranian Model” often claim that there is no waiting list at all .... If a patient chooses non-living donation, then much like the US the wait can take much longer than a year. "

Much of her interaction was with a social worker who was reluctant to enroll kidney sellers:
"Management was not unaware of Ms. xxx’s principled opposition to kidney selling and her attempts at talking people out of it. Ms. xxx explained to me once that she framed her activities as a benefit for the organization in the form of counseling for sellers. It would garner legitimacy for a program that had frequently come under domestic and international scrutiny, she argued. So management and Ms. xxx shared an interest in counseling prospective donors while assuring that a certain number made it to the list. For management, the interest had to do with protecting the organization’s credibility while also assisting in the treatment of suffering kidney patients. For Ms. xxx, it had to do with ensuring that fewer young men and women fell into what she called the “sick cycle of disease and poverty” (what she deemed to be the likely result of kidney selling) while also maintaining her employment."

One aspect of her work concerns the religious rulings that permit the Iranian kidney market.

Here's a quote from Ayatollah Makarem Shirazi  about what can be sold:
“The severing of an organ from a living person and the transplantation of that to someone whose kidneys have both decayed (fasid) is permissible on the condition that the owner (sahib) of the organ consents, and his life (jan) is not put into danger; and caution requires that if money is received in exchange, that it be in exchange for the permission to proceed with the taking (giriftan) of the organ, and not the organ itself.”

 I blogged about this part of Dr. Mireshghi's work earlier here:

Friday, June 5, 2015

The Shi'a religious jurisprudence behind Iran's legal market for kidneys

Ads for kidneys in Iran

An article in Haaretz describes the market for kidneys ("kidney bazaar" בזאר הכליות) in Iran, and includes this picture of ads written on a wall  in Tehran.

"Qasemi Mustafa, head of Kidney Patients Support Association in Iran, said the average sum received by the donors ranged around $ 6,000 [paid by the recipient]. The Government adds that another thousand dollars."

HT: Ran Shorrer

Here's a closely related story in the Guardian: In the only country where the organ trade is legal, the streets near hospitals have been turned into a 'kidney eBay'

"Iran is the only country where the selling and buying of kidneys is legal. As a result, there is no shortage of the organs – but for those trying to sell a kidney, there is a lot of competition.
... "Competition means that some ads have been torn down. Some have added their information to ads by other donors. Others have placed their ads on people's doors or simply written them in marker pen on trees where they think they will catch people's attention.

"At the heart of the capital, near the Charity Association for the Support of Kidney Patients (CASKP), the number of ads has made the streets of Tehran into a sort of kidney eBay.
...
"Iran's controversial kidney procurement system, which has been praised by many experts and criticised by others, allows people to sell and buy kidneys under the state-regulated surveillance of two non-profit organisations, the CASKP and the Charity Foundation for Special Diseases. These charities facilitate the process by finding potential vendors and introducing them to the recipients, and are charged with checking the compatibility of a possible donation and ensuring a fair trade.

"After the transplant, the vendor is compensated by both the government and the recipient. In an interview with the semi-official Mehr news agency, the CASKP's director, Mostafa Ghassemi, estimated the total official price list to be around 7m rials, of which 1m is paid by the government. Iranians are not allowed to donate kidneys to non-citizens.

"In 2010, a total of 2,285 kidney transplants took place in the country, of which 1,690 kidneys were supplied from volunteers and 595 from those clinically brain-dead," he said. According to Mehr, the majority of people selling kidneys are aged 20-30. Despite the state control, bureaucracy and time-consuming procedures have left the door open for non-official direct negotiations, making the Iranian system more like a kidney market.

"Dr Benjamin Hippen, a transplant nephrologist with the Carolinas medical centre in North Carolina, US, has studied successes, deficiencies and the ambiguities of the Iranian system.

"Making a judgment about whether the 20-year-old system as a whole has been successful was complicated, he said. "The majority of those selling kidneys in Iran are disproportionately poor, and information about the long-term outcomes for sellers is quite limited. Too, it is increasingly clear that there are many different systems, rather than a single unified system in Iran.

"That said, Iran appears to have successfully addressed the shortage of organs, incentives for organs have not substantially attenuated the growth and development of organ procurement from deceased donors, and reported outcomes for recipients have been favourable."

"Comparing Iran with Pakistan, where organ trafficking is nominally illegal but still occurs, Hippen, who is an associate editor of the American Journal of Transplantation, said: "It seems to me that if Iran had not developed a system of incentives, the situation there today would look very much like the state of affairs in countries such as Pakistan."

"In the US, more than 100,000 people were estimated to be on the waiting list for kidney transplants in 2010 – waiting lists were eliminated in Iran in 1999.

"Hippen has pointed out that "since 1999, more than 30,000 US patients with kidney failure have died waiting for an organ that never arrived".

"Arguing in favour of allowing people to sell their kidneys, Sue Rabbitt Roff, a senior research fellow at the University of Dundee, said last year that it was time to "pilot paid provision of live kidneys in the UK under strict rules of access and equity".

