Addressing the Shortage of Kidneys for Transplantation: Purchase and Allocation

[okarol]

Addressing the Shortage of Kidneys for Transplantation:
Purchase and Allocation through Chain Auctions
Lara Rosen
University of Wisconsin–Madison
Aidan R. Vining
Simon Fraser University
David L. Weimer
University of Wisconsin–Madison
Corresponding author: Professor David L. Weimer
Robert M. La Follette School of Public Affairs
University of Wisconsin–Madison
1225 Observatory Drive
Madison, WI 53706
E-mail: weimer@lafollette.wisc.edu
Key words: transplantation, commodification, organ donation, policy analysis, End-Stage Renal
Disease Program
Please do not cite or quote without permission.

Abstract
Transplantation is generally the treatment of choice for those suffering from kidney failure.  Not
only does transplantation offer improved quality of life and increased longevity relative to
dialysis, it also reduces End-Stage Renal Disease Program expenditures, providing savings to
Medicare.  Unfortunately, the waiting list for kidney transplants is long, growing, and unlikely to
be substantially reduced by increases in the recovery of cadaveric kidneys.  Another approach is
to obtain more kidneys through payment to living “donors,” or vendors.  Such direct
commodification, in which a price is placed on kidneys, has generally been opposed by medical
ethicists.  Much of the ethical debate, however, has been in terms of commodification through
market exchange.  Recognizing that there are different ethical concerns associated with the
purchase of kidneys and their allocation, it is possible to design a variety of institutional
arrangements for the commodification of kidneys that offer different sets of ethical concerns. 
We specify three such alternatives in detail sufficient to allow an assessment of their likely
consequences and we compare these alternatives to the status quo in terms of the desirable goals
of promoting human dignity, equity, efficiency, and fiscal advantage.   This policy analysis leads
us to recommend that kidneys be purchased at administered prices by a non-profit organization
and allocated to the transplant centers that can organize the longest chains of transplants
involving willing-but-incompatible donor-patient dyads.  1
Introduction
End-stage renal disease (ESRD) requires treatment either with dialysis or the
transplantation of a kidney to prolong life.  Most ESRD patients, when fully informed,
prefer transplantation to dialysis because it offers a higher quality of life, substituting the
complications of life-long use of immunosuppressive drugs for the physically and
emotionally debilitating sessions on dialysis machines.  Also, the medical (and real
resource) costs of transplantation are on average less than those of dialysis over the
patient’s lifetime.  Further, as the medical costs of dialysis and of the first three years
post-transplantation are covered by Medicare for patients of all ages, switching a patient
from dialysis to transplantation on average reduces federal expenditures.  Thus, kidney
transplantation offers higher quality of life, lower medical and social costs, and fiscal
savings.
The shortage of organs for transplantation strictly limits the opportunity for
realizing these gains in the United States.  The current waiting list for transplants has
more than 85,000 people, but donated organs allow only about 17,000 transplants per
year (see Figure 1).  While approximately 4,500 people die each year while waiting for a
kidney transplant, an additional 33,000 join the list.  If these rates continue, then the
length of the waiting list will grow.  Unfortunately, if the current epidemic of obesity
contributes to higher rates of diabetes and hypertension, which are important risk factors
for ESRD, then the number of people joining the waiting list each year will increase.
INSERT FIGURE 1 ABOUT HERE2
Kidney donations come from two sources: cadavers and live donors.  Currently,
about 60 percent of kidney transplants come from cadaveric donors, the vast majority of
whom suffer brain death within hospital intensive care units.  Many people signal their
intention to donate organs upon death, typically at the time they obtain drivers’ licenses. 
More commonly, next-of-kin authorize the donation for deceased who have not indicated
an intention to donate.  Indeed, the almost universal practice among organ procurement
organizations has been not to honor the intentions of the deceased to donate without the
