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Mar 20, 2008

Organ Sales and Moral Travails: Lessons from the Living Kidney Vendor Program in Iran

Nephrologist Dr. Benjamin E. Hippen critically examines the legal market for kidneys in Iran.

Kidney transplantation in the United States is burdened by a terrible policy failure. The

cost of this failure will be paid in the currency of years of human lives unnecessarily

lost, as well as a massive increase in federal expenditures over the next decade and beyond.

The number of patients with end-stage renal disease (ESRD) in the United States has grown,

but the supply of kidneys—for the preferred treatment for ESRD, kidney transplantation—has

not kept pace with the demand. Unfortunately, the issue is not simply one of supply and

demand: in the United States the supply of kidneys for transplantation is kept artificially

low by a prohibition on the sale of human organs.

If a decade’s worth of reports in the transplant literature are to be believed, only one

country in the world does not suffer from an organ shortage: Iran. Although Iran clearly

does not serve as a model for solving most of the world’s problems, its method for solving

its organ shortage is well worth examining. Organ donation is ubiquitous throughout the

world, but Iran is the only country that legally permits kidney vending, the sale of one

individual’s kidney to another suffering from kidney failure.

After a critical examination of what can be learned from the Iranian experience that will

help the United States solve its organ shortage, certain conclusions seem inevitable: The

portion of the National Organ Transplant Act of 1984 which prohibits the sale of organs

should be repealed. The savings that will likely accrue should be spent on long-term study

and maintenance of the vendor system and on the creation of mechanisms to ensure fair

trading. Finally, because so much is still unknown regarding how organ sales would work in

the United States, individual transplant centers and organ procurement organizations should

be permitted to experiment with how to implement a system of organ vending.

Entrenched health care policies can cost lives. Nowhere is that more evident than in a

comparison of the government policies on renal replacement therapies for end-stage renal

disease (ESRD) in the United States and Iran. While many Iranians in the past suffered

greatly for their country’s lack of ESRD policies, thousands of patients in the United

States continue to suffer today.

Political and financial realities in the United States and Iran directly influenced the

availability of scientific developments which changed ESRD from a fatal diagnosis to a

chronic disease. Dialysis was developed in the United States in the 1960s, but this

life-saving therapy was expensive and scarce.1 The first successful kidney transplant in the

United States was performed in 1951.2 In Iran, the first successful renal transplant took

place in 1967. Still, without reliable, effective immunosuppressant drugs, dialysis remained

the only reasonable alternative for many patients with ESRD until the early 1980s.4 Both the U.S. and Iranian governments paid for dialysis while continuing to develop transplant

options. In the United States, dialysis became the first fully funded Medicare health

benefit; a diagnosis of ESRD and a modest contribution to social security tax revenues is

all that is required to qualify for the entitlement, regardless of age or financial status. But the expense of dialysis, the economic collapse in Iran

following the 1979 revolution, and the expense of the subsequent protracted conflict with

Iraq encouraged the Iranian government to pay for transplantation as soon as

immunosuppressant drugs made it a viable alternative to dialysis.

The Iranian government paid for its citizens to have transplants abroad, while the United

States entrenched itself in its existing dialysis reimbursement policies. In 1972 a hearing

before the House Ways and Means Committee was enlivened by the performance of a dialysis

treatment before an audience of duly impressed legislators. This event was compelling enough that within weeks the Social Security Act was

amended to provide a full Medicare-funded entitlement for dialysis therapy. Then, in 1984,

an overzealous entrepreneur testified before Congress that he was planning to import

impoverished denizens from developing nations, remove their organs, transplant them into

American patients, and then return the “donors” to their homelands with a pittance to show

for their efforts. A horrified Congress passed the National Organ Transplant Act, including

a prohibition against “knowingly acquir[ing], receiv[ing], or otherwise transfer[ring] any

human organ for valuable consideration for use in human transplantation if the transfer

affects interstate commerce.” Two decades later the United States and most of the world is

still laboring under the ill-conceived notion that the sale of organs should be prohibited under all circumstances, and the number of people dying

on dialysis while waiting for an organ that never comes continues to steadily increase.

Meanwhile, in 1988 Iran began providing remuneration for unrelated donors, and its list of

patients awaiting transplants steadily decreased.

