Why Selling Kidneys Should Be Legal

[okarol]

[my note: be sure to read the comments too]

December 5, 2011
Why Selling Kidneys Should Be Legal
By ALEXANDER BERGER
San Francisco

On Thursday, I will donate one of my kidneys to someone I’ve never met. Most people think this sounds like an over-the-top personal sacrifice. But the procedure is safe and relatively painless. I will spend three days in the hospital and return to work within a month. I am 21, but even for someone decades older, the risk of death during surgery is about 1 in 3,000. My remaining kidney will grow to take up the slack of the one that has been removed, so I’ll be able do everything I can do now. And I’ll have given someone, on average, 10 more years of life, years free of the painful and debilitating burden of dialysis.

If kidney donation is this easy, why do the stereotypes about heroic sacrifice persist? Part of the problem is history: before modern medical advances, organ donation used to be quite painful and dangerous. But organ donation advocates also deserve some of the blame. In a misguided attempt to make the families of brain-dead patients consent to the posthumous donation of their organs, advocates treat donors like saints. But deifying donors only serves to make not donating seem normal. When I first told some friends and family that I wanted to donate a kidney, they assumed I’d gone off my rocker. They saw it as a crazy act of self-sacrifice, rather than what it is — one of the many ways a reasonably altruistic person can help others.

This is a serious problem, because there aren’t nearly enough saints in the country to tackle the growing waiting list for a kidney. More than 34,000 people joined the waiting list in 2010; fewer than 17,000 received one. Thousands of people die waiting each year.

This is a tragedy, but it doesn’t have to be this way. The people waiting for kidneys aren’t dying because of kidney failure; they’re dying because of our failure — without Congress’s misguided effort to ban organ sales, they would have been able to get the kidneys they desperately needed.

It has been illegal to compensate kidney donors in any way since 1984. The fear behind the law — that a rich tycoon could take advantage of someone desperately poor and persuade that person to sell an organ for a pittance — is understandable. But the truth is that the victims of the current ban are disproportionately African-American and poor. When wealthy white people find their way onto the kidney waiting list, they are much more likely to get off it early by finding a donor among their friends and family (or, as Steve Jobs did for a liver transplant in 2009, by traveling to a region with a shorter list). Worst of all, the ban encourages an international black market, where desperate people do end up selling their organs, without protection, fair compensation or proper medical care.

A well-regulated legal market for kidneys would not have any of these problems. It could ensure that donors were compensated fairly — most experts say somewhere in the ballpark of $50,000 would make sense. Only the government or a chosen nonprofit would be allowed to purchase the kidneys, and they would allocate them on the basis of need rather than wealth, the same way that posthumously donated organs are currently distributed. The kidneys would be paid for by whoever covers the patient, whether that is their insurance company or Medicare. Ideally, so many donors would come forward that no patient would be left on the waiting list.

In the end, paying for kidneys could actually save the government money; taxpayers already foot the bill for dialysis for many patients through Medicare, and research has shown that transplants save more than $100,000 per patient, relative to dialysis.

There’s no reason that paying for a kidney should be seen as predatory. Last week, the Ninth Circuit Court of Appeals issued a ruling legalizing compensation for bone marrow donors; we already allow paid plasma, sperm and egg donation, as well as payment for surrogate mothers. Contrary to early fears that paid surrogacy would exploit young, poor minority women, most surrogate mothers are married, middle class and white; the evidence suggests that, far from trying to “cash in,” they take pride in performing a service that brings others great happiness. And we regularly pay people to take socially beneficial but physically dangerous jobs — soldiers, police officers and firefighters all earn a living serving society while risking their lives — without worrying that they are taken advantage of. Compensated kidney donors should be no different.

When I first heard about altruistic kidney donors, I, too, thought they sounded crazy, a little too good to be true. But two years ago, for a philosophy class I was taking, I read a paper that mentioned offhand how safe the procedure had become. I was intrigued, and the more I learned about how much it would benefit the recipient, the more reasonable it seemed.

I thought about going to a Web site where people who need a kidney post profiles, but I didn’t trust myself to pick fairly. Instead, the summer before my senior year of college, I filled out some forms on the National Kidney Registry Web site. The registry will use my kidney to start a donor chain: it will go to someone who has a willing but incompatible donor, who in turn will donate to the recipient in another incompatible pair, and so on indefinitely. This can be anonymous, but if my recipient would like to meet me someday in the future, I think I’d like to meet him or her too.

Soon after filling out the forms, I visited my doctor and told my parents about my plans. They were nervous, of course, and so am I. I’m not really looking forward to having surgery, or to taking time off from a job I love. But in the scheme of things, I know this is a relatively easy way to really help someone.

People should not have to beg their friends and family for a kidney, nor die while waiting for one. Donating a kidney is one way to help. But it isn’t enough. The only way to really change the terms of the debate and end the waiting lists is to end the ban on compensation and create a legal market for kidneys.

Alexander Berger is a research analyst for GiveWell, a nonprofit that researches charities to help donors decide where to give.

http://www.nytimes.com/2011/12/06/opinion/why-selling-kidneys-should-be-legal.html

[fearless]

I disagree with this article.  If donating a kidney paid $50K, there would most definitely be people donating only for the money.  Especially in such a desperate economy, I think this would be disastrous.  All it takes is one death of a person who "sold" their kidney, and the entire egalitarianism of organ transplant is lost.  The poor would be disproportionately donating, and whatever risks there are would likewise be disproportionately manifested among the poor. 