approval of their next-of-kin. This practice has led many states to adopt first-person
consent laws and the creation of donor registries intended to force the honoring of donor
intentions.
A variety of initiatives have been undertaken to increase the supply of cadaveric
kidneys for transplantation. These include: the establishment of the National Minority
Organ/Tissue Transplant Education Program to increase the rate of donation by
minorities (Callendar et al. 2003); the formation of the Organ Donation Breakthrough
Collaborative with the goal of bringing the rate of recovery of organs in hospitals up to
the rates achieved by the most effective hospitals (Shafer et al. 2006); efforts to increase
the retrieval of organs from donors suffering from cardiac death as well as brain death
(Childress and Liverman 2006); making a second transplant waiting list available for the
so-called expanded criteria kidneys recovered  from older and sicker donors to encourage
their use (Schold et al. 2006); and the provision of financial subsidies to donor families,
such as contributions to funeral expenses in Pennsylvania (Ubel et al. 2000).  The
Institute of Medicine has also considered, but not yet endorsed, the recovery of organs
after cardiac death outside of the hospital setting (Childress and Liverman 2006).3
Although commendable and valuable at the margin, these efforts alone will not
prevent the waiting list from growing.  Of the approximately 2.3 million deaths annually
in the United States, only between 11,000 and 14,000 produce eligible donors under the
standard criteria currently employed (Sheehy et al. 2003).  Accidents, along with strokes,
are currently the primary causes of donor death, but the steady and substantial decline (22
percent) in highway fatalities since 2005 (NHTSA 2010) suggest that this source of
donors will decline in the future, exacerbating the gap.   
The 40 percent of kidneys transplanted from living donors come overwhelmingly
from family members or close friends, although they sometimes come from strangers
who answer appeals from ESRD patients or occasionally from so-called altruistic (“Good
Samaritan”) donors, who seek to make a non-directed donation to the waiting list, rather
than to a specific patient.  Because the presence of certain antigens accumulated over the
life courses of the patient and potential donor, they may be incompatible in the sense that
the patient’s body would reject the donor’s kidney so that the attempted graft would fail. 
Thus, some patients cannot accept kidneys from willing donors.   
In recent years two efforts have been made to get around the problem of willingbut-incompatible donors.  The first, paired exchanges, match incompatible pairs of
patient-donor dyads for which donations across the dyads are possible.  That is, the donor
from one dyad can and does provide a kidney to the patient in the other dyad and viceversa (Delmonico et al. 2004).  The second, chain exchanges, begins with a cadaveric or
altruistic live donation.  A kidney is first given to the patient in an incompatible dyad.  In
return, the willing-but-incompatible donor in the dyad donates to the patient in another
incompatible dyad.  This process can continue until no appropriate incompatible dyads 4
are available and the last donation goes into the pool of cadaveric donations.  Chains of
as many as thirteen transplants have occurred (Willingham 2009).  Currently, only
kidneys from altruistic live donors are being used to seed chains.
Despite these efforts to increase cadaveric and live donations, the shortage of
transplant kidneys is large and likely to grow.  What might induce considerably greater
supply that would reduce, or close, the gap?
Economists naturally think of addressing shortages through either the
establishment of markets where they do not exist or the perfection of markets that exist
but do not function well.  Well-functioning markets allow price to rise so that the gap
between supply and demand cannot persist.  A number of proposals focus on cadaveric
supply.  Along these lines, David Kaserman and A. H. Barnett (2002) propose a spot
market for cadaveric organs in which the next-of-kin of potential cadaveric donors would
negotiate a price with agents who would then sell the kidneys to the transplant system. 
Alternatively, Richard Schwindt and Aidan Vining (1986) propose a forward market in
which payments at administratively-set prices would be made now in return for a
commitment to donate in the future, after death.  These sorts of markets, or market-like