The contrast in the policies of the two countries is reflected in the stark differences in

the number of patients on dialysis, waiting for a kidney, and subsequently dying. In the

United States alone, 341,000 patients suffering from ESRD were dialysis-dependent in

2005—triple the number in 1988.12 Current estimates vary, but that number is expected to

grow to between 400,00013 and 520,00014 by 2010 and to approach 525,00015 to 700,00016 by

  1. Today, in the United States, more than 73,000 people are waiting for a kidney

transplant from a deceased donor, and by 2010, the waiting list is expected to grow to

nearly 100,000. In Iran, the waiting list for kidneys was eliminated in 1999, 11 years after

the legalization of organ vending, and for the past 8 years, Iran has had no waiting list

for kidneys. By contrast, since 1999 more than 30,000 U.S. patients with kidney failure have

died waiting for an organ that never arrived.

In addition to thousands of lives unnecessarily lost, another dimension of the U.S. ESRD

policy is the staggering cost to taxpayers. The cost of the ESRD entitlement grew to more

than $21 billion in 2005, nearly 6.5 percent of the Medicare budget, and was spent on behalf

of 0.6 percent of eligible Medicare beneficiaries in 2005.20 Of that $21 billion, only $586

million was spent on kidney acquisition and transplantation. The perversity of this vast

disparity in relative funding for dialysis and transplantation is compounded by the fact

that kidney transplantation confers a significantly improved quality and quantity of life

for nearly every category of patient with ESRD: The median survival rate for a new

dialysis-dependent patient is 35 percent after five years, compared to a 75 percent survival

rate after kidney transplantation. In short, kidney transplantation represents the best form

of renal replacement therapy for the vast majority of patients with ESRD and at a fraction

of the cost of dialysis. The extent of the U.S. policy failure with respect to ESRD is only

beginning to be fully realized, but some adverse consequences are already apparent:

  • Demand for renal replacement therapy escalated following the passage of an open-ended and

ballooning federal entitlement.

  • A perverse financial incentive favors dialysis over transplantation despite the manifest

medical superiority and relative cost-savings of the latter.

*The disparity between the demand for and supply of kidneys continues to grow.

*And, the death rate for individuals waiting for deceased-donor kidneys is increasing.

This Policy Analysis provides a critical overview of the 20-year-old Iranian system that has

legalized the purchase of kidneys from living vendors. Common criticisms of the Iranian

system are scrutinized with an eye toward understanding what the United States can learn

from the Iranian experience, incorporating what works, and improving what either does not

work or might not work, with special attention paid to the problems that Iranian transplant

professionals have identified as avenues for improvement. The Iranian system is far from

perfect, as Iranian transplant professionals are the first to admit. But a comprehensive

examination of the Iranian system suggests the United States can learn a great deal from the

Iranian experience. Many common objections to a market for organs in the United States are

not sustainable, and existing problems with the Iranian system can suggest alternative

solutions to the current deceased donor and dialysis system in this country.

How the Iranian System Works

Insofar as the kidney procurement system in Iran can be characterized as a “market,” it is a

highly standardized and regulated market with only modest room for negotiation. Once

potential kidney recipients are identified, they are evaluated by kidney transplant teams,

including transplant nephrologists and transplant surgeons. Recipients are counseled that it

is in their best interest to identify a biologically related living donor. If no

biologically related living donor is available or willing to donate, the recipient is

referred to the Dialysis and Transplant Patients Association. From there, disposition of the

recipient depends on whether the transplant center has an active deceased-donor program. For

example, at a major university hospital in Zhiraz, which has an active deceased-donor

program, recipients referred to DATPA must generally wait six months for a deceased-donor

kidney (though some recipients elect to circumvent this requirement by traveling to Tehran

for transplantation). If the recipient does not receive a transplant from a deceased donor

after six months, DATPA identifies an immunologically compatible kidney vendor for the

recipient.

DATPA is staffed by volunteers with ESRD and receives no remuneration for matching kidney

vendors with recipients. Neither the transplant center nor transplant physicians are

involved in identifying potential vendors. Instead, vendors express their own interest in

participating by contacting DATPA. Once identified, vendors are referred to the transplant

center and evaluated according to the same medical standards applied to living donors who

are not financially compensated, including the evaluating physician’s right to use his

medical discretion to veto a vendor’s candidacy.