I admire this young man who has been inspired to donate anonymously, and I think his motivation for supporting "selling kidneys" is a genuine hope for improving the plight of people in kidney failure.  But I don't share his view.  Also, i would like to say God bless him and give him a long, happy, healthy life. 

[MooseMom]

Whenever I hear arguments against setting up a regulated market for selling organs, I am intrigued by this assumption that "the poor" will be somehow unfairly exploited.

I don't understand why as a society, we don't particularly care about the poor when it comes to providing access to affordable healthcare, making sure our schools are fully funded and ensuring that all people have enough to eat.  But oh no...we must protect "the poor" from being able to be compensated financially for donating a kidney.

I'd ask that two things be kept in mind.  Too many people are made poor by dialysis in that this time-consuming treatment robs people of their ability to work.  There is not enough time, money and effort to truly rehabilitate dialysis patients.  Clinics won't open every day of the week, and people can't work AND go to inclinic dialysis, and not everyone has access to home dialysis, so these people BECOME poor, but we're happy to exploit THEM.  Dialysis providers want to keep making the big bucks and won't spend the money to staff clinics so that people can have more dialysis, so who exactly is being exploited in this equation?  "The Poor" who are healthy have choices.  Dialysis patients who are impoverished by their disease and their treatment have few choices, if any, so again, who is it that is being exploited?

Second, I submit that in the US today, most of "the poor" have little if any access to good food and good primary healthcare, so this is the population that probably would not medically be eligible for donation, anyway, at least here in the US.  Potential donors must go through rigorous testing, and this would still be the case if we had a regulated market in this country. 

I don't understand why donation MUST be "heroic" or "saintly".  Why does financial compensation necessarily make donation any less of a gift?  I am not sure I would be less grateful to receive a kidney that was sold than one that was taken from a deceased person, all draped in another family's grief.

All of this assumes that any potential donor is FULLY INFORMED of all possible risks and receives all testing free of charge.  This also assumes that a person cannot sell a kidney to another particular person.  The recipient must also be protected; you don't want to have some stranger showing up at your front door saying that you have their kidney, so you owe them bigtime.

I guess I am just beginning to feel that this whole "exploitation of the poor" argument is bogus.  When I look around me and see what is being done to old, sick and poor people in the name of "cost cutting" and "balancing the budget", it strikes me as disingenuous.

The truth is that ill health and renal disease is disproportionately manifested among the poor.  But we don't seem to care that much about THAT.

What I would prefer to see is some other form of compensation for donating, like free healthcare for life for the living donor, or perhaps the same for the family of a deceased donor.

People will ask, "What's in it for me?", and that's not an unfair question.  Maybe we should have a more substantial answer than, "Oh, you'll be a hero."

[fearless]

MooseMom, two wrongs don't make a right. 

[MooseMom]

I'd like a more compelling argument than "the poor will be exploited."  I'd like to know just how this exploitation would take place, what form it would take.

There seems to be this vision of poor people selling their kidneys to rich people.  If you really want to prevent that from happening, then have a regulated market so that any black market activity would be discouraged. 

And before anyone pipes up with the "we aren't Iran" argument, I'd like to think that in the United States of America, we could come up with a system that would regulate a market so that NO ONE would be exploited and that EVERYONE would benefit from informed consent.  We have UNOS in place already, and I don't see what we can't use that as a foundation.

There is nothing that says that if we were to have a regulated market, no one would be allowed to be an altruistic donor.  If someone wanted to donate and didn't feel right about selling a kidney, they wouldn't have to.

Of course two wrongs don't make a right.  But using one monumental wrong to hide behind another isn't right, either.  It's hypocrisy.

Again, I would really like for someone to explain to me why kidney donation MUST remain altruistic. 

I am not wedded to my opinion, and I am more than open to contrary argument, but I have yet to hear something to persuade me.  I'd like to be persuaded because the way I see it, the lack of transplantable organs will remain an ever growing problem.  Dialysis will never get cheaper.  Making people have to beg their friends or family to donate, or making people have to wait for someone to die so that they may live seem to be morally and ethically suspect, too.

Again, I would sincerely be appreciative if someone could tell me why buying/selling a kidney in a tightly regulated market would reduce this precious gift of life to nothing more than a commercial transaction.  Anyone who really believes this can't truly appreciate what a remarkable thing a new kidney actually is.  If any of you were transplanted with a kidney from someone who, after rigorous testing and full informed consent, sold their organ, would you actually appreciate it less? 

I have read so many posts about the sadness and/or anguish recipients here on IHD have felt when transplanted with a cadaver kidney.  Some suffer with guilt.  And how many posts have we all read from IHD members who are crushed when they realize that none of their loved ones care to even be tested?  Why make people suffer more than they are already suffering?

I've asked a lot of questions here, and I am most eager to hear some answers.  Again, I am very open to persuasion.  Persuade me. 

[cariad]

I'd like a more compelling argument than "the poor will be exploited." I'd like to know just how this exploitation would take place, what form it would take.

MM, with respect, I reckon that you would not be asking these questions if you lacked the financial resources to pay for an organ. That right there should illuminate a bit of how the poor will be treated unfairly. Most of us cannot afford a kidney. So, I guess on this side of kidney failure, I would wonder why a wealthier person should be allowed to jump ahead of me. None of us asked for this.

I hope I can return to this discussion at a later date because I really do not have the time for it presently, so my thought may be jumbled. You've asked to be persuaded, but how can you persuade me that the poor will NOT be exploited? Think of the sex trade. We could wonder 'why does sex have to be altruistic?' and we could also say 'I need a more compelling reason than women will be exploited because I don't believe that will happen'. Ignoring Iran is ignoring the one living example that we have of a cash organ market - you cannot build a case without examining how this is playing out in other parts of the world.