institutions, however, might not create substantially more supply of cadaveric donations
than the current system: the pure market system would likely interfere with the relatively
effective pure donation system already in place and the forward market would have a
limited impact because of the low probability, probably less than 1 percent, that the
contracted donor would die in the right way, in the right place, in a “timely” manner to
facilitate a donation.  This would result in a very low forward price.   5
Markets, or market-like institutions, that focus on procuring live kidney donations
almost certainly offer a larger potential for increasing supply significantly.  However,
markets involving live participants, which inevitably involve the direct commodification,
or monetization, of kidneys, have been largely ruled out by the overwhelming majority of
medical ethicists.  Mark Cherry (2005) has characterized this as a “global consensus” that
organ markets should be prohibited.  Aside from the concern with commodification itself,
which many see as an affront to human dignity, critics have voiced concerns about the
exploitation of the poor, the unfair advantage of the wealthy, the undercutting of altruism,
and, drawing on the study of blood donation by Richard Titmuss (1971a), a decline in the
quality of donated kidneys.  Cherry, however, along with a few other ethicists and
transplant professionals, has challenged the consensus on two grounds.  He challenges it
directly by emphasizing the human lives lost from prohibiting commodification and
indirectly by noting that the actual consequences of commodification depend crucially on
the institutional arrangements through which it is implemented.
In this article, we assess the direct commodification of live kidneys through their
pricing, which we will refer to simply as commodification.  We apply two important
concepts from policy analysis to assess the desirability of the commodification of kidneys
from live donors.  First, in contrast to many ethical treatments of the topic, we explicitly
recognize that there are competing values at stake.  Whether or not one ultimately
supports or opposes commodification, one should assess all the impacts in terms of
relevant social values.  Indeed, even within the conventional ethical analysis, a more
nuanced assessment of the bases for ethical concern help identify values that are
differentially affected by different mechanisms for commodification.  Second, also in 6
contrast to much of the ethical debate, we specify concrete alternatives for
commodification in sufficient detail to allow us to predict their consequences plausibly
and hence assess their implications for the promotion of social values.  Vague
institutional arrangements may allow a purely deontological assessment; they cannot
support a broader approach that predicts and values the consequences that are likely to
result.
We begin by unpacking the ethical arguments against commodification. We
attempt to show how some are relevant to monetary incentives to elicit supply and others
to pricing to allocate supply.  We then turn to the legal framework that currently prohibits
commodification in the United States.  After discussing the goals for assessing
commodification, we define several specific alternatives for commodification that differ
in terms of how they elicit supply, how they allocate supply, and the institutional
arrangements for reconciling these processes.  We conclude with an argument for a
specific alternative that involves a non-profit entity purchasing kidneys at an
administered price and allocating them through a bidding process in which the bids are in
terms of the length of transplantation chain that can be assembled.
Ethical Debate
The ethical debate surrounding kidney exchanges has been largely framed in a
simplistic two-sided manner: those against markets in organs versus those in favor.  As
James Stacey Taylor points out, however, “there is no such thing as the market for human
body parts” (2005: 16, original emphasis).  Kidney exchanges could be organized through 7
variety of different institutional arrangements, each of which would elicit different ethical
concerns.  For example, proposals for “mutual insurance pools” do not require that
organs be monetized, but rather that people exchange a commitment to donate upon death
in return for priority in allocation if a transplant is needed before death (Schwindt and
Vining 1998; Vining and Schwindt 1988)