The Iranian kidney market in Mashhad, by Mehdi Feizi and Tannaz Moeindarbari in Clinical Transplantation

Here's a new article in Clinical Transplantation:

Characteristics of kidney donors and recipients in Iranian kidney market: Evidence from Mashhad
Mehdi Feizi  Tannaz Moeindarbari
First published: 06 August 2019 https://doi.org/10.1111/ctr.13650

Abstract: The Iranian model of kidney transplantation is an example of a regulated living unrelated renal donation. In this paper, we collected and analyzed a unique dataset of 436 paired kidney donors and recipients, including their characteristics and the realized price of a kidney in Mashhad. As opposed to the global picture of kidney donation, we find that women are less likely to donate and more likely to receive a kidney. Moreover, the average price of a kidney amounts less than 2 years of work with the minimum level of wage.
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The article elicited a commentary by Gabe Danovitch, an eminent nephrologist at UCLA who speaks and writes frequently in opposition to compensation for donors:

COMMENTARY
Financial neutrality should replace the Iranian paid donor market
Gabriel Danovitch
First published: 16 July 2019 https://doi.org/10.1111/ctr.13665

He explains his opposition to markets in general this way: "the term “regulated market” is oxymoronic with respect to markets in general and specifically when it comes to human organs..."

(One wonders how the market for nephrologists works, and for medical specialists and subspecialists generally.  Someone should study that...)
**********

The article on Mashhad includes some very interesting description of the market there:

"Since the first live kidney transplant in Mashhad on 2 April 1985 until December 2017, more than 2500 people have had a kidney transplant in the Montaserie Organ Transplantation Hospital. It is operating as a center for dialysis and the only center in Mashhad and neighboring regions for transplantation of kidney, liver, and bone marrow. According to the latest reports, more than 7000 people from different age groups are now waiting for a kidney in Mashhad.

"In Mashhad, approximately 60 individuals refer to the IKF every week to sell their kidney. Of these donors, about 15 individuals are actively pursuing the process, while the rest are dissuaded due to various reasons. Out of these individuals, about one‐fifth are medically approved for kidney donation, after the 3 or 4 weeks of examinations.

"From the demand perspective, every end stage renal disease (ESRD) patient aged below 70 in Khorasan Razavi Province without having a willing related donor is referred through a nephrologist's letter to the IKF in Mashhad to enter the kidney waiting list according to their blood type. These patients can be entered in the waiting list of hospitals to receive a kidney from a deceased donor as well.

"From the supply perspective, each potential kidney donor, between 22 and 40 years old, should register at the IKF after undergoing the preliminary medical tests and bringing the notarized consent of him/herself and his/her family, including both parents for singles, only the spouse for married men, and the spouse and both parents for married women.
...
There are four different matching lines for each blood type, and the IKF usually pair each donor with a renal patient with the matching blood type in the waiting list based on a first come, first‐served basis. Nevertheless, this is not the only way of matching, and both sides can also publically advertise and find each other outside the IKF matching system. However, they have to register there and do the required paperwork and medical tests, as the transplantation centers only accept donors referred by the IKF, as a market maker.

"A renal patient should pledge in cash half the official price of a kidney to the IKF following the initial registration of the waiting list. Once a patient is matched to a donor and they both agree upon a price, the patient pays the remaining price of a kidney to the IKF via a cheque. After carrying out the transplantation, the IKF transfers all the amount of money received from the patient to the donor. However, the IKF neither receives any financial interest nor benefits from any monetary transactions, as it is a charity after all. Although there is no official ceil price, the IKF in Mashhad informally tries its best to convince and incentivize the donor not to ask a high price.
...
"Almost all kidney donors mostly face severe and urgent financial needs, for example, paying off debts (especially home rentals and blood money) and even living expenses, especially for single‐mother households. Thus, financial issues constitute the most frequent and primary motive for living unrelated donors in Iran.
...
"According to this law, compensated kidney donation in Iran is only possible between two individuals from the same nationality with the legal residence permits, especially refugees in Iran from Afghanistan.

"Since there is a large number of Afghan refugees in Mashhad, the IKF has formed a limited market for them. At the main kidney market for Iranians, donors do not have to wait to find a match, as there are always patients looking for a compatible kidney, especially those with a rare blood type such as AB. However, at the kidney market for Afghans, there is no patient in a queue to get a kidney and donors have to stay on the waiting list to find a suitable recipient.

"Moreover, for Afghan citizens, the amount of money a patient should pay to compensate a donor is determined not based on the official price of a kidney in Iran, but rather in a wholly agreed manner. In 2014, the total cost of kidney transplantation was about 6329 USD. While the government pays all kidney transplantation costs for Iranian patients and donors, Afghan renal patients should pay the hospital fees and other costs related to transplantation, which is estimated about 350 million IRR, almost 8650 USD, and reaches about 800 million IRR, almost 19 775 USD, with the cost of kidney purchase.
...
[Among Iranians] "Not only donors tend to be financially motivated for donation, but also recipients are not wealthy, as 47% of them are unemployed."

Mohammad Akbarpour on Iran's kidney market

My colleague Mohammad Akbarpour at Stanford GSB is featured in their newsletter.  

He thinks about kidney transplantation from a number of different angles...here's a snippet.

Is It Ever OK to Sell (or Buy) a Kidney?

"Iran’s paid kidney market emerged after the country’s revolution at the end of the 1970s. In the early ’80s, foreign sanctions against the government inhibited its ability to get dialysis machinery. The number of Iranians needing a kidney transplant, however, kept increasing, so in 1988 the government organized a system that regulated and funded kidney transplantation. Their system included compensation for donors.

Officials euphemistically described the money given to each donor as a “gift,” says economist Mohammad Akbarpour, an assistant professor of economics at Stanford Graduate School of Business, who, has been working with several colleagues to study Iran’s market and unpaid kidney exchange markets globally. “They were paying for it, but using different words,” says Akbarpour. The system worked so well that the kidney transplant wait list in Iran was nearly eliminated by 1999.