If someone wanted to donate and didn't feel right about selling a kidney, they wouldn't have to.

Oh, MM, do you really and truly believe this? Can you not see how far outside reality this argument is? Women in legalized prostitution don't have to sell themselves either. Or do they?

As for people who accept cadaver organs and then feel guilty about it, I do not see this as a major, national health problem. They did not have to accept an organ and I suspect that most if not all come to terms with it in the end. Plus, we cannot compare the suffering of the recipient to the suffering of the poor in organ donation - these are two entirely different populations and two entirely different sorts of potential suffering. What about the person who pays for an organ and then finds out the donor did not want to do it and has now suffered organ failure or died because of this operation? That might be a much worse type of guilt. What I am hearing from the 'let's create a kidney bazaar' side is that 'well, I paid them, so you see, I'm buying off that guilt and sense of responsibility, and ta-da! It's gone!' This is straight from Sally Satel's playbook.

Imagine a giant sign hung over America reading 'we pay cash for organs'. All the regulation in the universe will not stop what happens next.

What do you do with the pair that have negotiated this contract, all parties are ready to go, then the donor has second thoughts and decides it will take more money for them to agree to go through with this? Do you let that person renegotiate? Do you force them to donate because they signed a contract? I am sincerely asking. What happens to cadaver organs when families see living donors paid for their contribution? Being saintly or heroic, those are your words. It has nothing to do with that. It has to do with only wanting to accept donors who are not making this decision under coercion and duress. If you think there will still be altruistic donors aside other than the very rare millionaire/billionaire, then I would strongly disagree with you. The evidence from the organ market is that the list disappears so those without money have no option and the donors are no better off financially in the long term. The latter seems to me to be common sense, as a one-time payment very rarely solves the underlying financial problem that would lead people to sell their organs.

If we are going to do a cash organ market for living donation, then why not start with liver? Those people have no other option. I would not agree with that either, but you have to admit that it carries more weight than 'I don't want to be on dialysis.' (Of course I understand the seriousness of this statement - I've done dialysis and it was miserable for me, but I did not have all of the information or options that exist today.) I know it sucks, but by the same token, we all have to admit that renal failure patients have it easier in most ways than people facing other terminal illnesses. We receive way more public resources than other conditions as it is. My cousin not only has inoperable brain cancer but had to wait the customary year before getting on Medicare. He had private insurance, lucky him. If we now make the argument that people in tough financial situations should just shut up and sell their organs, jesus, I cannot imagine the fallout. Probably along the lines of "you give them an inch, they'll take your kidney". I don't get how people can argue against the opt-out provision. Isn't this a logical first step?? It may not solve the problem entirely, but that is really no excuse to ignore a policy that would help.

Again, I would ask you to persuade me that the poor will not be exploited.

[Bill Peckham]

My complaint is with looking at this as strictly a kidney issue.

Kidney transplantation is not walled off from the rest of medicine. Change the structure of the kidney acquisition/transplant process, and you change the structure of medicine. Most particularly by paying for kidneys you change the system that has developed for the acquisition/transplant of other organs and tissues.

If a kidney from a living donor is worth $50,000, what's a postmortem kidney worth? How much for a postmortem liver? Postmortem donation of hearts, livers, lungs and all manner of other useful tissues rely on altruistic donation. If body parts become commodities what will it mean for all the people waiting for postmortem donations? I think the needs of people waiting for irreplaceable body parts (e.g. hearts, lungs, liver (mostly)) should be considered before the needs of those waiting for a kidney.

I've spoken to the relatives of postmortem donors, the ones who had to make the decision to donate, and asked how compensation would have effected their decision. The ones I've spoken to were repulsed by the idea. I don't think an altruistic donor system can coexist with a paid donor system, it's one or the other. We will lose more than we'll gain if we allow kidneys to be sold.

At the very least we should give first consideration to any impact on altruistic donation of irreplaceable body parts.  Kidney patients should not put their interests above the interests of others.

[MooseMom]

Firstly, I would rather see the implementation of an opt-out system, and I agree that this is the logical first step.  But there has been steadfast resistance to this.  I don't know why. 

Surely there are other ways to widen the kidney pool other than financial compensation, but I haven't seen evidence of any other than the introduction of ECD kidneys, and I don't know if offering non-optimal organs to already sick people is particularly ethical, but there you go.

Secondly, I do not advocate individuals being able to buy kidneys (I will not speak of other organs because you can't sell your own heart, for instance).  I would like to see at least reasonable discussion about having a central organization like UNOS be the "buyer".  Buying a kidney and getting someone off dialysis must surely be less expensive than keeping people on dialysis for a decade.  A patient shouldn't have to purchase a kidney, although said patient would still probably need to have the necessary financial resources to pay for the surgery and meds just like they have to have right now.

Thirdly, there are many poor women who are not prostitutes, so no, women do not have to be exploited.  They choose to be so if they enter the sex trade.  There are calls for legal prostitution that could protect women from exploitation from vicious pimps, but we choose not to because we get all moral and ethical about sex.  Same goes for something like marijuana.  We spend exorbitant amounts of money fighting a bogus war on marijuana because we equate its use with unethical, illegal behaviour, and otherwise innocent people get thrown into jail.

We need to be more circumspect with how we define "ethical" if we really want to avoid exploitation.

Fourthly, yes, I really and truly believe that no one HAS to sell their kidney or sell themselves for sex in a legal framework.  If a woman (or a man) does not want to become a legal prostitute, then they don't have to.  Why would they have to if they don't want to?  You can't be exploited unless you allow it.