Vendors are paid in two ways. First, the Iranian government provides a fixed compensation to

the vendor of approximately $1,200 plus limited health insurance coverage, which currently

extends to one year after the exchange and covers only conditions deemed related to the

surgery. Second, the vendor receives separate remuneration either from the recipient or, if

the recipient is impoverished, from one of a series of designated charitable organizations;

this amount is usually between $2,300 and $4,500.30 The amount and source of the second

remuneration is arranged beforehand by DATPA. It is important to note that noncitizens are

not eligible to participate in the Iranian organ procurement system as either vendors or

recipients. As with dialysis, the Iranian government assumes the cost of treatment,

including the kidney procurement, transplant surgery, immunosuppression medications, and

postoperative care of the vendor and recipient. Thus, while the Iranian market in organs is

heavily regulated, it does allow people to receive several forms of compensation for their

organs, including financial compensation.

Unlike the rest of the world, and the United States in particular, the Iranians have found a

way to solve their organ shortage; and although their market system is not without problems,

it clearly has advantages over other organ procurement systems, primarily that thousands in

need do not die while waiting for a compatible donor.

Merits of the Iranian System

Permitting legal organ vending has brought the greatest benefit: By 1999 the waiting list

for kidney transplants in Iran had been eliminated, a success no other country can claim.32

In addition, the Iranians have found a way to minimize the potential negative impact of

financial incentives. DATPA serves as an alternative to the for-profit organ brokers who are

such a pernicious feature of illegal organ trafficking in other countries. Exchanges by

freelance brokers (particularly where legal protections against coercion or fraud are inconsistently enforced) can create incentives for both the broker and the

vendor to be untruthful if disclosures might thwart the exchange. For example, if a vendor

has a communicable infectious disease, or has kidney disease, there are clear disincentives

to identify, discover, or disclose such facts in a system that does not enforce organ

brokerage contracts. The Iranian system addresses this problem by making the intermediary a

nonprofit, patient-run service organization that trades on the moral commitment of patients

to help others in a position similar to their own. That, in turn, provides as powerful a

motivation to avoid harmful practices as a system that consistently and strictly enforces

laws against coercion and fraud, which redounds to the benefit of vendors.

The Iranian not-for-profit, charity-based system also provides a convenient intermediary

between the organ vendor and the patient or transplant center, thus mitigating a host of

potentially difficult, moral conflicts of interest. Separating the role of identifying

vendors from the role of evaluating their medical, surgical, and psychological suitability

permits transplant professionals to avoid confusing judgment on a vendor’s candidacy with

various financial and professional incentives to perform more transplants. Without dwelling

on which potential conflicts of interest might evolve into actual conflicts of interest, it

is clear that systemwide separation between identifying and screening potential vendors has

the advantage of reducing potential concerns.

The Iranians have eliminated their waiting list for kidneys by allowing a limited market in

live-donor kidney vending, and in so doing they have discovered a way to minimize some of

the perceived dangers of such a system. With DATPA acting as intermediary, the Iranians have

reduced the possibility that organ vendors will be taken advantage of by either overzealous

middlemen, procurement institutions, or physicians desperate to help their patients. Despite

those successes, however, the Iranian system is not without problems.

Concerns with the Iranian System

Both proponents and opponents of kidney vending from the living have reason to be skeptical

about the veracity of outcomes reported by Iranian transplant professionals. Precautions

must be taken to carefully parse out sound conclusions from those that lack sufficient

evidence. Both proponents and opponents share valid concerns regarding safety and the lack

of information on longterm outcomes for vendors. Furthermore, the vast political, cultural,

and religious differences between Iran and the United States might make in-depth comparative

analyses of little value. But, given that thousands of Americans die each year waiting for a

kidney, rejecting the Iranian system out of hand, and without careful analysis, is

ill-advised. While the Iranian system may not be as successful as that country’s transplant

professionals claim, concerns voiced by opponents of kidney vending are typically predicated

on opposition to organ vending in general rather than any specific concerns about the

Iranian system in particular.