“We have this discussion in the West about what would happen if you have a paid market for kidneys,” says Akbarpour. “The expectation has been that poor people will be selling their kidneys to rich people. But the debate has been largely based on speculations, as opposed to evidence.”

Akbarpour looked at five years’ worth of data about kidney sales and transplantation in the country, and his preliminary findings show that the average wealth of those buying kidneys is almost exactly the same as the average wealth of Iranians. Most of the payment for each transplant comes from the patient, not the government.

“It’s not just rich people who can buy a kidney in Iran,” he says. “Even poor people find the money for it, because it’s so valuable. There are also charities they can tap.”

But one suspected consequence of a cash market for kidneys did turn out to be true: Poor people sell kidneys far more than any other economic group. In Iran, most kidneys come from those whose incomes are in the bottom 25% of earners."

The Iranian market for kidneys

The AP has published this descriptive story about the Iranian market for kidneys:
IN IRAN, UNIQUE SYSTEM ALLOWS PAYMENTS FOR KIDNEY DONORS BY NASSER KARIMI AND JON GAMBRELL

Some paragraphs from the story:

"The AP gained rare access to Iran's program, visiting patients on dialysis waiting for an organ, speaking to a man preparing to sell one of his kidneys and watching surgeons in Tehran perform a transplant. All of those interviewed stressed the altruistic nature of the program - even as graffiti scrawled on walls and trees near hospitals in Iran's capital advertised people offering to sell a kidney for cash.
...
Iran started kidney transplants in 1967 but surgeries slowed after the 1979 Islamic Revolution and the storming of the U.S. Embassy in Tehran, in part due to sanctions. Iran allowed patients to travel abroad through much of the 1980s for transplants - including to America. But high costs, an ever-growing waiting list of patients and Iran's grinding eight-year war with Iraq forced the country to abandon the travel-abroad program.

In 1988, Iran created the program it has today. A person needing a kidney is referred to the Dialysis and Transplant Patients Association, which matches those needing a kidney with a potential healthy adult donor. The government pays for the surgeries, while the donor gets health coverage for at least a year and reduced rates on health insurance for years after that from government hospitals.

Those who broker the connection receive no payment. They help negotiate whatever financial compensation the donor receives, usually the equivalent of $4,500. They also help determine when Iranian charities or wealthy individuals cover the costs for those who cannot afford to pay for a kidney.

Today, more than 1,480 people receive a kidney transplant from a living donor in Iran each year, about 55 percent of the total of 2,700 transplants annually, according to government figures. Some 25,000 people undergo dialysis each year, but most don't seek transplants because they suffer other major health problems or are too old.

Some 8 to 10 percent of those who do apply are rejected due to poor health and other concerns. The average survival rate of those receiving a new kidney is between seven to 10 years, though some live longer, according to Iranian reports.

In the United States, about a third of kidney donations come from living donors. The average kidney from a deceased donor lasts 10 years, while one from a living donor averages about 15 years, according to Dr. David Klassen of the United Network for Organ Sharing, or UNOS, which oversees the U.S. transplant system. Recipients of living-donor kidneys in the U.S. fare better in part because they haven't been on dialysis as long before their transplant."

The Iranian kidney market--Associated Press

The Associated Press has a nice story on the Iranian market in which donors can be compensated for kidneys. Here's the version in the Denver Post

In Iran, unique system allows payments for kidney donors

Some interesting paragraphs:

"Iran started kidney transplants in 1967 but surgeries slowed after the 1979 Islamic Revolution and the storming of the U.S. Embassy in Tehran, in part due to sanctions. Iran allowed patients to travel abroad through much of the 1980s for transplants — including to America. But high costs, an ever-growing waiting list of patients and Iran’s grinding eight-year war with Iraq forced the country to abandon the travel-abroad program.

"In 1988, Iran created the program it has today. A person needing a kidney is referred to the Dialysis and Transplant Patients Association, which matches those needing a kidney with a potential healthy adult donor. The government pays for the surgeries, while the donor gets health coverage for at least a year and reduced rates on health insurance for years after that from government hospitals.

"Those who broker the connection receive no payment. They help negotiate whatever financial compensation the donor receives, usually the equivalent of $4,500. They also help determine when Iranian charities or wealthy individuals cover the costs for those who cannot afford to pay for a kidney.

"Today, more than 1,480 people receive a kidney transplant from a living donor in Iran each year, about 55 percent of the total of 2,700 transplants annually, according to government figures. Some 25,000 people undergo dialysis each year, but most don’t seek transplants because they suffer other major health problems or are too old.

"Some 8 to 10 percent of those who do apply are rejected due to poor health and other concerns. The average survival rate of those receiving a new kidney is between seven to 10 years, though some live longer, according to Iranian reports.
...

"Poverty around the world drives black market kidney sales, a lucrative business the World Health Organization estimated represented at least 5 percent of all transplants in 2005, though it acknowledges that figure is only a guess. The U.N. health agency’s guiding principles on organ transplantation call for banning organ sales, though it allows for “reimbursing reasonable and verifiable expenses,” including the loss of income by a living donor."

German organ transplant law should be amended or reinterpreted to allow kidney exchange: my op-ed in Der Tagesspiegel

During my recent visit to Germany, I spoke with a number of people about the fact that the German transplant law effectively outlaws kidney exchange.  I was invited to write an op-ed on the subject for the German newspaper Der Tagesspiegel, and it has just appeared:

OrganspendenDeutschland muss sein Transplantationsgesetz ändern

In den USA können Patient-Spender-Paare untereinander ein Organ spenden, in Deutschland ist dieser Tausch verboten. Das muss sich ändern. Eine Position. 