Fifthly, by all means examine Iran, if only to know what to avoid.  Iran must definitely NOT be ignored.

Sixthly, if you want to start with the liver, that's fine by me.  If a person has a terminal illness that can be treated/cured by any sort of transplant that will leave a donor still in good health, then let's consider that, too. 

Seventhly (!), I would never say that people who are struggling financially should just "shut up and sell their organs".  Why would you even say that?

Eighthly, I can't pursuade you that the poor would not be exploited because I am having a hard time seeing where it would be always true that it would be.  With respect, turning the question around doesn't go toward answering.  "The Poor" is not some monolithic group to be treated like children who have no ability to make rational decisions if given all the information.  Like I've said before, I'd much rather see some other compensation, like free healthcare forever for donors and/or their families.  If we set up a system whereby people could exchange a kidney (assuming they are eligible medically to donate) for free healthcare for life, would that be defined as exploitation? 

Lastly, I will reiterate that I am NOT advocating the purchase of organs by patients.  With that, most of your argument is moot.

Remember, we Americans have soundly rejected the most obvious course of action, which is an opt-out system.  With that in mind, what do you think, Cariad, would be a workable solution?  What has been your own experience waiting on the cadaveric kidney waitlist?  While you were on the waitlist, did you ever think about what you would do to address the shortage of organs if you had all the reins of power?  What would you like to see happen, given the intransigence of Americans regarding this issue?

[MooseMom]

Bill, I agree that first consideration should be given to irreplaceable body parts.  My apologies if I sounded selfish.  I have been talking only about kidneys simply because that's where my life experience is, but yes, you are right.

I am sure you are right when you say that families who have chosen to altruistically donate organs from a deceased loved ones are repulsed by the idea of being financially compensated, but they would say that, wouldn't they.  These are people who are already of the mindset that they want to push through their grief and still find it in themselves to think of others, so they do not need financial persuasion.  If you want to increase the pool of cadaveric organs, is there really anything wrong with offering something in return to those families who may not think of donation?  It doesn't have to be a fee...maybe it could be a tax break or discounted healthcare or something!

Again, I don't want to see a free market in body parts, but you are not going to increase the pool of any organ by relying solely on altruistic donation.  If you believe that it can only be one or the other, ie only altruistic or only compensated, then think hard before you make that calculation.  More people than ever are needing organs.  Don't condemn patients to either certain death or life in a dialysis clinic before considering this very carefully.  If you want to continue to rely solely on altruistic donation, either living or cadaveric, then this problem will only grow while we sit around and debate "ethics" for the next 2 decades like we already have done.

Either that, or let's spend a LOT of money on biomedical engineering, ie, growing new hearts and new livers and new kidneys.  THAT's what I'd rather see, but don't expect any federal funding for projects like these.   I don't want a new kidney from another person either dead or alive.  I'd much rather have a new kidney that was bio-engineered or grown from my cells!  Dialysis and transplanation are sub-optimal in so many ways, but that's all we have, and we'd better find ways to make these treatments better/more accessible/more available because in the meantime, people are dying.  And the harsh truth is that all too many of these people who need new organs are poor themselves.

[cariad]

Thirdly, there are many poor women who are not prostitutes, so no, women do not have to be exploited. 

I did not say that all of them have to. Many would and do. Prostitution is legal in Vegas. It is regulated. It also leads to exploitation. In the book about the Mustang Ranch, the doctor who wrote about that place found that the majority were there because someone had sent them there to earn money.

Fourthly, yes, I really and truly believe that no one HAS to sell their kidney or sell themselves for sex in a legal framework.  If a woman (or a man) does not want to become a legal prostitute, then they don't have to.  Why would they have to if they don't want to?  You can't be exploited unless you allow it.

If this were true, no one would ever be exploited. Who wants to be exploited? Who would allow it? I think we just fundamentally disagree on this and will always be at an impasse.

Sixthly, if you want to start with the liver, that's fine by me.  If a person has a terminal illness that can be treated/cured by any sort of transplant that will leave a donor still in good health, then let's consider that, too. 

Live liver donation is not even on most people's radar. I don't know why. Yes, if we are going to do this, start there.

Seventhly (!), I would never say that people who are struggling financially should just "shut up and sell their organs".  Why would you even say that?

Because this is what will be said to the poor. I know you would not say that and was not suggesting you would. However, I can name a fair number of politicians who would use this as an excuse to cut programs.

Eighthly, I can't pursuade you that the poor would not be exploited because I am having a hard time seeing where it would be always true that it would be.  With respect, turning the question around doesn't go toward answering.  "The Poor" is not some monolithic group to be treated like children who have no ability to make rational decisions if given all the information.  Like I've said before, I'd much rather see some other compensation, like free healthcare forever for donors and/or their families.  If we set up a system whereby people could exchange a kidney (assuming they are eligible medically to donate) for free healthcare for life, would that be defined as exploitation?

Everyone should get free healthcare for life. Those who do not have to worry about free healthcare (the rich) would never donate under these conditions. That would only be appealing to the poor. Also, turning the question around is meant to show that you are asking for the impossible. You do not believe this will happen and are saying that we should persuade you. I did try to answer your question while also saying that your request to be persuaded is rather unfair.

Lastly, I will reiterate that I am NOT advocating the purchase of organs by patients.  With that, most of your argument is moot.

I totally disagree.

Remember, we Americans have soundly rejected the most obvious course of action, which is an opt-out system.  With that in mind, what do you think, Cariad, would be a workable solution?  What has been your own experience waiting on the cadaveric kidney waitlist?  While you were on the waitlist, did you ever think about what you would do to address the shortage of organs if you had all the reins of power?  What would you like to see happen, given the intransigence of Americans regarding this issue?

