What to do when the wait for a transplant can take seven years?

OPINION MAY 29, 2009 Bookshelf
Organs Needed, Supply Limited
What to do when the wait for a transplant can take seven years?
By EDWARD MORRISSEY
Wall Street Journal

More than 1,000 Americans die every year awaiting a kidney transplant. Surgeons in the U.S. perform about 7,000 of the transplants annually, but that doesn't come close to meeting demand: As many as 250,000 patients require kidney dialysis -- all of them subsidized by Medicare -- but half of them are deemed not sick enough to warrant referral to a transplant program. The wait for a kidney transplant from a cadaver-donor can take seven years.

I'm familiar with these statistics, and the wrenching stories they suggest, because my wife has lived in this precarious wait-and-hope world. She was the recipient of a cadaver-organ transplant, and twice in her life she was blessed with the unbelievable good fortune of receiving kidney donations from friends. Non-family donors are rare, and even within a family, as in our case, finding a good tissue match can be a challenge.

Desperation, then, can slowly seep into the wait for a kidney transplant. It was desperation that drove the ailing Larry Feldman and his cousin, writer Daniel Asa Rose, to break the rules. In "Larry's Kidney," Mr. Rose and his "black sheep" cousin travel to China to buy a gray-market organ in defiance of that country's ban on the sale of organs to Westerners -- and in defiance of mounting world-wide revulsion over China's practice of selling organs from executed prisoners.

Mr. Rose had sworn never to return to China after visiting it 25 years earlier on a travel-writing assignment. But he allows family bonds to trump his sour memories of the country's post-Cultural Revolution era and his own unease over the ethics of his cousin's proposal. Mr. Rose writes a gripping tale, especially notable for its revealing look at modern China. He is less successful at rationalizing the story's kidney-hunting angle. A central fact, after all, is unavoidable: More than two million Chinese need a kidney transplant -- and Larry isn't one of them. The author helps his cousin barge to the head of the line by using money and connections, all the while complaining about the inflexible American system.

I know how frustrating the process can be in the U.S., but I'm not convinced that the Chinese alternative is an improvement. Mr. Rose is told at the medical clinic where the transplant is performed that Larry's kidney came from a prisoner who committed heinous murders and deserved execution. But China also kills dissidents -- that's why its human-rights record as well as its transplant industry are criticized in the West. To Mr. Rose's credit, he notes that China outlawed transplants for Westerners in retaliation for that criticism -- but he seems to accept at face value the claim that Larry's kidney did not come from a dissident. He tries to wave away the ethical considerations by saying that saving his cousin's life was paramount, but ethics apply most when the questions get most difficult; otherwise, we're simply talking about etiquette. (Mr. Rose also never adequately explains why he himself didn't offer one of his own kidneys to Larry.)

Mr. Rose seems similarly naïve about how the two Americans managed to circumvent Chinese law. It isn't until the book's end that a Westerner living in Beijing enlightens him, pointing out that the waitress who volunteered as his guide was almost certainly a government spy assigned to keep an eye on him and to help with the organ-shopping once officials, for whatever reason, decided to look the other way.

Readers might find it difficult to forgive the murky doings in "Larry's Kidney" even if the trip was undertaken in the service of saving a secular saint, but Larry most decidedly doesn't qualify. He carries a gun and consorts with organized-crime figures back in the U.S.; in China, he picks up a mail-order bride in addition to a kidney. Salvation through organ transplant does nothing to redeem him, much to Mr. Rose's chagrin. For that reason, "Larry's Kidney" might be a good yarn but not a satisfying one.

The unwieldy kidney-donor system in the U.S. that drove Larry to seek help in China might be improved by the solution proposed by Dr. Sally Satel and other essayists in "When Altruism Isn't Enough." They present the case for paying live donors for kidneys. Compensation would dramatically increase the number of kidneys available, the writers argue, saving lives not just because more transplant operations would be possible but also because live-donor organs perform better than those from cadavers. Another advantage of paying for kidney donations would be a radical reduction in costs to Medicare and thus to American taxpayers. Estimates of the annual costs for dialysis treatment and care for end-state renal disease approach $20 billion.

How would a compensation system work? Dr. Satel considers both government and free-market options, but she and her contributors clearly favor the former. The federal government has the means and the incentive to drive down costs through compensation, either with cash or in-kind allotments such as college tuition or tax deductions.

As in "Larry's Kidney," "When Altruism Isn't Enough" faces a challenge in selling the ethics of what it describes. Would Americans accept the idea of paying for organs, especially if the market seemed to exploit the poor and the desperate? Dr. Satel makes a solid opening argument aimed at health-care and policy professionals, but more discussion is clearly needed. One point in her favor: Under Dr. Satel's scheme, donors, as well as patients, can live long and healthy lives -- far better than China's solution.

Mr. Morrissey writes online about politics and culture for Hot Air.

Larry's Kidney
By Daniel Asa Rose
(William Morrow, 305 pages, $25.99)

When Altruism Isn't Enough
Edited by Sally Satel, M.D.
(AEI Press, 228 pages, $25)

http://online.wsj.com/article/SB124355532423664661.html