Vendor Organs, Donor Organs: A Closer Look at Recipient Outcomes

The outcomes for recipients of organs from vendors do not appear to be as good as outcomes

for recipients of living donor organs, with at least one report of a 10-year organ survival

of 44 percent for recipients of organs from living vendors, compared to a 10-year organ

survival of 53 percent for recipients of organs from living donors. When compared with

outcomes from living related donors in Iran, however, this difference did not reach

statistical significance. Why might outcomes not be as good for recipients of organs from

vendors? One explanation can be found by examining the socioeconomic demographics of kidney

vendors in Iran. In the available literature on the subject, there is widespread agreement

that the majority of vendors are “poor.” Although this term is often used imprecisely

(sometimes it is undefined, but sometimes it denotes living at or below the poverty level in

Iran, which means an income of less than $5 per month), there is little reason to doubt the

general truth of the assessment. In the United States, some evidence suggests that low

socioeconomic status alone is a predictor for the development of kidney disease. That is not

to say that being poor somehow causes kidney disease, but low socioeconomic status may

predict exposure to a host of environmental factors (particularly infections) which can

increase the risk of developing kidney disease. If kidney vendors in Iran are

disproportionately poor, then as a group they are quite possibly more likely to have

subclinical kidney disease at the time of their kidney vending. In addition, they may be

malnourished or suffer from other conditions which make them a less than ideal source of

kidneys. That might also account for the slightly lower organ survival rate in recipients

from impoverished donors.

What Happens to Organ Vendors?

The most contentious disagreements in the literature regarding kidney vending in Iran have

to do with the personal, physical, and financial consequences for vendors themselves. This

issue is complicated by an absence of routine follow-up. Still, the hypothesis that the

long-term health of vendors is adversely impacted is plausible, since such a conclusion

would logically coincide with the slight trend toward worse long-term outcomes for

recipients of transplants from kidney vendors.

Since there is no central repository of outcome data for recipients, donors, or vendors in

Iran, the information available to outsiders consists of what is published in the medical

literature and anecdotal evidence provided by those who live in or visit Iran. Conceivably,

both the reassuring and the worrisome reports on vendor outcomes are true, with each report

accurately reporting facts in different geographic areas. Absent a system of routine vendor

follow-up, just how to integrate reports and popular accounts remains an open question.

While the lack of accurate data justifies concern, it does not justify abandoning the idea

of organ vending. The solution is to carefully monitor outcomes and adjust the vending

system or, if need be, abandon it should results prove unacceptable.

Does a System of Organ Vending Undermine Deceased Donation? Not in Iran

William Harmon and Francis Delmonico have charged that the number of kidneys procured “per

million population” in Iran is lower than in countries without remuneration policies. Since

deceased donation was not really feasible in Iran until 2000, such claims are misleading. In

2000, the Iranian parliament made organ retrieval from deceased donors possible by

legislating the acceptance of a cessation of brain function as death instead of accepting

only heart-lung criteria. Once this legislative commitment was made to respond to cultural

and religious concerns regarding donation after death, the number of kidneys from deceased

donors increased significantly. Neither the donor’s estate nor the families of deceased

donors receive payment for these kidneys. At least in Iran, the concern that a system of

compensating living vendors inevitably renders a system of unpaid deceased donation moribund

is unsupported by the evidence.44 Lastly, whether Iran obtains as many kidneys per million

population as other countries is simply irrelevant. Quite apart from whether Iran has not

procured the same number of kidneys per million population, the evidence shows that Iran has

procured enough kidneys to eliminate its waiting list, a claim that no other country, and

particularly no “donor-only” country, can even begin to approach.

Living Organ Donation and Living Organ Vending: Not Mutually Exclusive

Admittedly, the kidney vendor program in Iran has resulted in fewer kidneys procured from

biologically related donors, than from living vendors; however, that does not necessarily

mean that altruistic donations have dropped. Despite a flourishing kidney vendor program,

biologically related donation has consistently constituted 12–13 percent of all donated

kidneys, and that fraction has persisted in tandem with the rapid rate of growth in kidneys

procured (without compensation to the donor’s estate or family) from deceased donors. While

a great many recipients choose to purchase a kidney from a living vendor through DATPA, in

2006 some 28 percent of recipients did not do so. That raises a troubling problem for

critics of the Iranian system, and of a market for kidneys more generally. The Iranian

system, as any market-based system for organ procurement would do, permits, but does not

require, altruistic donation. A market permits recipients and potential donors/vendors to

choose whether they prefer remuneration or more altruistic rewards. The data from Iran

suggests that allowing remuneration does not discourage those who believe altruistic

donation is the only acceptable option from continuing to donate or receive donated organs

exclusively.

