December 18, 2007

Two Times

by PG

1. Despite my skepticism of Adam Freedman's book, he does make a plausible-sounding argument against relying too much on Founding-era punctuation, and in favor of the "ablative absolute" of the Second Amendment. (I say plausible-sounding because, like 2008's presidential candidates, I have no Latin training myself.)

2. I could see the concluding paragraphs of Sally Satel's piece coming as soon as I read this one:

I wanted my donor to be completely anonymous so I could avoid the treacherous intimacy of accepting an organ from someone I knew. I would have gladly paid someone to give me a kidney, but exchanging money for an organ is a felony in this country. Altruistic giving is the metaphorical bedrock of our transplant system. Organ donation, we are told, should be the ultimate gift: the "gift of life," a sublime act of generosity. The giver -- whether living or deceased -- must not expect to be enriched in any way.
Despite the "treacherous intimacy" Satel achieved with Virginia Postrel, rather than "becoming a 'transplant tourist' in Turkey or the Philippines, where [she] could buy a kidney," the takeaway lesson of her piece is not that we should all sign organ donor cards (which Postrel had not, because she "wouldn't have done this for a stranger").

My story, it turns out, is a triumph of altruism. Looking back, I see that my anxiety over my future donor was a neurotic luxury. I worried about finding the ideal donor, but thousands of people have no donor at all -- no relative who will do it out of love or obligation, no friend out of kindness, no stranger out of humane impulse. Alas, I have no kidney to give away. Instead, I am urging wherever I can -- in articles, in lectures, from assorted rooftops -- that society has a moral imperative to expand the idea of "the gift."

Altruism is a beautiful virtue, but it has fallen painfully short of its goal. We must be bold and experiment with offering prospective donors other incentives for giving, not necessarily payment but material reward of some kind -- perhaps something as simple as offering donors lifelong Medicare coverage. Or maybe Congress should grant waivers so that states can implement their own creative ways of giving something to donors: tax credits, tuition vouchers or a contribution to a giver’s retirement account.

In short, we should reward individuals who relinquish an organ to save a life because doing so would encourage others to do the same. Yes, splendid people like Virginia will always be moved to rescue in the face of suffering, and I did get my kidney. But unless we stop thinking of transplantable kidneys solely as gifts, we will never have enough of them.

I admit up front that I have a strong opposition to selling organs, particularly from live donors. The area of live organ donation is beset with enough ethical issues (though less so for kidneys than some other organs, particularly because live kidney transplants yield better outcomes) without adding the element of inducing the loss of an organ through payment. It is Satel's framing the issue as one of payment that makes me particularly unhappy.

Lifelong health coverage for organ donors is an excellent idea, but not because people should receive a payment in return for their organs; rather, it is sensible to guarantee that should one's generosity end up negatively impacting health -- even in a very long term and indirect way -- that one won't be burdened by medical bills. Someone who would like to donate, but lacks health insurance and thus must be more fearful of even the low risk of complications, certainly should be able to do so with that fear removed inasmuch as possible. I even would be willing to expand this and have government-guaranteed benefits to someone who is disabled in a way traceable to the donation, or to his survivors if he dies because of it. But none of this has to do with appealing to someone's desire for money; it is about ensuring that his generosity will not be to his own detriment. (In an unfortunate coincidence, Postrel is now in chemotherapy because of breast cancer -- thankfully she reports that her prognosis is good.)

Like Kristof, Satel feels no need to cite any study or even an individual who says that they would give organs in exchange for monetary benefits. I'd be surprised if Postrel would have, inasmuch as her gift seems to have been strongly founded in valuing Satel, the recipient. I doubt that is a regard that money can buy.

December 18, 2007 06:16 PM | TrackBack

Over half of the 98,000 Americans on the national transplant waiting list will die before they get a transplant. Most of these deaths are needless. Americans bury or cremate about 20,000 transplantable organs every year. Over 6,000 of our neighbors suffer and die needlessly every year as a result.

There is a simple way to put a big dent in the organ shortage -- give organs first to people who have agreed to donate their own organs when they die.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.

Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

Posted by: Dave Undis at December 20, 2007 08:51 AM

The program you suggest certainly appeals to me more than turning human organs into something that can be bought with money. It sounds like instead, one buys another organ with (the promise of) one's own. I'd be curious as to the enforceability of signing up for the program. E.g., have any people died and their families refused to give up their organs?

I am frankly puzzled as to the psychology of why people don't donate their organs. I signed up as an organ donor at 16, as soon as I got my driver's license. I understand that some people, particularly poor and minority folks, are afraid that doctors will be aware that they are donors and not work as hard to save their lives. It seems to me that instead of programs to induce people to ignore their fears and concerns with the promise of getting some personal benefit from it, we should be figuring out what stops people from donating, and should work on erasing those barriers. Clearly things can be done to improve donation rates -- without setting up a system that turns the organ from a gift into an item for exchange -- if the number of hospitals eligible for this award has increased dramatically in four years.

Posted by: PG at December 20, 2007 02:08 PM

Life Sharers is fine, but it cadaveric organs are grossly insufficient for addressing the kidney crisis. Even if everyone who died in the very special way needed to make a kidney transplantable signed an organ donor card, most of the people suffering and dying on the UNOS list would still die before receiving an organ.