ALVIN E. ROTH

Normally at this point I would use Google Translate to give a sense of the article, but in this case, since I wrote the op-ed in English, I can give you the original:

German organ transplant law should be amended or reinterpreted to allow kidney exchange

By Alvin E. Roth[i]

Kidney failure is epidemic around the world, and a shortage of organs for transplantation condemns many patients to dialysis, and early death. 

Most transplantable organs come from deceased donors, and there aren’t enough to fill the need. But because healthy people have two kidneys and can remain healthy with one, a healthy person can donate a kidney to a sick person.  A living-donor kidney works better than a deceased-donor kidney.

In the U.S. we now have around as many living donors as deceased donors (although we still have more deceased-donor transplants, since a deceased donor donates both kidneys).

But living donation isn’t always possible, even when a willing donor is available, because a kidney must be well-matched to its recipient. Often the life-saving gift cannot be given, because the donor’s kidney is incompatible with the patient. (It is now sometimes possible to successfully transplant an incompatible kidney, but, like a deceased-donor kidney, this does not keep the patient as healthy for as long as would a compatible living-donor kidney.)

In the U.S., there is a way for incompatible patient-donor pairs to help each other, through what we call kidney exchange, or kidney paired-donation. In its simplest form, two incompatible patient-donor pairs are identified by their doctors such that each patient is compatible with the kidney of the other patient’s donor. Then four surgeries are performed, two nephrectomies and two transplants, so that each donor gives a kidney and each patient receives a compatible kidney. Kidney exchange has become a standard form of transplantation in the U.S., and has saved thousands of lives. (This is one of the “matching” markets I helped design, and wrote about in my recently translated book, Wer kriegt was - und warum?.)

Notice that no money changes hands in this paired donation. It is just an exchange of gifts between two patient-donor pairs, which allows each donor to save a life and see his intended recipient restored to good health.

Laws around the world prohibit buying a kidney for transplantation, because of fear that allowing organs to be sold would exploit the poor and vulnerable. (The single exception is Iran, which has a monetary market for kidneys.) But German transplant law  imposes a severe further restriction: a patient may receive a living-donor kidney only from a member of his or her immediate family. This means that, unless a judge intervenes, kidney exchanges are illegal in Germany. (This law also restricts the number of direct living donations in Germany compared to countries like the U.S., in which uncles, cousins, friends, colleagues, members of the same church, etc., are often living donors.)

I surmise that the reason for this strict limitation in German law is to remove any possibility that a kidney being transplanted has been purchased rather than freely given. But if when you want to give a kidney to your brother there is no suspicion that you are a paid organ-seller, you should remain above suspicion even if your kidney is incompatible with your brother. Kidney exchange allows you to give a kidney and save a life, and have your brother’s life saved. Kidney paired donation is a mutually beneficial exchange of life-saving gifts, not a commercial transaction.

The U.S. law that includes the prohibition on organ sales is the National Organ Transplant Act of 1984.  When American surgeons explored kidney exchange in the first decade of this century, it wasn’t initially clear what its legal status might be, but in 2007 Congress passed an amendment to the NOTA making kidney exchange explicitly legal.  Kidney exchange is legal elsewhere in Europe, and is well developed in the Netherlands and Britain. A similar amendment to the German law, or even instructions to judges that kidney exchanges should be allowed after being examined, could save the lives of many patients in Germany, without opening to door to commercial transactions in body parts.

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[i] Alvin Roth, a professor of economics at Stanford University, shared the 2012 Nobel Prize in Economics for his work on market design. His recent book about markets has just appeared in German translation, Wer kriegt was - und warum?: Bildung, Jobs und Partnerwahl: Wie Märktefunktionieren

Iran's market for kidneys in the NY Times

Tina Rosenberg writes about the Iranian kidney market: Need a Kidney? Not Iranian? You’ll Wait.

Here's a part:

"Iran’s system has many deficiencies — not least that the very idea clashes with ethical norms observed in many other countries — and the program varies greatly from region to region. But its chief advantage is this: People who need kidneys get them rapidly, rather than die on the waiting list.

In the vast majority of cases, donors know in advance what they will be paid and receive appropriate screening and good medical care before and during the operation. And by getting patients new kidneys instead of keeping them on dialysis, the society saves a lot of money and avoids much misery.

The Iranian model suffers from insufficient funding, lack of follow-up for donors and other problems. But as waiting lists for kidneys grow around the world, Iran offers an important lesson: With good design and regulation, a system that pays donors need not be exploitative or immoral. In Iran, the legal kidney market has prevented the development of the abusive black markets and kidney tourism seen in other countries. As the kidney crisis intensifies, governments should look closely at what Iran has achieved.

For many people, the specifics of how a kidney market works are beside the point — the very idea of paying people to donate organs ends the debate before it starts.

One reason the idea of organ-selling is repugnant is that the human body has a special dignity. But if there’s an ethical barrier to selling the pieces, it was crossed long ago. We sell blood products, sperm and eggs. We pay people to do weird things to their bodies in risky clinical trials.

Perhaps kidney donation is different because kidneys do not grow back (although one healthy kidney is sufficient), and donation requires surgery. It is very safe surgery, but there is always some risk for donors. Perhaps the biggest moral issue in economically unequal societies is that a paid donor is almost always in dire straits, willing to do desperate things for money.

Yet people, especially poor people, take risks for money all the time. “We should ask ourselves why some people find accepting money to donate a kidney and save a life repugnant, but accepting money for being a policeman or miner or soldier — all of which are statistically riskier than donating a kidney — is O.K.,” said Mohammad Akbarpour, a research fellow in the Becker-Friedman Institute of the University of Chicago. “Is there a fundamental difference?”

