In the United States, over 100,000 people are waiting for an organ transplant; many will die – including over 6,000 patients this year alone - before they are lucky enough to receive one.
Researchers are working diligently to alleviate the organ shortage. For example, doctors are experimenting by transplanting genetically modified pig organs into brain-dead humans. Another tantalizing possibility is lab-grown organs. However, these and other research into the field is preliminary and yet to enter clinical trials, and fraught with ethical issues.
This then begs the question: can and should anything be done today to remedy the deadly supply/demand imbalance for human organs? In our view, the answer is yes.
A market-based system to buy and sell certain body parts would help correct an imbalance that kills ~6,000 Americans per year. Horrified at this suggestion? Prima facie, we were too.
There are certainly moral and “ick” factors that surface. But after removing emotion from the calculus, we concluded that buying and selling certain body parts was indeed an appropriate solution. Before we argue the merits for an organ exchange, let us introduce a few interesting facts about organ transplantation in America:
Key Facts
• According to the United Network for Organ Sharing (UNOS), in 2021, 41,354 organ transplants were performed in America.
• When an organ becomes available, primary deciding factors regarding allocation are need, location and compatibility.
• Since data collection began in 1988, ~850,000 organ transplants have been performed.
• In 1954, the kidney was the first organ to be successfully transplanted, followed by the liver (‘67), heart (’68), and lung (’83).
• Organ “rejection” was – and still is – a primary concern for recipients. The first effective medicine to combat rejection (by suppressing the immune system) was Cyclosporine, introduced in 1983.
• According to the American Transplant Foundation, “organs that can be donated after death are the heart, liver, kidneys, lungs, pancreas, small intestines, hands, face and uterus. Tissues include corneas, skin, middle ear veins, heart valves, tendons, ligaments, bones, and cartilage.”
• The most bestowed organ from living donors are kidneys. Other organs that living donors can offer are portions of lungs, livers, pancreas, and intestines.
• ~6,500 living organ donor transplants are performed each year, ~33% of recipients are not related to the donor.
• Kidneys are the most transplanted organ, followed by livers, and hearts.
• The cornea is the most transplanted tissue, over 40,000 transplants take place per year.
Organ Exchanges
Organs can lawfully be purchased for research. A market for organs that can be donated by the living does not exist and is currently outlawed in the United States (and everywhere else except Iran). This should not be.
The thought of an exchange to buy and sell organs certainly has an “ick” factor, but the indisputable facts are these: There is an acute shortage of organs in America. This translates into over 100,000 people currently on a waitlist for a transplant; with ~5 needy people added each hour.
Worse, ~6,000 Americans die annually – and in our view unnecessarily - or ~17 everyday, waiting for an organ transplant. See the table below for a snapshot of mismatches for key organs:
Kidney: Demand (currently waiting) ~90,000 / Supply (transplants performed) ~25,000.
Liver: Demand (currently waiting) ~11,900 / Supply (transplants performed) ~9,200.
Heart: Demand (currently waiting) ~3,500 / Supply (transplants performed) ~3,800.
Lung: Demand (currently waiting) ~1,051 / Supply (transplants performed) ~2,524.
Source: organdonor.gov
Let us peel back the onion further and concentrate on the kidney: For a market to function efficiently, it must have an ample number of willing buyers and sellers. The overwhelming majority (~60%) of annual organ transplants is kidneys. This makes sense; of the ~100,000 Americans on the national transplant wait list, amazingly, ~85% of them need a kidney. And of the ~6,000 Americans who die each year waiting for organs, ~5,000 of them, or ~83%, perish waiting for a kidney.
That data is astonishing and highly supportive of a market-based approach to closing a gaping supply demand spread for this vital organ. Indeed, a free market for just kidneys would save the overwhelming majority of people who die waiting for organ transplants!
A surplus of kidneys already exists. Humans are born with two; but only need one to live. (A kidney transplant is performed when a patient has no functioning kidneys.)
According to healthline.com “Although most people have two kidneys, you only need one functioning kidney to live an active, healthy life… Most people with a single kidney live a normal life without developing any long- or short-term problems...”
At TQC, we advocate for a national kidney exchange. Individuals who need a kidney can bid to purchase one. Donors would need to be well informed. Although most people with one kidney live normal lives “the risk of developing mild high blood pressure, fluid retention, and proteinuria is slightly higher if you have one kidney instead of two…”
Donors who are willing to incur that risk in exchange for monetary compensation and part with a kidney can offer to sell theirs.
What is the “right price” for a kidney? We have not the slightest idea. The market would quickly figure that out. What is all but certain is that the wait list would vanish, donors would be well compensated, and ~5,000 American lives per year would be saved.