Virginia Postrel, incidentally, strongly favors a market for live kidney donation (she has a pretty snappy presentation on the subject and has written about it on her blog). She also favors any and all other methods to encourage live donation, including churches sponsoring (i.e., supporting) one of their members to make an altruistic donation.

One of her more creative proposals is to forgive the medical-school loans of med students who donate their kidneys. This proposal targets a young, healthy, and well-informed population who could benefit from the experience of being a surgical patient. Since this group is typically cash-strapped but has high expected future income, there is no question of financial exploitation.

Posted by: srp at December 21, 2007 09:44 PM


Thanks for your comment. Has Mrs. Postrel said that she would have sold her kidney had it not been for the laws preventing that option? What I am looking for is some factual basis for the repeated claim that once kidneys can be exchanged for "valuable consideration," there will be a significant overall increase in the number of kidneys available. The example of med students is perfect: has any surveyed this group to find out 1) the number who currently are cadaveric organ donors, 2) the number who claim to be willing to donate a kidney while alive and without compensation, and 3) the number who are not in the first two categories who say they would become live kidney donors immediately in order to have their loans forgiven?

I know that the argument that making X sale-able will necessarily increase the number of Xs available is economically intuitive. What I question is whether the economics of widgets will necessarily apply to all other things -- and even if it does apply (as would be evidenced by a finding that yes, more med students would be willing to exchange kidneys for loan forgiveness than would be disgusted by this monetization and would withdraw from donation entirely), whether that's sufficient to overcome the reason we didn't want X on the market in the first place. After all, I think Posner was probably right that a legal market in babies would increase the number of babies available; I just don't think an increased availability of healthy white babies is sufficient benefit to open ourselves to the costs that such a market is likely to entail.

Posted by: PG at December 21, 2007 11:35 PM

I just read a couple of Mrs. Postrel's essays about organ donation, and did not find any of the kind of evidence I had sought. I did find one where she says, "As people become more and more aware of the financial value of their body parts, something Michele's book also discusses, resistance to no-strings donation will only increase."

However, as with the option of lifelong medical care that Satel proposes, I can endorse the following: "A pool to make up for lost wages (legal, but rare today) would enable many otherwise willing friends and relatives to contribute." Again, this isn't buying the kidney; it a tort-style attempt to put the donor in the same position she would have been had she not donated. The guarantee of medical care looks to the potential of lost health from donation; the guarantee of recompensed wages looks to the potential of lost income.

I suspect both would have been welcome suggestions to the National Kidney Foundation, had the AEI's conference not been titled, "Buy or Die," which rather strongly suggested that one had to give valuable consideration for the kidney itself, not recompense for the lost health or income associated with the donation. Indeed, the NKF letter specifically endorses "evaluating the impact of paid leave for organ donors." Admittedly, Mrs. Postrel is technically correct that "even talking about incentives is taboo to some self-styled patient advocates," inasmuch as the IOM report seemed to put the subject of incentives to rest. What is still open to debate, and what has always been legal, is the type of restitution I have discussed, which addresses the harms suffered by donors and attempts to ameliorate them.

To continue a point near the surrogacy analogy raised in Mrs. Postrel's Texas Monthly piece, a couple adopting a newborn can compensate the birth mother for her lost wages and can pay for her medical care. (As described in Dan Savage's The Kid, the couple can even pay for a place for her to live, at least in their case where the birth mother was homeless.) What they cannot buy is the baby -- under state law, she retains the right to the baby until the adoption process is complete. I don't think organs should be any more purchasable than babies.

On a systemic level, I completely agree that donors need to be given discretion over their donation. Without that discretion, it slides from the territory of charity to that of levy. If I can decide whether to donate money to one 501(c)(3) or another, I also should be able to decide to whom I wish to donate my organ. The petty dictatorship of transplant centers that forbid stranger donation is unacceptable. However, I suspect those attitudes will only be heightened if people are being paid for their organs. Doctors who currently want to psychologically scrutinize stranger donors to make sure they have the "right" motives are likely to refuse to perform the transplant at all when they know the motive is monetary.

Posted by: PG at December 22, 2007 12:07 AM

On the one hand, it is deeply immoral to kill people by preventing them from buying organs from willing sellers. On the other hand, medical tourism is probably the answer. What's a good micronation to do one's organ brokering in?

Posted by: 'vark at December 26, 2007 01:21 AM

Freedman is right that it's an ablative absolute, but then he pulls a switch. “Because a well regulated militia is necessary to the security of a free state, the right of the people to keep and bear Arms shall not be infringed.” In other words, the amendment is really about protecting militias, notwithstanding the originalist arguments to the contrary. No, using his 'because' formulation, the meaning is that the right to keep and bear arms shall not be infringed.

Posted by: 'vark at December 26, 2007 01:28 AM

"On the one hand, it is deeply immoral to kill people by preventing them from buying organs from willing sellers."

As stated above, I'm curious as to how many of these willing sellers, in conditions that would not make their consent questionable under contract law, actually exist in the U.S. If Mrs. Postrel is serious about her med student idea, for example, I'd be happy to help her run a survey (I currently have family and friends in five different medical schools around the country).

Re: Freedman, I'm not clear on how he pulls a switch. He seems to be claiming through the "because" formulation that the "right of the people" exists to serve "a well regulated militia." If a well-regulated militia became for some reason wholly unnecessary, the right of the people also would become unnecessary.

Posted by: PG at December 27, 2007 03:41 PM
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