Organ transplantation in Iran

Robert Gutman draws my attention to this article from the English language Iranian Financial Tribune:  Sunday, April 23, 2017 Strides in Organ Transplant

I'm not sure where the claim in the first sentence of 50,000 organ transplant "surgeries" comes from, but the rest of the article (which seems to talk about a total closer to 5,000 transplants) is an interesting view of the situation in Iran.


"Over 50,000 organ transplant surgeries were conducted during the last fiscal year that ended on March 20.

Around 2,500 kidney, 802 liver, 119 heart, 30 pancreas and several intestine and lung as well as 1,040 bone marrow transplants were performed in Iran during the period, said Seyyed Mohammad Kazemeini, head of the Organ Transplant Management Office at the Health Ministry.

“This impressive number of transplant surgeries has helped save many lives as well as more than $1.8 billion in foreign exchange, as patients would otherwise have paid huge amounts for the medical help abroad. Some were even treated free,” the official was quoted as saying by ISNA.

However, he regretted that insurance companies still refuse to cover expenses of organ transplants despite a government directive last year.

“Insurance companies are not complying and the Health Ministry has to draw on its own resources to provide free services for some patients,” he said and hoped the ministry’s support would continue.

“During this year’s New Year holidays (March 21- April 2), 93 transplants were performed,” which shows the preparedness of the medical fraternity.

Iranian organ transplant teams are capable of providing assistance and training to neighboring countries, he said.

Last year a team of experts from Mashhad, capital of the northeastern Khorasan Razavi Province, carried out 47 renal transplants in Afghanistan, and medical teams from Shiraz, capital of the southwest Fars Province, conducted 20 operations in Pakistan and Tajikistan.

Shiraz University of Medical Sciences is known for its accomplishments in liver transplants and the hospitals under its coverage are among the top medical centers in the world with regard to the number of surgeries performed. On average, 500 liver transplants and 300 kidney surgeries are annually undertaken in Shiraz, which also has the distinction of performing the first kidney transplant in Iran in 1968 at the prestigious Namazi Hospital.

A specialized hospital is now planned to be established in Shiraz for organ transplants.

Iran ranks third worldwide in organ donation and is the only country in the world that has addressed the shortage of transplant organs through a legal payment system since 1988 when living non-related donation (LNRD) was legalized,  making it the only country where organ sale is legal.

There are currently 46 organ transplant centers in the country and 25 facilities for organ donation.

  Increase in Brain-Dead Organ Donation

According to Kazemeini, people’s tendency to donate organs of brain-dead patients in their families has increased significantly.

“Last year, 57% of transplant kidneys were donated by brain-dead patients,” he said.

In the past organ donation or sale by living people was predominant. The acceptance of organs of brain-dead patients has improved remarkably due to legal and religious decrees and widespread awareness campaigns on the issue.

Organ transplant is a medical procedure in which an organ is removed from one body and placed in the body of a recipient, to replace a damaged or missing organ.

Today, over 1.4 million people have voluntary organ donation cards in the country. On average, 700 organ donations (nine per million people) are made annually according to official statistics.

Organs that have been successfully transplanted include heart, kidney, liver, lung, pancreas, intestine, and thymus. Worldwide, kidneys are the most commonly transplanted organs, followed by liver and heart. Organ donors may be living, brain dead, or dead via circulatory death.

In the fiscal year that ended in March 2016, from among the 8,000 people confirmed as brain dead at Iranian hospitals, 1,400 kidneys (and 2,300 organs) were donated.

Kidney transplants account for nearly 75% of all organ replacement surgeries while liver and heart transplants comprise 22% and 3% of the total number. More than half of all transplanted kidneys (56%) were from brain-dead donors and 44% were from living people.

Kazemeini had earlier pointed to Iran’s top position in the field of kidney transplant in the Middle East. On average, 3,000 kidney transplants are conducted every year and Iranian surgeons have transplanted over 35,000 kidneys so far."

The sale of kidneys in Iran: a report from Shiraz

A recent article, and an accompanying editorial, in the American Journal of Transplantation concern the health of kidney sellers in Iran, based on a comparison of paid donors with unpaid related living donors at the Shiraz Transplant Center in Iran.

The article is Comparison of Health Status and Quality of Life of Related Versus Paid Unrelated Living Kidney Donors  by M. K. Fallahzadeh, L. Jafari, J. Roozbeh, N. Singh2, H. Shokouh-Amiri, S. Behzadi, G. A. Rais-Jalali1, M. Salehipour, S. A. Malekhosseini1, M. M. Sagheb

Abstract
The aim of this cross-sectional study was to assess the health status and quality of life (QOL) of paid unrelated versus related living kidney donors postdonation at Shiraz Transplant Center in Iran. We invited all donors (n = 580, 347 paid unrelated, 233 related) who underwent donor nephrectomy at our center from 2004 to 2010 to participate in a health survey and physical examination. Of 580 donors, 144 consented to participate; participation of paid unrelated donors was significantly lower than related (52/347 vs. 92/233; p < 0.001). Participants underwent a complete physical examination, QOL assessment (using a 36-item short form health survey [SF-36] questionnaire) and laboratory work-up. The paid unrelated donors compared with related donors were younger (34.2 ± 7.2 vs. 40.7 ± 9.7 years, p < 0.001), had shorter time since donation (2.9 ± 1.6 vs. 3.8 ± 2 years, p = 0.004), had higher estimated GFR (72.6 ± 22 vs. 63.8 ± 15.3 mL/min/1.73 m2, p = 0.006) and had a higher percentage of patients with microalbuminuria (35% vs. 0%, p < 0.001). Additionally, general health and social functioning scores among paid unrelated donors were significantly lower (p < 0.001 and p = 0.02, respectively) than related donors. Other SF-36 scores, although lower in paid unrelated donors, did not reach statistical significance. Iranian paid unrelated donors have lower QOL and higher incidence of microalbuminuria compared with related donors.