It is not at all clear that “donor-only” policies encourage altruism. In donor-only

countries, like the United States, identified donors are free to refuse to donate, but they

do so with the clear understanding that their designated recipient may be significantly

disadvantaged and perhaps die waiting for a kidney as a consequence of their decision. Under

such conditions, at least some donors surely choose to prevent that consequence by donating.

Even so, that shouldn’t be interpreted as fostering altruism. Donations motivated by

familial or social pressures, or profound feelings of guilt, are hardly the hallmarks of

altruistic action. In Iran, however, biologically related potential donors who choose not to

donate can make that choice without jeopardizing the health of their relative, because in

Iran it is easier to obtain a kidney from other sources than it is in countries where organ

vending is not permitted. In this sense, a market for kidneys serves to clarify altruistic

choices. As Tibor Machan has argued, when acts of altruism are permitted but not required,

choosing to act altruistically is correctly understood as acting above and beyond the call

of duty, and thus accrues additional moral credit in ways that merely meeting moral

obligations does not.

Are Organ Vendors Coerced into Selling Their Kidney?

Paying for kidneys is not “coercive,” as opponents of the Iranian system often claim. A

preponderance of evidence confirms that kidney vendors in Iran are disproportionately (more

than 70 percent in every available survey) impoverished—by nearly any definition of the

term. But whether remuneration of kidney vendors in Iran is therefore coercive is not as

self-evident as the critics suppose—though obviously much turns on what is understood in

labeling an offer coercive. The broader the concept of what constitutes a coercive offer,

the narrower the range of noncoercive choices available. Stipulating that the range of

options open to poor people is generally more limited than the range of options open to the

well-off, the question is this: Are all offers made to impoverished persons coercive, or

only some? If all offers made to the impoverished are coercive, this leads to the

counterintuitive conclusion that no choices made by impoverished persons are uncoerced,

and thus there is nothing morally unique about offering them remuneration for their organs.

A charitable offer, or the offer of employment, to an impoverished person would be coercive

in exactly the same way, in that circumstances coerce the person into accepting a gift or a

paying job. However, if some offers are coercive and some are not—and the coercive nature of

an offer is morally relevant—then some defensible distinctions must be drawn between

coercive and noncoercive offers.

It is useful to compare the offer of remuneration for an organ with other options available

to impoverished vendors, and to consider whether organ vending is somehow uniquely coercive

in a way that (for example) the offer of charity or the offer of a paying job is not

coercive. Voluntariness is antithetical to the concept of coercion, and an offer cannot be

coercive if the relationship is initiated by the person in danger of being coerced. In Iran,

vendors present themselves voluntarily to DATPA for consideration based on general knowledge

about the option of organ vending. The Iranian system specifically prevents physicians in

need of an organ for a particular patient from initiating organ vending. More expansive

interpretations of coercion would apply, equally and unfavorably, to offers such as a

charitable gift or a menial job, which are not typically thought to be coercive. If those

examples are judged coercive, then perhaps the same can be said of the psychological

pressures inherent in currently acceptable methods of soliciting organs for donation.54 In

short, any claim that offers to impoverished organ vendors in Iran are inherently coercive

bears the burden of explaining what makes an offer to vend uniquely coercive and other

offers relevantly less so.

The Best of Both Worlds: Learning from the Iranian Experience and Moving toward Solving

the Organ Shortage in the United States##

Taking into consideration the concerns described above, the United States can learn

important lessons from Iran. Seven such lessons make clear that organ vending is a

remarkably effective means of eliminating a country’s organ shortage. The only plausible

explanation for Iran’s accomplishment of eliminating its waiting list for kidneys is its

system of organ procurement from living vendors. Twenty years of experience with organ

vending in Iran has demonstrated that a vendor system can exist in harmony with both a

living-related-donor program and a flourishing deceased-donor program. Far from restricting

access to transplantation to the well-off, access to organs in Iran is possible regardless

of the recipient’s ability to pay. In addition, the Iranian system has spared that country

the atrocities that accompany gray-market organ trafficking, a practice made possible only

because desperate recipients from countries such as the United States have no recourse to a

legal market in organs.