This is too huge of a question to tackle right now. I like the age-matching suggestion, but you seem to recoil at that one. I want to see opt-out. I want to see people persuade me that it would not help. If we say it must solve the issue or we won't do it, it will never be addressed.

By the way, I think I made many of the same points as Bill (maybe not as coherently), but you seem rather more aggressive in debating with me. I seem to have angered you along the way, so I apologise. This is just meant to be an intellectual exercise as I don't think either one of us has the world's ear currently.

[cariad]

Oh, but I agree with you on the marijuana bit, MM. But we both know which thread to go to if we want to continue to advocate for that....

[MooseMom]

Cariad, my apologies for sounding aggressive.  I didn't realize I was coming across that way.  I received some very distressing news yesterday and even more today, and I think all of that spilled into my response here on IHD.  It's not you, it's me.

I guess I can imagine some politicians try and tell people to sell their organs so that we can cut X program.  To be able to imagine that scenario tells you a lot about our politicians these days.

I agree that everyone should get free healthcare for life, but that is never going to happen.  As much as I would like to see it, costs are still soaring and there is no real incentive to reel them in, and we all ultimately have to pay for healthcare.  It can never be "free".  As the premiums go up and coverage diminishes, health insurance become a rarer and more valuable commodity, so it occurs to me that perhaps live donors or the families of deceased donors could be issued with a health care policy for life paid for by the state and underwritten by a company licenced in said state.  Each state could set up their own protocol with whichever limitations they deem appropriate.  Just an idea.

I was initially in two minds about the new UNOS allocation proposals, but the more I mulled it over, the more I realized that it is fair as long as it doesn't suddenly increase wait times for a particular age group.  I think it is entirely appropriate to want to match a 20 year old kidney with a 20 year old recipient as opposed to a 65 year old recipient, but I am not entirely sure that it is fair to make the 65 year old who has already waited 4 years wait even longer.  Perhaps that is where ECD kidneys come into play.  It is very hard to guess what will, in the long run, turn out to be fair and equitable.  It is hard to quantify someone's suffering, and I am not sure that a truly fair system will come out of algorithms.  But I do applaud the attempt.  But a rethink of the allocation process isn't going to enlarge the pool of organs; it is only going to get more years out of kidneys/organs we already have, and while that is certainly a good thing, the fundamental problem essentially remains.

I never got the impression that people thought an opt-out policy wouldn't help, rather, I always had the impression that there was this fundamental resistance to having to actually DO something to opt-out.  People seemed to really resent having to actively opt-out of the proposed program.  Perhaps I'm mistaken.

Again, I do apologize for my tone.  I enjoy these theoretical discussions and don't want to spoil them just because I'm having a very bad day.

[fearless]

FACT: "Diabetes and high blood pressure are the most common causes of chronic kidney disease".

These are the diseases of the working poor, who can't afford regular check-ups, and rely on fast, cheap food - loaded with refined carbs, sodium and calories.  It's true, as said in earlier posts, that the sick are already exploited (our GNP goes up every time someone gets cancer or goes on dialysis), and because these diseases have skyrocketed in the last few decades, so has the number of people needing new kidneys.

The best thing we can do to increase the rate of transplant for people who need one is try to increase the health of our general population.  By so doing, we would decrease the number of kidneys needed AND increase the pool of people who would be willing and able to donate.

[MooseMom]

The best thing we can do to increase the rate of transplant for people who need one is try to increase the health of our general population. 

Even better, this is the FIRST thing we should do!  I absolutely, wholeheartedly agree.  But how do we do that?  I was hoping that we could ensure that all people have access to primary, preventative healthcare free from point of purchase, but then that's decried as "socialized medicine", and we certainly can't have THAT.

One enormous obstacle is the food lobby.  Because federally funded school lunches are supposed to meet a minimum nutritional value AND since the food lobby is so influential, those companies make a lot of money from the frozen foods they supply to schools, and in their infinite wisdom, Congress has declared that pizza is a vegetable (because of the tomato topping) in order to allow the schools to continue purchasing crap food.  So instead of increasing the health of our general population, we start with the kiddos in an attempt to fill the ever-growing maw of the this particular special interest group, and any effort to have healthier kids is undermined from the very beginning.  No one seems to care about the future expense of having these kids grow up, develop hypertension and/or diabetes and then progress into ESRD. 

I've been seeing a TV add lately where there is this lady in the supermarket filling her cart with liter jugs of pop.  She goes onto say how unfair it would be to have the government tax soft drinks (a proposal that would begin to tackle the expense of maladies caused by ingesting massive amounts of sugar) and that the federal government shouldn't be telling us what we can and cannot drink.  So much for "personal responsibility".  We spend huge amounts of money on vitamins and diet plans while at the same time, we spend even more money on fast food and Big Gulps.  So, we don't take responsibility for our own health AND we don't want anyone telling us what to do AND we don't want to spend money on getting good food and good health care to everyone.  So what is left, realistically? 

[cariad]

I received some very distressing news yesterday and even more today, and I think all of that spilled into my response here on IHD.

Ack, I am so sorry to hear that, MM. Not what you need compounding an already stressful situation. If it would help to discuss it, you know your options....

I guess I can imagine some politicians try and tell people to sell their organs so that we can cut X program.  To be able to imagine that scenario tells you a lot about our politicians these days.