In their concluding discussion the authors note
"To our knowledge, this is the first study comparing the health status and HRQOL of Iranian PUKDs with those of LRKDs. Our results show that Iranian PUKDs, compared with LRKDs, have poor follow-up, lower HRQOL scores and higher incidence of microalbuminuria.

One of the major drawbacks of the Iranian model of living donor kidney transplantation is the lack of long-term follow-up of LKDs [2, 3]. In our study, the rate of participation of PUKDs was significantly lower than LRKDs. Similarly, in a previous report from Iran, only 6 of 500 LKDs who were invited to participate in a health survey responded [2]. In another Iranian study, a majority (79%) of PUKDs were reported to have no regular follow-up after donation [6]. Inability to pay for follow-up visits, and insufficient knowledge of the complications of the nephrectomy and the need for regular follow-up postdonation have been suggested as the major reasons for lack of long-term follow-up among PUKDs [2, 6, 9]. Educating the LKDs, providing an extended long-term government sponsored medical insurance program beyond 1 year, and probably even payment for clinic visits could enhance their adherence with postdonation follow-up."
***************************

The accompanying editorial is Where There Is Smoke There Is Fire: The Iranian System of Paid Donation by E. J. Gordon, J. S. Gill

"Nearly 30 years after its introduction, the Iranian model remains an enigma to the Western transplant community. Established in 1988, the government-funded, compensated living unrelated kidney donor program was Iran's answer for its urgent transplantation needs. The modest fixed sum (currently about $400 US dollars) provided by the government was intended as a reward rather than as a payment for the donated kidney. The real incentive for those who have submitted to nephrectomy was a supplementary payment negotiated directly between the recipient and living donor (typically in the amount of $10 000 US dollars). Putative oversight by a not-for-profit organization maintains a buyer's market by providing a back-up donor in the event that a recipient and potential donor cannot agree on a price. The government pays for all transplant-related expenses and provides the donor with medical coverage for 1 year after the nephrectomy. It is worth noting that such depictions of the Iranian model have been contested as disingenuous by members of the Iranian transplant community [1]. Accordingly, one must interpret any analyses of the Iranian model with caution.

Predictably, critics of commercialization have opposed the program primarily out of concerns of exploitation and disrespect for human integrity [2, 3]. Aside from such opposition, the model fails to meet many of the proposed standards for a regulated system of organ sales, including nondirected donations, provisions to ensure long-term donor follow-up, and access to health care [4]. Despite the facilitation of tens of thousands of transplants, the lack of public reporting and transparency have precluded acceptance of the Iranian model as a solution to the organ shortage internationally, and have fueled questions about the integrity of the program.

The report by Fallahzadeh et al [5] in this issue of the journal provides a novel glimpse into the Iranian model. The study shares many of the limitations of other studies from Iran, including a small and selected study sample. However, their identification of a difference in microalbuminuria postnephrectomy between paid and unpaid donors fuels concerns that the clinical evaluation of donors may be compromised when donor payments are allowed. Although the absence of prenephrectomy information precludes definitive conclusions, the short time since donation suggests that abnormalities may have been present prior to nephrectomy and accordingly, that the donor clinical evaluation may not have been as thorough as necessary. The potential presence of predonation abnormalities is worth considering given the ethical ramifications. A scrupulous pretransplant evaluation and conservative approach to donor acceptance may be particularly important for paid donors who may be vulnerable to adverse health outcomes for other reasons. Subjecting paid donors to unnecessary harms without sufficient safeguards in place during the evaluation process tips the delicate risk–benefit balance against living donation.

The most plausible alternative explanation for the findings is that the proteinuria was in some way related to the higher level of poverty in the paid donors. There is limited research to suggest a link between poverty and development of proteinuria in living donors. In a cross-sectional study of living related donors from Hyderabad, India, 40% of the 50 donors studied developed microalbuminuria, and 14% developed overt proteinuria (>300 mg/day) after an average of 63 months postdonation [6]. Irrespective of the basis for the observed difference, it is not clear that the Iranian system will financially support the authors' recommendation for long-term follow-up of the individuals who developed microalbuminuria in the study.

Sadly, the risk factors for and clinical significance of proteinuria in living kidney donors remain unclear. The existing literature on this subject is hampered by use of nonstandardized definitions, a paucity of controlled studies, and virtually no information regarding progression over time. Therefore, although it is tempting to criticize the lack of organized donor follow-up in the Iranian model, to do so would be hypocritical [7]. The findings of this study therefore serve as a reminder of our collective responsibility to better understand the long-term consequences of living kidney donation.

The findings of Fallahzadeh et al [5] add to the accumulating literature that there are problems with the existing Iranian model and that the program must evolve. It is clear that the majority of paid donors are poor males, whose quality of life after nephrectomy is lower than that of the general Iranian population, and who are frequently dissatisfied with their decision to undergo nephrectomy [8]. Further, the program has been a contributing factor limiting the advancement of deceased donation and living related donation in Iran. For these reasons, a program that was once justified on the basis of need, may now be a barrier to the advancement of transplantation in Iran. How much harm to living donors' health and quality of life should Iranian transplant centers tolerate? As transplant centers are responsible for ethically sound clinical care, all potential living donors must be assured a high standard of clinical and psychosocial evaluation before the Iranian model can publicize its success.

