If you lose your job, you can sell your home. If you lose your home, you can sell your possessions. If you lose your possessions, you can prostitute yourself. And if you lose everything else, you can sell one more thing: your organs.
Twice in the last two weeks, transplant experts from around the world have convened in Europe to discuss the emerging global market in human flesh. Two maps presented at the meetings tell the story. One shows countries from which patients have traveled for organs in the last three years: Saudi Arabia, Taiwan, Malaysia, South Korea. The other shows countries from which organs have been sold: China, Pakistan, Colombia, the Philippines.
The numbers on the maps add up to thousands. According to the World Health Organization, the annual tally of international kidney transactions alone is about 6,000. The evidence includes reports from brokers and physicians, accounts from Indian villages, surveys of hospitals in Japan, government records in Singapore, and scars in Egyptian slums. In Pakistan, 40 percent of people in some villages are turning up with only one kidney. Charts presented at the meetings show the number of "donations" from unrelated Pakistanis skyrocketing. Two-thirds of the people getting these organs are foreigners. Data from the Philippines show the same thing.
The first successful organ transplant took place half a century ago. Since then, diabetes, hypertension, and other kidney-destroying diseases have spread. Antibiotics have improved, as have drugs that suppress the immune response to foreign organs. More people need transplants, and more can be saved by them. But donations haven't kept up with demand. An estimated 170,000 patients in the U.S. and Europe are on waiting lists. More than 70,000 Americans are waiting for kidneys, and the list has grown at a rate of almost 5,000 per year. People are dying.
Instead of waiting, many patients have set out to recruit their own donors. They started with billboards, then moved to Web sites such as MatchingDonors.com, JoeNeedsaLiver.com, and HelpMyGrandpa.com. Around the world, people have learned that their organs are assets. Peruvians, Ukrainians, Chinese hospitals, and American inmates advertise their innards. Last year, a South Korean playwright used his kidney as collateral for a loan.
Politicians have tried to rein in this market. The United States banned organ sales two decades ago. India did the same in 1994, and China followed last year. But when lives are at stake, rules get bent. To procure more organs, doctors have discarded brain-death standards, donor age limits, and recipient health requirements. States have let transplant agencies put patients on life support, contrary to their living wills, to preserve their organs. If Congress revises its ban on organ sales, as some advocates hope, lawmakers in South Carolina plan to offer prisoners reduced jail time in exchange for organs or marrow.
If national governments can't control wages or prices in a global economy, they certainly can't control the purchase of extended life. In the last two years, Israeli organ brokers shifted their business from Colombia to China for faster service. If China closes its doors, they can shift again. In Pakistan, kidneys already sell for a fraction of what Chinese hospitals charged. Brokers can compare organ prices from country to country, just like wheat or corn.
Already, bans on organ commerce are crumbling. Indians who lost their livelihoods in the tsunami of 2004 sold their kidneys, ignoring the law. Bulgaria imposes stiff sentences on organ traders, but that didn't deter a local hospital from serving Israeli transplant tourists last year. Nor did China's ban stop a Chinese hospital from offering a liver to a BBC correspondent. Three weeks ago, a Korean newspaper reported that China's organ crackdown had simply raised the price of a Chinese kidney in South Korea.
Some reformers think they can solve the organ shortage and tame the market by legalizing sales. Their latest proposal, presented at one of the European meetings last week by Dr. Arthur Matas of the University of Minnesota, is a single-payer system for organs. It's half libertarian and half socialist. On the one hand, Matas says markets for eggs and sperm are harmless, kidney purchases can save countries money, and offering poor people cash for organs is no more coercive than offering them money to work in mines or join the army. On the other hand, he thinks the government can fix kidney prices and determine who gets them.
Good luck. As any country with national health insurance knows, people find ways to buy more than they're allotted. Ration medical care abroad, and affluent foreigners will come here. Ration organs here, and affluent Americans will go abroad, as they're already doing. It's true that payments would elicit more "donations." But studies reviewed at the meetings in Europe show that flooding the market with purchased organs reduces the incentive to donate.
The key to reversing the organ market is to turn that equation on its head. Stop fighting capitalism, and start using it. What's driving the market is scarcity. Americans, Britons, Israelis, Japanese, and South Koreans are going abroad for organs mostly because too few of their countrymen have agreed to donate organs when they die. Some have religious objections. Others are squeamish. Many figure that if they don't supply the organs, somebody else will.
They're right. Somebody else will supply the organs. But that somebody won't be a corpse. He'll be a fisherman or an out-of-work laborer who needs cash and can't find another way to get it. The middlemen will open him up, take his kidney, pay him a fraction of the proceeds, and abandon him, because follow-up care is just another expense. If he recovers well enough to keep working, he'll be lucky.
The surest way to stop him from selling his kidney is to make it worthless, by flooding the market with free organs. If you haven't filled out a donor card, do it now. Because if the dying can't get organs from the dead, they'll buy them from the living.
A version of this article also appears in the Outlook section of the Sunday Washington Post.