More Organs from All Sources

Presumably, altruism could persist and even flourish alongside a kidney market in the United

States as it does in Iran. Contrary to critics’ assertions, the Iranian model of kidney

vending does not preclude either living or deceased donation, as demonstrated by stable

rates of biologically related living donation, as well as escalating rates of deceased

donation. Deceased donation would and should continue in the United States as it does in

Iran. Some have raised the concern that the introduction of market mechanisms would result

in lower rates of procurement from living and deceased donors, a claim unsupported by the

evidence. The donor system, whether relying on living or deceased donors, permits

individuals who are morally committed to donating (not selling) their organs to do so.

Recipients with moral objections to receiving an organ purchased from a vendor need not pay

for that decision with their lives. Instead, those recipients can request that they only

receive an organ from a donor; and donors who plan on donating at death can stipulate that

their organs may be procured only if they are not subsequently sold. If a vendor market in

the United States can be as successful in reducing demand as it has in Iran, the recipient

pool for deceased donors would be far smaller than it is today, making the actualization of

the moral commitment not to receive an organ from a living vendor less likely to be a fatal

decision.

Minimizing Risks to Vendors

In the United States, a market approach to kidney procurement could function far better than

the Iranian system by working to ensure optimal outcomes and minimize risk for vendors and

recipients alike. If the long-term outcomes of organ vendors are formally included as a

moral and financial responsibility of the vending system, then market forces will minimize

costs by selecting a vendor population with the lowest risk of developing social or physical

complications after the exchange. There is a growing consensus throughout the transplant

community regarding standards for evaluation and care of the live organ donor. That is the

obvious starting point for generating analogous standards for the live organ vendor. The

government’s financial interest in identifying a vendor population at lowest risk of short-

and long-term complications after organ procurement overlaps with the obligations of

transplant professionals to minimize the risk of harm to vendors. In turn, the obligation

not to harm vendors suggests that standards for choosing vendors should be more stringent than current standards for living donors. Furthermore, in a vendor

system, an increased potential pool of organs from the healthiest vendors should reduce

pressure on transplant professionals to consider living donor candidates of questionable

medical acceptability. The hazardous temptation to balance the ongoing suffering of a

recipient with the sheer determination of a living donor to donate regardless of the risks

to themselves would be sharply reduced in a vendor system. For all the well-founded concerns

about safety, a properly constructed vendor system would quite probably be safer for all

parties compared with the current system.

Good Outcomes for Vendors Have Moral Value and Market Value

The moral value of safe practices can be traced to the general obligation of a physician to

avoid doing harm to patients. For both donors and vendors alike, providing a clear,

evidence-based understanding of the long-term risks of exchanging a kidney are paramount for

achieving authentically informed consent. The market value of safe practice has many facets.

First, a system where the safety of vendors is given priority offers the stability and

reproducibility necessary for fostering trust. Second, a safe system minimizes adverse

outcomes by definition, which results in lower expenditures on the consequences of adverse

outcomes. Consider that, in the United States, the vast majority of people with moderate

kidney disease do not live long enough to develop kidney failure because any degree of

kidney disease significantly accelerates the progression of heart attacks and strokes.

Kidney vendors with undetected, preexisting kidney disease or risk factors for kidney

disease are likely to develop the attendant cardiovascular complications of reduced kidney

function and, by extension, incur considerably higher health care expenses. Thus, a system

that selects as organ vendors those individuals least likely to develop short- and

long-term complications is most likely to reduce overall health care expenditures. In this way, moral obligations and market

pressures to maximize cost-efficiencies intersect when the safety of organ vendors and organ

recipients is a priority.

The United States Has the Infrastructure to Adopt the Best Aspects of the Iranian

System###

In the United States, no institution precisely compares to the Iranian DATPA. But organ procurement organizations (OPOs) have served basically the same function for procuring and

distributing organs from deceased donors, so the responsibility for identifying and

screening living organ vendors can reasonably be assigned to OPOs. OPOs in the United States

have cooperative relationships with individual transplant centers, limited to the

identification and procurement of organs from deceased donors. Living donors are typically

identified and evaluated by individual transplant centers. Individual centers provide the

counseling and disclosures necessary for informed consent without the involvement of the

OPO. In Iran, a clear division of labor exists between the DATPA and transplant centers,

with the former identifying potential organ vendors and referring them to transplant centers

for medical and surgical evaluation.