As Fallahzadeh et al [5] point out, studies have found that few paid unrelated donors undergo follow-up care due to insufficient finances to pay for care, and donors lack knowledge about living donor complications or the need for follow-up care [9, 10]. Accordingly, transplant centers operating within the Iranian model should take extra care to optimally inform donors about the short- and long-term complications of living donation, as well as inform, encourage and enable living donors, particularly donors most at risk—paid unrelated donors—to undergo long-term follow-up care. The government's provision of health insurance to living donors for 1 year is a start toward removing some of the disincentives to donation; however, the recognition of paid donors as a particularly vulnerable group behooves the government to provide long-term follow-up care.

Sally Satel on EconTalk, talking about organ donation (podcast)

PERMANENT LINK | JULY 24, 2017 Sally Satel on Organ Donation EconTalk Episode with Sally Satel Hosted by Russ Roberts	PRINTEMAIL  SHARE
You Are What You Eat...

Sally Satel, psychiatrist and resident scholar at the American Enterprise Institute, talks with EconTalk host Russ Roberts about the challenges of increasing the supply of donated organs for transplantation and ways that public policy might increase the supply. Satel, who has received two kidney donations, suggests a federal tax credit as a way to increase the supply of organs while saving the federal government money. She also discusses the ethical issues surrounding various forms of compensation for organ donors.

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Readings and Links related to this podcast episode

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This week's guest: Sally Satel's Home page Sally Satel on Twitter. This week's focus: "The Kindest (Tax) Cut: A Federal Tax Credit for Organ Donations," by Sally Satel and Alan Viard. Tax Notes, June 12, 2017. PDF file. "A College Tuition Payment for Your Spare Kidney?," by Sally Satel. Slate, September 13, 2016. Additional ideas and people mentioned in this podcast episode: "Here's Looking at You, Kidney: How and why I became an organ donor -- and how I kept people from talking me out of it," by Virginia Postrel. Vpostrel.com, Texas Monthly, June 2006. "Desperately Seeking a Kidney," by Sally Satel. The New York Times, December 16, 2007. A few more readings and background resources: National Organ Transplant Act of 1984. Wikipedia. "Life-Saving Incentives: Consequences, Costs and Solutions to the Organ Shortage," by Alex Tabarrok. Library of Economics and Liberty, August 3, 2009. "How Free-Market Kidney Sales Can Save Lives--And Lower the Total Cost of Kidney Transplants," by Kathryn Shelton and Richard B. McKenzie. Library of Economics and Liberty, March 5, 2012. Health Care, by Michael A. Morrisey. Concise Encyclopedia of Economics. A few more EconTalk podcast episodes:  Virginia Postrel on Style. EconTalk. November 2006.  Tina Rosenberg on the Kidney Market in Iran. EconTalk. September 2015.  Alvin Roth on Matching Markets. EconTalk. July 2015.  Michael Munger on Exchange, Exploitation and Euvoluntary Transactions. EconTalk. June 2011.  The Economics of Organ Donations with Richard Epstein. EconTalk. June 2006.

Highlights

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0:33

Intro. [Recording date: July 6, 2017.] Russ Roberts: Sally Satel recently wrote an article with Alan Viard entitled "The Kindest (Tax) Cut: A Federal Tax Credit for Organ Donations," and that's going to be our topic for today.... So, you bring a special perspective to kidney donations. Talk about your personal story. Sally Satel: Yeah. I got a kidney in 2006; and then I got another kidney a year ago, almost a year ago today. And, when I got my first one it was sort of a surprise. A lot of people who know that they're going to need a kidney--well, by definition, they know that they're going to need a kidney. What I meant is that they have certain illnesses--they are either diabetic, or they've got lupus, severe hypertension that's been poorly managed for a while, high blood pressure. People know they are at risk for this, for kidney failure. But my case was sort of a surprise. I just went to the doctor for a regular checkup. This is the part of the story that scares everyone, because I felt completely fine. And during a routine blood draw, found out that I had--well, that I had kidney failure. Which is rather easy to diagnose. It's a test called a creatinine level. But when you go for a regular blood draw, a routine blood draw, that's one of the indexes they measure. So, they tested it again, and that was the same. So, the clock was ticking for me, because I knew from my medical training that if you have kidney failure, you need a new kidney, or you will languish on dialysis for years. And no matter how long you are on dialysis, your life will be prematurely shortened. I mean, people have lived for 20 years, even a little longer, on dialysis. Some people tolerate it better than others. That's a process where your blood is cleansed of toxins about 3 times a week for about 4 hours at a time; you go to a clinic. Most people feel very debilitated by it. The average person on dialysis can't hold a job. But some do. And, some people--it isn't as psychologically devastating to some folks. But others find it so distressing, they are actually--suicide is not that unusual. So, the idea of being tethered to that machine, while, granted, it would keep me alive. Now, if my liver had failed and I didn't get a transplant, that would be it. So, kidney dialysis does keep people alive for awhile. But it just seemed like a really, really half a life. So, I knew I needed a kidney, but I didn't know exactly when I would need dialysis. So, as I said, the clock started ticking. And it turned out I had a good year before the function got to the point where I really was becoming physically debilitated. But it was very hard finding a donor. And that's what kind of galvanized me, this whole issue of the shortage. But, just in terms of finding a donor, as I say, it was extremely difficult. It's not like every day you ask people for a body part. And I didn't have--I have a very tiny family. And, to make a long story short, none of them--I didn't feel I could ask any of them. And in fact I never really asked anyone. I would do it all differently if, heaven forbid, there is yet a third time I have to go through this--see, I'm very nice to my interns. But I would just talk about it with folks and wasn't even being coy. I just sort of thought magically, 'Oh, well some people will think of being a donor, and it will work out.' But it became pretty clear that it wasn't working out. And a lot of people actually said they would do it; and I appreciate that in that I know they wanted to be--I know they felt empathy for my situation; but in the end, basically, a lot of them got cold feet and backed out. And then you're in this terribly awkward position, because you really can't be angry. I mean it's an enormous thing to ask, and it would be incredibly presumptuous to have the expectation that they owed you anything. So, I was really getting very demoralized and about to get ready to go on dialysis. And, Virginia Postrel, who I knew, not very well, had been at a cocktail reception somewhere--this was in November of 2005--and she ran into a mutual friend and asked that friend how I was. And the friend said, 'Not so hot. She needs a kidney.' And, Virginia went--I think the next went to her computer--I remember the subject line; I still have a printout of her email--it said, 'Serious Offer.' And she said, 'So-and-so told me you needed a kidney, and if I match, I will do it.' And I think she followed up a few minutes later with another email: 'I won't back out.' And, so, she went through with it. This was March of 2006. And I'm almost as grateful to Steve, her husband, as to her, because that was one of the reasons that two of my friends, other of my friends who had seriously considered donating did not go through with it--because their spouse basically said, 'It's the kidney or a divorce.' [More to come. 6:48]

