Organ donations in China: Will official financial incentives starve the black market?

Health and medicine explained.
June 13 2011 4:38 PM

Yuan a Kidney?

China's proposals to pay organ donors flout the status quo. That's a good thing.

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Nor are organ sales "a filthy business in the same subcategory as the sex trade and child pornography," as nephrologist Gabriel Danovitch of the University of California at Los Angeles has claimed. Prostitution and child pornography—legal or not—debase everyone involved. Organs, by contrast, are the rare trafficked good that saves lives. And if the vendors were able to engage in licit, safe, transparent, and regulated transactions they too could improve their welfare.

But alas, this sensible vision runs afoul of ideology. "Altruism is the bioethical foundation [for obtaining organs]," affirmed a 2009 report by Council of Europe and the United Nations, "Organs should not give rise to financial gain."[i]

Why not?It is all too easy to romanticize altruism. The "gift of life" is indeed precious. I received it from a friend in 2006. But I am not so naive about my good fortune as to ignore reality that altruism is not producing enough organs. Government-sponsored compensation of healthy individuals who are willing to give one of their kidneys to save the life of a dying stranger is the best solution.

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In-kind benefits such as those China is considering, paired with lengthy medical screening, would be unattractive to desperate people (who might otherwise rush to donate for a large sum of instant cash). This should allay concerns that poorer citizens would be effectively forcedto donate.

But coming from a government that has legitimized organ harvesting from detained individuals, China's proposals may be rejected out of hand by the international medical community. Understandably so. After all, China's transplant practices are profoundly opaque with few details on clinical protocols or outcomes published in the medical literature except in the breach.

If China is serious about creating an incentive program, transparency and accountability will be vital to its integrity and safety. Transactions on a black market are dangerous because they are illicit, not because they are transactions.

A number of countries recognize this and have carefully modified their laws to permit donor enrichment. Singapore, for example, helps cover health insurance costs for living kidney donors.. In Manila, a major transplant center offered business grants and home-improvement packages to donors. That government-approved program lasted four years until 2008, when it was dismantled by the Philippine government under pressure from the World Health Organization.

In Israel, citizens who register to become posthumous donors get slight priority on the waiting list for organs, if they ever need one. Israeli families may also now accept up to $13,400 to "memorialize" the deceased donor with, for example, a scholarship in his name. More controversially, Iran pays cash to kidney donors. China's initiative, should it be undertaken with requisite oversight, would be unprecedented in scope and in range of benefits offered to donors.

These countries' efforts are being studied by the Nuffield Council on Bioethics, a British ethics think tank that's pondering how the United Kingdom can increase organ donation. It's considering a broad range of potential actions, from the innocuous (an official "thank you" to the donor) to the audacious (creating a free market in body parts). The council will release its report in the fall. 

No one seriously thinks the council will opt for unfettered sales, but the bottom line of any serious consideration is inescapably this: The only way to save lives and starve underground markets abroad is to provide more transplants at home. And the only way to do that is to break radically—and ethically—with a status quo that forbids an informed donor to be rewarded for saving the life of a stranger.

Sally Satel is a psychiatrist and resident scholar at the American Enterprise Institute.

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