And sadly, politicians would not say it if it were not for what they perceive to be wisespread support for this. The argument these days seems to center around accepting responsibility for everything, including circumstances like being stupid enough to sign up for kidney failure, because that has got to be our own fault somehow. Not only should we let the hypothetical 30-year-old uninsured coma patient die, but we should demand that the poor exhaust ALL of their options before turning to anyone for help, and then they should only receive it at the largesse of a private benefactor, not on public expense. 

I agree that everyone should get free healthcare for life, but that is never going to happen.  As much as I would like to see it, costs are still soaring and there is no real incentive to reel them in, and we all ultimately have to pay for healthcare.  It can never be "free".  As the premiums go up and coverage diminishes, health insurance become a rarer and more valuable commodity, so it occurs to me that perhaps live donors or the families of deceased donors could be issued with a health care policy for life paid for by the state and underwritten by a company licenced in said state.  Each state could set up their own protocol with whichever limitations they deem appropriate.  Just an idea.

I hear you, but firstly, donors already receive tax breaks in wisconsin for donation. It is inadequate because it is a $10,000 deduction, not a credit, and if you don't earn a certain amount it is useless. I am all for making sure that no one pay to be a donor, but it would require a reimbursement system, not tax breaks. Like I was trying to say earlier, just try to propose that we have the government pay for kidneys on top of what renal patients already receive. I don't think that message will get us very far, but I have been wrong before. I am not ready to give up on the idea of universal healthcare, but once we get into a mindset of some sort of financial compensation for donors (not reimbursement) what if we do later pass universal coverage? Then the donors are back to receiving nothing. It would be a nice problem to have, I grant you, but I do think there is a psychology to this that will not be undone easily once we go down this path.

It is very hard to guess what will, in the long run, turn out to be fair and equitable.  It is hard to quantify someone's suffering, and I am not sure that a truly fair system will come out of algorithms.  But I do applaud the attempt.

I agree.

I never got the impression that people thought an opt-out policy wouldn't help, rather, I always had the impression that there was this fundamental resistance to having to actually DO something to opt-out.  People seemed to really resent having to actively opt-out of the proposed program.  Perhaps I'm mistaken.

I have heard that argument repeatedly, that it won't do much good because of the small number of transplantable organs that come available every year. Not much good is still more than no good. With paying for organ donors, I agree with Bill when he says that there is real harm that could come of this, and potentially little to no gain, or even a step backwards.

This relates to a discussion we had in Psychological Anthro, the issue of whether or not the poor are currently being exploited. Someone said that she did not think she should be coerced by public pressure into thanking soldiers because she did not agree with killing and the war in general. A veteran in the class mentioned that Vietnam veterans should be thanked, and in her mind the distinction was that they were drafted and current soldiers chose to go. Did they really have an honest choice? As I was addressing this (just for a quick rundown - enlisting in the military is a job in a rotten economy, it gives you free healthcare, you get housing assistance, it is a path to citizenship, you can have your education paid for,and probably more) the student who introduced himself as 'highly political' and who I saw at the Occupy protest was nodding his head so vigorously that I thought he might dislocate something. Let's face it, the poor overwhelmingly fight our wars and do the dangerous, messy jobs that no one else wants in this country, and now we are suggesting that they should sell us their organs as well. This is how this sounds to me.

I did ask my prof for any examples of anthropologists who believe that this would be a good idea, for the US to buy organs. He gave me a name, if I investigate and she has some good points, I will share.

[cariad]

The best thing we can do to increase the rate of transplant for people who need one is try to increase the health of our general population. 

Even better, this is the FIRST thing we should do!  I absolutely, wholeheartedly agree.  But how do we do that?

This is what Public Health is all about, and I am currently writing my Public Health paper/presentation on reducing incidence and prevalence of CKD. But it is most certainly a tangled web of factors and competing interests and I highly doubt I can do it much justice in a 10 page paper/15 minute presentation.

Oh, but here I thought I really couldn't learn anything major about CKD risk and last night in my research I read that acetaminophen accounts for almost 8% of ESRD cases. I was gobsmacked. I checked my bottle of acetaminophen and it only mentions liver, not kidney. I just sat in front of the computer thinking I must be reading this wrong. Acetaminophen is what transplant patients are told is safe, but this report said it was more dangerous from a CKD perspective than NSAIDs.  It found that aspirin comes with no increased risk of CKD. Aspirin, which I was told to never take because of the risk of stomach ulcer, especially for people on prednisone.

[MooseMom]

I, too, am really surprised by this news re:  acetaminophen and CKD.  Yeah, that is completely contrary to what I've ever been told.

Now Cariad, you've gone and raised and entirely new and interesting topic to this discussion, and that is about those with the fewest financial resources being largely the ones to serve in our military.  As for the whole organ donation topic, I hear what you are saying and I can't say that I disagree.  I don't like the whole idea of offering some sort of reimbursement/payment for donation, but I am not sure what else we can do to relieve the suffering of so many people.  I don't like the idea of anyone being exploited, but I also don't like the idea of people who have had the extraordinarily bad luck to suffer from diseases that could be treated with transplantation being burdened with more suffering than is necessary.  I just don't believe that relying solely on altruistic living or deceased donation will keep up with demand, so transplantation will end up being rationed even more severely than it is already, and you will be faced with decisions like, "Who deserves a kidney more...a child, or the single mother of a child with special needs?"  There are more slippery slopes than there are lighted pathways.

I guess we'll just end up going as we are going now, and more people will die.  Maybe the increased number of deaths of people waiting for organs will propel more funding into research for transplant alternatives.  Eventually, some venture capitalist will have a wife or a brother or a friend die while waiting for a new heart or a new kidney, and maybe s/he will funnel cash into more research into viable artificial or bio-compatible organs.  It won't be compassion that will be the impetus, rather, I'd bet that it will be loss, grief and frustration.  But a lot can be accomplished through these emotions. 