Super bowl thought by Kim Krawiec: football players are paid, why not kidney donors?

While checking up on the super bowl, I'm reminded that Kim Krawiec posted this:
 Super Bowl Week OpEd

"As the Super Bowl approaches, Phil Cook and I have an OpEd running in the Raleigh News & Observer and a few other publications:

Why ban payment to kidney donors but not football players?

BY PHILIP J. COOK AND KIMBERLY D. KRAWIEC 

February 01, 2018 01:06 PM

Super Bowl week rivets national attention on America’s most popular and lucrative sport, professional football. If stories of concussion and permanent injury to players make some fans uneasy, there is always the reassuring fact that the players volunteer for the job and are well compensated – so well compensated that there are untold thousands of young men who would gladly take their place.

Football is so ingrained in our culture that we generally accept this situation without much scrutiny. However, our research got us thinking about the stark contrast with another risky but valuable activity – kidney donation.

About 6,000 people per year donate one of their two kidneys. This selfless act has some risk to the donor, both from the surgery and years later when there is a chance the remaining kidney will fail. In return, kidney donors are rewarded with the knowledge they helped save the life of a loved one. They receive nothing tangible. Indeed, federal law bans compensation for kidney donors, as do the laws of all other countries except Iran (really).

So, why do we pay football players to entertain the public, but are unwilling to pay kidney donors to save lives?

The stakes in both cases are high, but much higher in kidney donation. The total value of NFL teams is about $60 billion. If, in some unlikely future, the risk of serious permanent injury to players led to a ban on professional play, that value would be destroyed.

Meanwhile, the ban on compensation for living kidney donation currently costs thousands of lives and billions of dollars in taxpayer money every year. The waiting list for a kidney now includes 100,000 patients, who for the most part are kept alive by renal dialysis at federal government expense. If they survive long enough, typically more than five years, in this debilitated state, they may hope to rise to the top of the list and receive a kidney from a deceased donor.

Deceased donors are a limited resource: few people die under conditions that permit donation and the United States already procures a large percentage of healthy kidneys from deceased donors. What is needed are many more living donors. Current estimates suggest an offer of $50,000 per living donation would be adequate to recruit sufficient numbers to meet the needs of all transplant-eligible renal patients. This would eliminate the waiting list and prevent thousands of unnecessary deaths and years of unnecessary disability. Given standard value-of-life estimates, the present value of the public benefit of converting to a system of compensated donation would exceed $1 trillion – many times the value of professional football.

It should be noted that the alternative to the current ban on compensation is not a laissez-faire free market. Rather, the current system for regulating the allocation of available kidneys could be readily expanded. A nonprofit or government organization could offer a fixed payment to living donors who were screened to be physically and mentally sound, and then fully informed of the risks. To avoid “impulse” donations, there could be a mandatory waiting period.

And it should be noted that the medical risks to kidney donors are far less than the risks of a football career; most donors lead normal lives, while most NFL veterans are, to some degree, disabled.

Inevitably the chance to sell a kidney for $50,000 would be most attractive to people who are struggling financially. Some ethicists opine that a compensated system would exploit the poor. Yet, more than a few NFL players also come from poor homes and 70 percent are black, causing many to view the concussion crisis as another example of racial inequality. In our view, the risk of exploitation is not a legitimate reason for forbidding compensation to kidney donors, thus denying the poor full use of one of their potential assets.

Millions of Americans, not just NFL players, work in occupations that have a substantial risk ofserious injury. Loggers, fishermen and others accept these risks in exchange for compensation. Extending that list to include kidney donors is just common sense.

PHILIP COOK IS TERRY SANFORD PROFESSOR EMERITUS OF PUBLIC POLICY AND PROFESSOR OF ECONOMICS AND SOCIOLOGY AT DUKE UNIVERSITY’S SANFORD SCHOOL OF PUBLIC POLICY. KIMBERLY KRAWIEC IS THE KATHRINE ROBINSON EVERETT PROFESSOR OF LAW AT DUKE LAW SCHOOL."