for the complete article with figures and graphs go to http://users.polisci.wisc.edu/polphil/WeimerKidney_Commodification.pdf

[mcclane]

i know that there is a european country that has a mandatory organ donor thing, you specifically have to ask to not be an organ donor, if you don't ask they'll harvest any healthy organs upon death.

in north america, organ donation is not widely publicized nor is it on anyone's radar.  I believe that in n. america, we can all benefit from a mandatory organ donor program (yes i know that religious beliefs and ethics come into play).

Another hot topic is should those on death row be forced to donate ?  Ethics come into play here big time.  Would there be any doctors willing to perform the organ harvestation in the first place, since a doctor has taken a vow to save lives.  On the other hand, those that are facing death row are condemned by the state to die anyways. 

There really is no easy solution to transplantation.  I have conceded that i'll most likely wind up pushing daisies before i even make it to the top 1000 on the wait list.

[MooseMom]

I've always suspected that in the final analysis, economics (not necessarily profit, though, an important distinction) would dictate transplantation protocols.  It was just a matter of time, really.  The cost of dialysis is becoming prohibitive, and with more and more people headed to ESRD, people are going to start looking at cheaper treatment options.  We don't invest enough in preventative care, and the result of that will be more people on dialysis.  Neither taxpayers nor insurance companies are going to want to continue to finance growing dialysis costs when dialysis isn't even a cure.  I know transplantation isn't a cure, either, but for many patients, it is a least a cheaper treatment.

[mcclane]

I feel it comes down to how the public and the media view diseases, and what eventually happens is that diseases become prioritized.

Someone in another thread (general discussion ??) mentioned about breast cancer and asked if he could tack on kidney awareness.  Right now, all i see in the medica and advertisements is 'pink'.  I don't want to belittle breast cancer at all, however, kidney disease is non gender specific, it doesn't care of your skin colour is purple, orange or what not.

So what happens eventually is more research dollars are being poured into breast cancer while kidney treatment options and research is getting next to nothing in terms of money.

Plus, where the research dollars are means more researchers are put into that area.  If there is no research dollars, who is going to work pro bono ?

I work at a university, and the research that gets done focuses on cancer (in our faculty of medicine).  There is zero mention on kidney cures or alternative treatments to dialysis.  I also see alot of doctor's names as well (our health centre and university are linked).  I rarely see anything that has to do with nephrology.

Again, i feel it comes down to importance placed on a disease, and this importance is due in part to the media.

[MooseMom]

Agreed, mcclane.  ESRD isn't the Disease of the Week.  I am not generally an optimistic person, but I AM optimistic about new technologies and treatment protocols for kidney disease.  I read a lot of nephrology blogs online, and there is progress being made.

I personally feel that a lot of kidney disease is preventable, so I'd love to see a nationwide campaign focussing on prevention of hypertension and diabetes.

The cause of fsgs has just been discovered, so there is hope there.

It's hard to know whether to focus media attention on the drama that is transplantation or the trudgery that is dialysis.  Many renal advocates are miffed that there seems to be so much more attention on transplantation than on optimal (ie, more) dialysis, especially dialysis at home.  So even the renal community is split on this.

I think we can all do our part in raising awareness.  I took a real shot in the dark a couple of months ago.  You've read Robin Fields' ProPublica articles on the poor dialysis outcomes we get here in the US?  (Her articles are probably stickied on IHD somewhere.).  Well, I contacted both The Daily Show and The Colbert Report and suggested they have Robin Fields on their shows to talk about the state of dialysis.  I have no idea if my emails went directly to spam or not, but I took a chance, anyway.

Breast Cancer Awareness started as a grassroots movement, and perhaps we could do the same for CKD.  There are big renal advocacy groups all over the place, and I have to wonder why they don't do more to raise awareness. 

I still think that ultimately, providing dialysis to an ever expanding patient group will become too big of a financial burden, and that will be impetus enough to start finding some cures or something better and cheaper than dialysis as we know it today.

[mcclane]

Americans will benefit from the new technologies/treatments for kidney diseases first before it will ever cross the 49th parallel (ie. Nxstage), due to differences in laws and policies.

I wholeheartedly agree, high blood pressue is a crucial factor for chronic kidney disease (that is partly why mine gave up the ghost).

What I'm disappointed about is that I know of big name celebrities that req'd a kidney transplant (George Lopez, Steve Cojocaru - entertainment tonight), and they've not did any endorsements that i know of for organ transplantation.

Due to the fact that the hospital pays for all of my supplies, I never know the full cost or how much of a financial burden I am on our health care system.  But you are right, dialysis is expensive and due to the fact that dialysis is done everyday (or almost everyday), the numbers add up fast.