Anyway, as a Psychological Anthropologist, I'd love it if you could mull over a question I've had ever since I've returned to the US back in 2003.  There seems to be this over the top praise of "our brave men and women in uniform" every where you go, and if you don't give this praise in equally lavish terms, then you are seen as unpatriotic or anti-American.  You can't watch a sporting event without a flyover or without some other military presence, and I don't understand it.  We as a people have not been asked to sacrifice much of anything in this war that is protecting our way of life.  We tell ourselves that our soldiers are fighting ragtag terrorist groups in Afghanistan so that we can enjoy our freedom here on the other side of the world.  I can't help but suspect that we are elevating our military AND "the mission" because one percent of us are fighting and the other 99 percent are not, and largely, that fighting one percent are drawn from the more financially unstable part of our population.  So, we elevate them and praise them and use them as political and budgetary pawns out of a sense of collective guilt.

I can see how with this in mind, you suspect that we are using "the poor" to fight our battles for us and might thusly use them to supply our organs.  Yes, that is an analogy that I can understand.

So, bottom line question...do you think that we may feel a collective guilt about sending our younger and poorer to fight a battle with few rules, and that this is why we are so effusive in our adulation?

What do you think is going to happen to all of these soldiers now that they are returning home?  Do you think that the civilian population will be effusive with more than just thanks and praise, ie, will they offer jobs and other financial assistance and benefits, particularly in this time of high unemployment and savage budget pruning?  I'd be REALLY interested to hear your thoughts!  Has this come up in your class at all?

[Bill Peckham]

I think for me to be persuaded that an organ market is a good idea I would need to see much more thought given to how it would manifest. If this living donor kidney market is going to extended into post mortem organ procurement, as I think it would have to, then that must be the primary point of discussion. This kidney business is secondary.

$50,000 for a kidney, we're talking real money for two; the pancreas not to mention the heart, liver, lungs. What, a quarter million dollars? For a young, otherwise healthy individual. Let's walk through what that means, given what we know about humans, before we open the doors for business.

[MooseMom]

Yes, I would think that a market should extend to post mortem organ procurement, and I'm happy to have that be the primary point of discussion.

Walk us through it.

[cariad]

I, too, am really surprised by this news re:  acetaminophen and CKD.  Yeah, that is completely contrary to what I've ever been told.

Anyway, as a Psychological Anthropologist, I'd love it if you could mull over a question I've had ever since I've returned to the US back in 2003.  There seems to be this over the top praise of "our brave men and women in uniform" every where you go, and if you don't give this praise in equally lavish terms, then you are seen as unpatriotic or anti-American.  You can't watch a sporting event without a flyover or without some other military presence, and I don't understand it.  We as a people have not been asked to sacrifice much of anything in this war that is protecting our way of life.  We tell ourselves that our soldiers are fighting ragtag terrorist groups in Afghanistan so that we can enjoy our freedom here on the other side of the world.  I can't help but suspect that we are elevating our military AND "the mission" because one percent of us are fighting and the other 99 percent are not, and largely, that fighting one percent are drawn from the more financially unstable part of our population.  So, we elevate them and praise them and use them as political and budgetary pawns out of a sense of collective guilt.

I can see how with this in mind, you suspect that we are using "the poor" to fight our battles for us and might thusly use them to supply our organs.  Yes, that is an analogy that I can understand.

So, bottom line question...do you think that we may feel a collective guilt about sending our younger and poorer to fight a battle with few rules, and that this is why we are so effusive in our adulation?

What do you think is going to happen to all of these soldiers now that they are returning home?  Do you think that the civilian population will be effusive with more than just thanks and praise, ie, will they offer jobs and other financial assistance and benefits, particularly in this time of high unemployment and savage budget pruning?  I'd be REALLY interested to hear your thoughts!  Has this come up in your class at all?

A huge (but extremely interesting and challenging) question, MM. I most definitely think you are on to something. In discussing soldiers through a psychological antrho lens, we focused on trauma. The theory by the writer we were analyzing, Arthur Kleinman, was that we normalize trauma through courage, and that is one way that we collectively avoid addressing society's role in sending people off to commit atrocities. I thought of you whilst reading the book because Kleinman is both an anthropologist and psychiatrist, and he was my prof's advisor back in the day. The book is a collection of case studies. The two chapters that angered me focused on a man with chronic pain and a woman who had contracted AIDS. I said to the class that I found his conclusion hypocritical, because he selected two very unusual people who were finding not only great meaning but a type of salvation through pain and chronic illness. So, on the one hand he's condemning society for praising these soldiers while ignoring their suffering, but on the other he is talking about how the woman with AIDS transformed her life and changed from "a taker to a giver" to quote him. I think that does a real violence to people with chronic illness and pain - it is just more of "see, it's not all bad" and while I can usually wring something good out of every experience I've had, that should not stop people from recognizing how traumatic these experiences were and can be. Oh, and he wrote some crap about how chronic pain could be interpreted as having an ulterior motive, and while he was tripping all over himself saying that he knows there are many who are just brought low from pain and illness and there is no gain at all, I really think the suggestion was a stretch at best, ignorant and damaging at worst.

So I said all of this, and then..... the prof ended the discussion and the course for the term. It was a bit bizarre. But hey, I had to say it or my head was going to explode.

I have the book on my NookColor and it has the Lend Me feature. I have no idea how that feature works, but if anyone is interested in reading it, I would be happy to attempt to pass it along. It's short and the analysis is pretty light.