A similar division of labor would make sense in the United States for several reasons.

First, making OPOs, not transplant centers, solely responsible for identifying and screening

potential organ vendors would mirror OPOs’ current role in deceased donation. That would

limit the burden on OPOs to assimilate new responsibilities beyond their traditional areas

of technical expertise. Second, the responsibility for the medical and surgical evaluation

of organ vendors would lie with transplant nephrologists and transplant surgeons, where it

belongs. Third, this division of responsibilities would mitigate potential conflicts of

interest between the competing goals of increasing rates of organ procurement and ensuring

safe practices in the screening and approval of potential organ vendors. OPOs can be offered

incentives for correctly identifying appropriate candidates for organ vending; and conflicts

of interest which might encourage the approval of inappropriate candidates can be mitigated

by offering very different incentives to transplant nephrologists and surgeons. The

incentives for OPOs should be geared to maximizing the supply of organs, but the incentives

for physicians should be directed toward maximally ensuring the safety of organ donors and

organ vendors alike.

Parallel Charitable Structures Could Develop

In the United States, multiple institutions could develop to support a system of organ

vending. In Iran, compensation for vendors comes from a variety of sources including

charities and the DATPA, which is run by volunteers who match vendors with recipients. As

indicated in the previous section, the United States could more feasibly rely on existing

infrastructure to distribute organs, rather than try to emulate the Iranian DATPA.

Nevertheless, the creation of alternative mechanisms for identifying potential vendors and

paying their fees should not be discouraged.

One of the great strengths of the American social and economic structure in general is that

it permits economic, government, and charitable institutions with overlapping goals to

coexist. As H. Tristram Engelhardt has argued, one virtue of markets is that they permit

persons with diverse and conflicting moral views to cooperate in limited ways with others

who agree with them. The same can be said of charities. Since charitable organizations exist

primarily to advance a particular moral vision, different charitable organizations could

help find vendors for and from within their specific moral community.

Organ vendors motivated by more than mere self-interest might actualize multiple moral goals

with assistance from such charities. Different charities might be devoted to advancing a

plurality of moral visions: one might be dedicated to improving access to transplantation in

a geographic area; another to members of groups disproportionately affected by kidney

disease such as African Americans; another toward encouraging organ allocation to

individuals in need, independent of other considerations. Charities could even spring up to

promote organ donation, dedicating funds to defray financial disincentives to organ donation

such as lost wages from time away from work and travel expenses, or to broadly publicizing

appeals to particular moral communities on behalf of a member in need. Far from appealing to

an abstract concept of organ vendors as interested only in financial gain, parallel charity

structures would permit vendors, recipients, and entire moral communities to cooperate in

finding ways to end the organ shortage.

Caveat venditor? Avoiding Bad Outcomes for Vendors

If a regulated system of kidney vending were observed to routinely reduce vendor well-being,

that would be cause for moral concern. The concern would arise not because the impoverished

are unable to make choices which might entail bad outcomes, but because the impoverished,

like the rest of us, are ostensibly less likely to make bad choices if the consequences are

known in advance. If an offer is attractive only because its manifestly unattractive

features have been deliberately concealed, then the offer is predicated on deceit, and the

vendor is a victim not of coercion, but of fraud.

The evidence reviewed here does not support the contention that kidney vendors are coerced,

nor that an offer of compensation for kidneys in any way constrains a vendor’s autonomy.

However, it may be the case that kidney vendors in Iran suffer reduced well-being often

enough to warrant closer scrutiny of how vendors are selected. Several studies reporting

outcomes from kidney vendors in Iran support that concern. As previously discussed, reports

on the social and economic consequences of kidney vending in Iran vary from the reassuring

to the dire, with no dispositive means to discern which reports are closer to the truth, or

indeed whether both accounts are accurate. Given the lack of dispositive evidence, the

United States should track long-term vendor outcomes in case unanticipated negative side

effects arise from permitting the sale of organs.