Good Livers
Liver transplants are much less common. And thankfully, the supply / demand metrics are better. Just over 9,000 liver transplants are performed each year vs ~11,200 people on the waitlist.
Nonetheless, a national liver exchange might also make sense. Perhaps surprisingly, a portion of a healthy liver can be donated by a living subject. This is possible in part because unbeknownst to most, the liver is the only human organ that can regenerate itself. However, currently only a tiny percentage of liver transplants are done using a section of healthy liver from a living donor.
A liver exchange whereby potential living donors could be compensated for donating (selling) a portion of their liver would certainly increase this number, as with kidneys vanquish the waiting list, and save lives.
Portions of the lung and pancreas can also be donated by the living. However, a market for these organs would probably not function well because the number of active participants would be too small.
Delineation
At TQC, generally we put our faith in the invisible hand – the market - and the “p” word, “price,” to channel scarce resources to where they can be utilized most efficiently and effectively. However, in atypical circumstances, a market-based system to allocate resources is inappropriate.
Specific to buying and selling organs, it is important to frame our argument in the context of and delineate between organs that can be donated by the living, and organs that become available only after somebody has died. While we are in favor of a market mechanism to match buyers and sellers of the former, we are against it for the latter for a litany of reasons. The most obvious being the person parting with their organ would die.
In theory, somebody could make an informed, objective choice to willfully forgo life to sell their heart (or another organ) in exchange for monetary (or other) compensation to their next of kin or a good friend. In practice, doing so would probably introduce too much room for coercion or sinister actions by unscrupulous people.
Regardless, even if a subject’s choice was completely independent of outside influence, psychologically, it is a hurdle that we simply cannot overcome. Hence, in our view buying and selling organs for transplantation that are accessible only after a donor has died - such as for a heart - should remain outlawed.
Pushback
Organs present a special case because there are pronounced ethical components when considering buying and selling them. Aside from utter shock, we suspect there will be two primary pushbacks to our arguments in favor of organ exchanges for kidneys and perhaps livers.
First, the poor would be taken advantage of. They would be more likely to sell an organ via either being duped and or because they are under financial distress. To make matters worse, they would be less able to afford to procure an organ should they need one. Second, criminals might impose their will on vulnerable subjects by means of coercion or fear of reprisal, force them to sell an organ, and pocket the money.
Retort
Regarding the first point of contention. That somebody is poor is mutually exclusive from them being able to make an informed decision. Furthermore, a financially disadvantaged person making the objective choice to sell an organ might provide a pathway into the middle class, extinguish debt, or provide funds for a down payment on a home, etc.
When markets function properly, they tend to be mutually beneficial. In this case, the recipient would live instead of die waiting. The seller would not be poor anymore (or be less poor).
Gestational surrogacy/surrogacy contracts are legal in most states (it is illegal in Nebraska, Michigan, & Louisiana) and offer a somewhat similar counterargument. Almost always, a wealthy woman (couple) who cannot carry a baby to term (or does not want to) or affluent men in same sex relationship pay a poor(er) woman to carry the baby to term and deliver it for them.
Carrying a baby for 9 months and birthing it takes a physical toll. Giving the baby back to the biological mother probably takes an emotional toll. That is why surrogates are almost always paid at least $50,000 and sometimes more than $100,000 for their labor, excuse the pun.
In the case of gestational surrogacy, adults enter into a contract on their own free will. The result is mutually beneficial. The buyer(s) gets a baby and the seller receives a lot of money. A market for organs would facilitate something analogous.
The point that an impoverished person in need of an organ would not be able to afford one is very fair and resonates much more with us. It would be unacceptable.
Indeed, just as we believe a market for organs would preclude someone from dying while they wait, we also believe that everybody who needs an organ should be able to afford to buy one on the exchange.
Private donations via well-known social media sites like Go Fund Me and especially existing organ charities would help fill the void. Government healthcare organizations could easily and should provide funds too. Whether they would is another question. Here we concede, our ideas scratch the surface at best and require more thought.
Pertaining to the second point of contention. In virtually every legitimate business vertical, there are criminals lurking, waiting to prey on somebody vulnerable. Start a unique business, somebody will figure out a new crime. To argue that Business X or Business Y should not be allowed to exist because it would introduce criminality is essentially taking the position that every new business that disrupts (and improves) the current way of transacting should not be allowed to form. That is ridiculous.
It would take a seriously depraved human being to force another person to sell an organ. There are not many, but unfortunately the odds those people exist are 100%. In our view, to all but eliminate the waiting list for organ transplants in America and save thousands of lives per year trumps the fact that a few very unlucky people would indeed be preyed upon if an organ exchange came to fruition.