Organ Peddling

E-mail debates of newsworthy topics.
June 4 1998 3:30 AM

Organ Peddling

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       Current U.S. policy allows the gift but not the sale of organs. In Mortal Peril, and more recently in the Wall Street Journal, I took up a cause shared by a few brave souls to reverse that policy and to allow the sale of organs, live or cadaveric, in a legal market. The motivation for that position is simple enough: We have shortages of usable organs today, and people die as a consequence. The hope (and it is not a certainty) is that a price inducement can increase the supply of organs and counteract the shortage, as it does in other markets. Better that we have 200 people alive with one kidney each than 100 people alive with two kidneys. Better that cadaveric organs be used than be buried with the decedent. Markets could make either, or both, these things happen.
       Atul, you rightly note in your Slate article " Organ Meat" that the proposal is not part of some vast (right-wing?) conspiracy to incapacitate the poor and unwitting. My thanks for your fair-minded treatment of the issue. But you have doubts, which turn on two themes--confusion and exploitation. You treat these as reasons for keeping the ban. You're right to signal the difficulties. You're wrong to treat them as trumps. Let's take them in order.
       The issue of confusion arises whenever patients seek advice about medical treatments. The array of choices, the probabilities of success with each, and the downsides of failed treatment all offer an ideal laboratory for decision theory. And we know, as you say, that patients often make a mess of it. But we don't ban their choices because they are sometimes erroneous. Rather, we try to supply more information--and more sources of information--to counter the risks. A legal doctrine of informed consent is a tiny part of the picture. The larger element is a set of support services ("Look it up on the Web" is the first response when people learn of serious illness within their families) that helps overcome the difficulties. If it is possible to do this kind of research with standard illnesses, it should be possible to do it with organ transplants. It is difficult to generate information about illegal transactions; it is far easier to generate good information about legal transactions. And if the difficulties with live donor transactions are too formidable, then the cadaveric market could still operate.
       The basic mistake in your worldview is to treat difficulties as insuperable barriers when they are only formidable challenges to rational behavior. Exploitation fares no better as a reason for closing down markets. The cases of proposed organ transplants are all odd. A 55- or 63-year-old donor is not the prime candidate for this business. Nor is the weak, poor, and infirm individual who does not have healthy organs to give. The targeted population for live donations will have to be people of sober and frugal habits with some short-term need of their own: perhaps funds for an operation on their own child. The targeted population for cadaveric transfers could be just about anyone, for just about any reason. The exploitation fear is not credible in the second market; and it can be countered in the first. Once transactions are legal, markets cease to be thin. As the number of choices increases, information becomes more available, and the likelihood of real exploitation is effectively curtailed. Brokers and other middlemen can add stability to the market. And there is now unimpeded access to the Web. It is always a mistake to assume that legal markets will be just a magnification of illegal ones. Their entire internal structure changes as well, and for the better.
       The time has come to put aside ethical squeamishness. There are ways to counteract these practical difficulties. But we have to try in order to have any chance of success.

This dialogue grows out of Gawande's article "Organ Meat," which appeared recently in Slate.

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