Saturday, October 29, 2011

To buy or not to buy

A number of years ago, I was at a lecture given by a transplant surgeon from London. He was discussing the dangers surrounding living unrelated kidney transplantation and he told the story of a member of a royal family, of a country that will remain nameless, who had come to London to get a transplant from his cousin. The cousin did not speak any English and, in fact, spoke a very obscure dialect so the translators had been provided by the Prince rather than the hospital. The night before the operation, the transplant fellow was doing his rounds and stopped to talk with the cousin. By coincidence, he was from the same area as the donor and started talking with him. It turned out that the donor was a private in that nation’s army and had no idea what he was doing there. Of course, the transplant was cancelled.

I was reminded of this by the case of Levy Izhak Rosenbaum (previously mentioned in a post by Nate) who pleaded guilty this week to three sample charges of organ trafficking. He was selling kidneys to wealthy Americans for over $100,000 each and allegedly paying donors in Israel around $10,000 for each kidney. He is likely to spend the next 20 years in prison.

Iran is currently the only country where it is legal to pay donors although it was legal in India until 1994. There are very short waiting lists in that country as a result although, as you might expect, there is very little intra-family donation because of the ready availability of organs from unrelated donors. The Declaration of Istanbul stated unequivocally that transplant tourism and organ trafficking are unethical and lead to exploitation of the poor but this certainly has not ended the debate. Last year, there were a number of posts on RFN on this very topic with some impassioned debate.

One of the key arguments in favor of allowing payment for donation is the lack of adverse outcomes for donors but many programs still do not monitor long-term outcomes, although it must be said that most published data suggests that it is relatively safe. However, any operation carries some risk and it is inevitable that a portion of these donors would die in any given year. Remember that donation carries no medical benefit for the donor.

This is a very difficult ethical topic and I don’t know what the correct answer is. My own bias is that it should not be allowed and I think it would take a lot to convince me otherwise. This particular case is interesting because the concept of organ trafficking is usually discussed in the abstract in the US but this shows that it is certainly going on here and care must always be taken if there is any suspicion of money changing hands.

In a related case, 3 Brazilian doctors were convicted this week of removing organs from patients in a public hospital for use in an expensive private hospital. The patients, with the collusion of a neurosurgeon, were diagnosed with brain death and the doctors were convicted of murder. There were allegations of payments being made although these were never proven. The complexity of this topic is shown by the fact that it took 25 years for this case to come to a conclusion – the original operations occurred in 1986.


MooseMom said...

I am uncomfortable with the "the poor will be exploited" argument. It seems to me that we could come up with a system to make sure that anyone who might want to sell an organ was tested, protected and fully informed. We could then trust people to make decisions for themselves instead of assuming that "the poor" are too stupid and need to be protected from themselves.

But if you insist on using the "someone will be exploited" argument, then why are you not fighting against the exploitation of sick people by the leading dialysis providers? Someone who might want to sell an organ at least would have a choice, but dialysis patients have no choices, really, and are exploited to the point where clinics won't even open every day of the week so that patients can't have access to more dialysis. Really, if you think about exploitation, worry more about your patients who are withering away on standard, inclinic dialysis. You can't be all bothered about protecting one group of people when an even more fragile section of the population is being exploited every day just because they have the very bad luck of having ESRD.

MooseMom said...

PS...does the whole idea of making a profit out of the woes of sick people not strike you as "exploitation" in any way? Dialysis companies are making shedloads of money, but they don't want to pay for more staff, better training, better facilities and better scheduling. And how many nephrologists are allowing this to continue happening to their patients? Cherry picking patients, messing about with ESA dosing...all to make a bigger buck...and you are concerned about theoretical exploitation when REAL exploitation is occurring right here, right now, for the sake of profit? Really? This just strikes me as awfully precious.

Anonymous said...

But what about the patients who cannot afford to buy the organs? They will then fade away while those with money will get better.

I don't think anyone should make money with organ trafficing. Everyone should have the right to receive a transplant at the same time.