Your specific question about what will happen when the soldiers return home did not come up in class. I think the small gestures and the public displays of praise will continue. I think that especially while the economy is so awful, most soldiers will really struggle to find employment, but I do not know. I think the adulation is more a reaction to the aftermath of Vietnam. Whenever I see someone thanking a soldier, I see it as saying "Look, I get it. We let the soldiers down after Vietnam, but I am not like that."  I was trapped in an elevator with an older man and a kid wearing an ARMY t-shirt at Northwestern once. The man really wanted to go through this ritual in front of me. He asked the kid if he was in the army and the kid said no. Rather than just say 'oh, just wondering' the man went on and on about how he was going to thank him if he was a soldier. Yeah, but he just said he wasn't, so does this conversation really have to last through 19 floors? That poor kid was obviously uncomfortable because he could not get out of this weird, pseudo-thanking conversation. It was a spectacle and one I got to bail on because my stop was first. I suspect that kid (who was probably 16 tops) will think twice before wearing that t-shirt again.

I think that woman in class who spoke about not wanting to thank soldiers had a point. It's not a popular point at the moment, but it was important to her to voice it. The trauma in this book came from being placed in situations where you did not have the authority or ability to follow your own morals and you were forced to do things that you knew were unethical but were a matter of survival or similar.

[cariad]

Oh, and here is a free copy of the acetaminophen article. It takes a fair amount to be dangerous, although not outside the range of what some people probably use. The fact that it is worse than NSAIDs is the real shocker to me.

http://www.nejm.org/doi/full/10.1056/NEJM199412223312502

Click on PDF on the right sidebar to see the entire article.

[MooseMom]

"...we normalize trauma through courage."  Oh, that caught my eye.

Do you think assigning the label "courageous" to someone who has suffered a trauma is our way of wanting to ward off trauma to ourselves?

When my son was very young, he started out in mainstream school.  It was immediately obvious that something was "wrong" with him; this was before he finally got a formal diagnosis.  Stories about his behaviour naturally travelled from his schoolmates to their parents, and there were many times when, while standing out in the schoolyard waiting to collect our respective kids, kind and well-meaning moms would tell me how "brave" I was.  One, I wasn't sure how having a child with an as-yet undiagnosed disability made be brave, and two, it just wasn't true.  I was scared to death, and I'm STILL scared to death.  But I was struck by how important it seemed to be to these moms to call me "brave" because it was usually followed by something along the lines of, "I don't think I could cope with that."  It was all code for, "This is happening to YOU because YOU are brave, but I do not claim to be brave, so this will not happen to ME."  I am always interested in this apparent need for people who are not living through pain or trauma to use words like "brave", "courageous" and "hero" to describe those who are.  Why do you think this is?

I have a Nook Color, too, and would be interested in borrowing the book.  I've never used the Lend Me feature, either, but would be happy to look into it in the near future.  I'm reading the third book of "The Song of Ice and Fire" series at the moment and don't want to spoil my current literary mood with case studies that might make me mad.

[cariad]

"...we normalize trauma through courage."  Oh, that caught my eye.

Yeah, I should have put that in quotes. It is Kleinman's wording, or very close. I, too, think he scored with that phrase.

Do you think assigning the label "courageous" to someone who has suffered a trauma is our way of wanting to ward off trauma to ourselves?

When my son was very young, he started out in mainstream school.  It was immediately obvious that something was "wrong" with him; this was before he finally got a formal diagnosis.  Stories about his behaviour naturally travelled from his schoolmates to their parents, and there were many times when, while standing out in the schoolyard waiting to collect our respective kids, kind and well-meaning moms would tell me how "brave" I was.  One, I wasn't sure how having a child with an as-yet undiagnosed disability made be brave, and two, it just wasn't true.  I was scared to death, and I'm STILL scared to death.  But I was struck by how important it seemed to be to these moms to call me "brave" because it was usually followed by something along the lines of, "I don't think I could cope with that."  It was all code for, "This is happening to YOU because YOU are brave, but I do not claim to be brave, so this will not happen to ME."  I am always interested in this apparent need for people who are not living through pain or trauma to use words like "brave", "courageous" and "hero" to describe those who are.  Why do you think this is?

I have a Nook Color, too, and would be interested in borrowing the book.  I've never used the Lend Me feature, either, but would be happy to look into it in the near future.  I'm reading the third book of "The Song of Ice and Fire" series at the moment and don't want to spoil my current literary mood with case studies that might make me mad.

I'll have to come back to the rest of this when I get a chance. It is an interesting topic. The offer for the Lend Me book does not expire, so if/when you want to give it a go, just contact me.

[okarol]

I think for me to be persuaded that an organ market is a good idea I would need to see much more thought given to how it would manifest. If this living donor kidney market is going to extended into post mortem organ procurement, as I think it would have to, then that must be the primary point of discussion. This kidney business is secondary.

$50,000 for a kidney, we're talking real money for two; the pancreas not to mention the heart, liver, lungs. What, a quarter million dollars? For a young, otherwise healthy individual. Let's walk through what that means, given what we know about humans, before we open the doors for business.

The costs would be $50,000 if you have a PPO, $500 if you have Medicare. 

[Rerun]

Why not get the rich people off the list and then the poor would have a shorter wait time.  Have both.  The rich can pay for their kidney and I can wait in a shorter line.  Geez what is so hard about that.

I play Mega Million twice a week waiting for my kidney.  Too bad someone in the United States will lose out on $50,000 because I'm going to go help some "poor" person in the Philippines.  HA HA   

MM I agree with YOU!