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."

More debate about legalizing kidney sales

There's nothing new in this debate, but here is more on compensating kidney donors.  As far as I can see, the weakest argument against compensating donors is that the illegal black markets for kidneys work badly...

From Gizmodo:
Should You Be Allowed to Sell Your Kidney?

Gabe Danovitch, a distinguished transplant nephrologist and an active opponent of compensation for donors, is quoted saying this about markets:
"Any attempt at so-called regulating… a market, by definition, is not regulated. Markets don’t like regulations. Let’s say we were to allow a regulated market, and a donor would get $30,000. I’m just throwing this out. Why wouldn’t Singapore say you can get 50? In Doha you can get 80? And why wouldn’t the donors go around the world to get the best price? If we were to do that in the United States, it would be a disaster."

This argument strikes me as strange: is the problem with compensating donors  that it might open up competition for American transplant centers??

Danovitch also makes an argument that, as a nephrologist who evaluates potential donors, he couldn't trust them as much if they were getting paid.
**************

On a related matter, this from the LA Times
'Kidney for sale': Iran has a legal market for the organs, but the system doesn't always work

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."

The ASSA / AEA meetings, preliminary program

This year's ASSA preliminary program is now online:  https://www.aeaweb.org/conference/2018/preliminary 
The AEA sessions were organized by President Elect Olivier Blanchard (and his program committee).  David Laibson will give the Ely lecture.

Here are two sessions that caught my eye from just the first page (of 11).

Thursday, Jan. 4, 2018   5:30 PM - 7:00 PM
 Marriott Philadelphia Downtown, Grand Ballroom Salon H
 Econometric Society Presidential Address

Drew Fudenberg, Massachusetts Institute of Technology 

Inner Workings of Organ Markets and Organ Allocation

Paper Session

• Chair: Eric Budish, University of Chicago

The Inner Workings of Kidney Exchange Markets

Nikhil Agarwal

,

Massachusetts Institute of Technology

Itai Ashlagi

,

Stanford University

Eduardo Azevedo

,

University of Pennsylvania

Clayton Featherstone

,

University of Pennsylvania

Omer Karaduman

,

Massachusetts Institute of Technology

Abstract

The market for kidney exchange was created to address the shortage of kidneys for donations. The market allows patients with a willing but incompatible live donor to swap donors, so that they can perform transplants, and has grown to about 800 transplants per year. This paper uses detailed administrative data to describe the functioning of this market. The most striking finding is that the market is fragmented into dozens of small platforms instead of working in a single large platform, with most transactions happening in platforms that operate within a single transplant center. This may lead to substantial inefficiency if there are increasing returns to scale to matching patients in a large, thick market.

A Regulated Market for Kidneys

Mohammad Akbarpour

,

Stanford University

Abstract

The persistent shortage of kidneys for transplantation is a global problem for end-stage renal disease (ESRD) patients. Many countries have tried to address this issue by increasing deceased donation, by introducing kidney exchange programs, and by optimizing the allocation algorithms. Despite such efforts, the problem of shortage is growing in most countries, with more than 100,000 people waiting for a kidney transplant only in the U.S. Iran is the only country in the world that has introduced a different program of living unrelated renal donation, which includes two kinds of monetary compensation of donors: a "gift for altruism" from the government to donors, as well as an additional compensation from the patients themselves. We will discuss the impacts of this program on waiting times, organ shortage, and its equilibrium effects on other kinds of live donation.

Strategic Behavior in the Kidney Waitlist

Nikhil Agarwal

,

Massachusetts Institute of Technology

Itai Ashlagi

,

Stanford University

Paulo J. Somaini

,

Stanford University

Abstract

A transplant can improve a patient's life while saving several hundred thousands of dollars of healthcare expenditures. Organs from deceased donors, like many other common pool resources (e.g. public housing, child-care slots, publicly funded long-term care), are rationed via a waitlist. The efficiency and equity properties of design choices such as penalties for refusing offers or object-type specific lists are not well understood and depend on agent preferences. This paper establishes an empirical framework for analyzing the trade-offs involved in waitlist design and applies it to study the allocation of deceased donor kidneys. We model the decision to accept an offer from a waiting list as an optimal stopping problem and use it to estimate the value of accepting various kidneys. Our estimated values for various kidneys is highly correlated with predicted patient outcomes as measured by life-years from transplantation (LYFT). While some types of donors are preferable for all patients (e.g. young donors), there is substantial heterogeneity in willingness to wait for good donors and also substantial match-specific heterogeneity in values (due to biological similarity). We find that the high willingness to wait for good donors without considering the effects of these decisions on others results in agents being too selective relative to socially optimal. This suggests that mild penalties for refusal (e.g. loss in priority) may improve efficiency. Similarly, the heterogeneity in willingness to wait for young, healthy donors suggests that separate queues by donor quality may increase efficiency by inducing sorting without significantly hurting assignments based on match-specific payoffs.

Discussant(s)

Utku Unver, Boston College

Glen Weyl, Microsoft Research

Benjamin R. Handel, University of California-Berkeley

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

Related Readings HIDE READINGS

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

Time

Podcast Episode Highlights HIDE HIGHLIGHTS

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]

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."

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."

Opposition to kidney sales in Iran

Afshin Nikzad points me to the following story in Farsi, and provides the translation below. He writes:

http://donya-e-eqtesad.com/SiteKhan/1136026/

"I edit/copy parts of the article from google translate (since it didn't give a great translation) : 

The 78 years old residing in America in an interview with US media said he had been in America for a kidney transplant and doctors had told him he should stay on the waiting list for a kidney transplant from brain death or that of one of his two children. All catch. But he found a third way through his Iranian birth certificate: buying a kidney in Iran. In his interview he talked about the youth in Iran who from the poverty and desperation were lined up to speak to him for selling their kidney.

Doctor, "Ali Husseini,” the head of the Transplantation Society of the Middle East in response to the letter, said: "Buying and selling kidney with strangers is dirty and inhumane and is banned even in countries like India and Pakistan" He also said “among all the thousands seller in the country there is not a single a rich person, all were poor and sold the kidney from poverty and desperation; undoubtedly they  have not donated their kidney.”

Dr. Mohammad Reza Ganji, head of the Iranian Society of Nephrology said “… In the past two years  63% of the transplants have been from brain-dead (that is two thousand and six hundred transplants), and this is statistically significant in the world."

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."

A skeptical view of the Iranian market for kidneys, from Shiraz

Here's an article (gated) from a recent issue of Transplantation, describing how the transplant program in Shiraz is discouraging patients from the (legal) market there for buying kidneys from living unrelated donors (they impose a six month waiting time for such transplants). Most patients who have transplants at Shiraz are receiving deceased donor kidneys.

Transplantation:

June 2016 - Volume 100 - Issue 6 - p 1165–1169

doi: 10.1097/TP.0000000000001164

In View: Around the World

Paid Living Donation and Growth of Deceased Donor Programs

Ghahramani, Nasrollah MD

Abstract

Abstract: Limited organ availability in all countries has stimulated discussion about incentives to increase donation. Since 1988, Iran has operated the only government-sponsored paid living donor (LD) kidney transplant program. This article reviews aspects of the Living Unrelated Donor program and development of deceased donation in Iran. Available evidence indicates that in the partially regulated Iranian Model, the direct negotiation between donors and recipients fosters direct monetary relationship with no safeguards against mutual exploitation. Brokers, the black market and transplant tourism exist, and the waiting list has not been eliminated. Through comparison between the large deceased donor program in Shiraz and other centers in Iran, this article explores the association between paid donation and the development of a deceased donor program. Shiraz progressively eliminated paid donor transplants such that by 2011, 85% of kidney transplants in Shiraz compared with 27% across the rest of Iran's other centers were from deceased donors. Among 26 centers, Shiraz undertakes the largest number of deceased donor kidney transplants, most liver transplants, and all pancreas transplants. In conclusion, although many patients with end stage renal disease have received transplants through the paid living donation, the Iranian Model now has serious flaws and is potentially inhibiting substantial growth in deceased donor organ transplants in Iran.

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

The black market for kidneys in South Asia

It sounds like you can buy a kidney in India, and have it transplanted in Sri Lanka. But it isn't clear how large the market is compared to the vast worldwide demand or even to the number of legal kidney  transplants around the world (in the US we have about 17,000) a year). When I say it isn't clear, I mean that the story is based mostly on anecdotal information from market participants...
However I can supply an additional anecdote about social media: almost every morning as I get ready to publish my blog post for the day, I delete spam "comments" on previous posts about kidneys, offering phone numbers to call if you want to sell yours...

Al Jazeera has the story:
Need a kidney? Inside the world’s biggest organ market
The illicit kidney trade in South Asia has exploded as brokers use social media to find donors.

""If you have the money and want it fast, you come here. I will find you a donor and you can go home with a new kidney in a month," Vikas told Al Jazeera, speaking on the condition that his real name not be published.

"According to the World Health Organisation (WHO), South Asia is now the leading transplant tourism hub globally, with India among the top kidney exporters. Each year more than 2,000 Indians sell their kidneys, with many of them going to foreigners.

"This gaping hole between demand and the legal supply of kidneys is being filled by what may be the world's biggest black market for organs, which criss-crosses India, Nepal, Bangladesh, Pakistan, Sri Lanka and Iran.

"However, in recent years, Sri Lanka's capital Colombo has become the new nerve centre of this network, where most transplant operations are carried out. In recent years, Sri Lanka has attracted kidney buyers from as far afield as Israel and the United States.

"This development came after India tightened its rules on organ exchanges in 2008, following the arrest of a "kidney kingpin" running one of the world's largest kidney trafficking rings. Many donors are also taken to Iran, the only country in the world where selling kidneys is legal, though not to foreigners.

"Anurag, one of the top names in brokering circles, told Al Jazeera that many agents in India and Bangladesh were working at the behest of individual doctors or hospitals based in Colombo who offered "complete packages" to foreign recipients, with prices ranging from $53,000 to $122,000.

"It covers everything - hospital bill, doctor's fee, payment to the donor, his travel and accommodation cost, and, of course, broker's commission. This is the best way because it saves everybody time and hassle," Anurag - who also wanted his real name withheld to avoid trouble - told Al Jazeera from Sri Lanka.

"Although the illicit racket has flourished since the 1990s, social media has catapulted the trade into a new dimension. Brokers like Vikas and Aadarsh are openly lurking on dozens of Facebook pages fashioned as kidney and transplant support groups.

HT: Mohammad Akbarpour