Registries, Lifelong Health Care Coverage, and Medical Judgment

Reforms advocated by Iranian proponents of their own system of organ vending overlap with

safeguards included in organ market proposals for the United States. Both advocate a

registry for vendors and donors, as well as lifelong health care coverage, to more clearly

define the short- and long-term consequences of exchanging a kidney;66 and both reserve the

right of transplant professionals to veto a vendor’s candidacy based on medical judgment

alone.

To ground generalizations about long-term outcomes of donors and vendors in verifiable fact,

any organ vending system should track the medical, surgical, psychological, and

socioeconomic consequences of both organ donation and organ vending. The most obvious way to

do this would be to provide lifelong, comprehensive health insurance to living donors and

vendors, perhaps making it a mandatory benefit of any privately arranged organ vending

agreement. As Arthur Matas and Mark Schnitzler have shown, the cost savings to the

government of paying for transplantation instead of dialysis are vast.68 Thus, it might be

both cost-effective and morally salutary to compensate vendors with regular tax-free

deposits into personal health savings accounts, which vendors could use to purchase

comprehensive insurance coverage from private insurers. Private insurers, in turn, should

have an interest in providing health insurance to rigorously screened vendors. If vendor

screening is such that organ vendors, as a group, can part with a kidney and suffer even

fewer short- and long-term complications than donors, vendors as a group would be

attractive to insurers from an actuarial standpoint.

The lessons learned from the Iranian system of organ vending suggest several potential

hazards that need to be taken into account. First, physicians have an obligation to avoid

cooperation with vendors if the vending system regularly and predictably results in the

reduced well-being of kidney vendors. Whether this will be the case in the United States is

unclear, but the possibility certainly exists. Iran has avoided the problem by having the

DATPA arrange recipient/vendor matches. Second, the government has a fiduciary obligation

not to permit a program of kidney vending if a significant number of vendors suffer from

serious complications, including but not limited to an increase in kidney disease. It is

unclear whether the Iranian government is meeting that obligation. The U.S. government

should monitor outcomes right from the beginning to make sure serious complications are

identified and avoided. And third, kidney vending must routinely provide mutually beneficial

exchanges;70 otherwise, fostering such exchanges constitutes moral complicity with unfair

arrangements. The degree to which these hazards apply to the current system of kidney

vending in Iran is not known. Regardless, a system where these concerns, when identified,

are systematically managed, minimized, or eliminated is clearly preferable.

First Steps toward a System of Organ Vending in the United States

A system of organ vending in the United States, informed by the Iranian experience, will

entail several reforms. To be successful, such reforms must allow room for experimentation

with various types of vendor arrangements while simultaneously ensuring the fairness of

those arrangements. No single success or failure should define the acceptability of a market

approach to organ vending. Many options may need to be tried and, with time and careful

study, a fair and equitable market approach to solving the organ shortage should be

possible.

Legalize Organ Vending

A straightforward repeal of Section 301 of the National Organ Transplant Act,71 which

proscribes the exchange of “valuable consideration” for organs, would be the most effective

first step toward establishing a comprehensive system of organ vending in the United States.

A more feasible but politically difficult first step would be for Congress to allow

exemptions from Section 301 of NOTA to permit pilot programs in organ vending. However,

whether or not such programs proved successful could depend on many variables. For example,

a pilot program might increase the number of organs without fulfilling other obligations to

organ vendors, inviting unflattering comparisons to underground organ trafficking. Or a

program might be successful in one community but ineffective (or inappropriate) in other

communities. An incentive program that works in Chicago might not be nearly as effective in

Poughkeepsie. By extension, a single program which fails to increase the number of organs

should not lead to the conclusion that all incentive proposals are certain to fail. For

these reasons, a straightforward repeal of Section 301 would be preferable.

Use the Savings Wisely

By making use of existing institutional structures such as transplant centers and OPOs, the

maintenance costs of a vendor market would be much lower than for dialysis, and efforts

should be made to use the surplus wisely. The vast expense of dialysis means that the amount

of money potentially available to pay vendors and still break even is quite high (by some

estimates, more than $100,000 per vendor). Thus, a successful vendor market will probably

reduce government expenditures significantly compared to the current system. At a minimum,

the financial liabilities to a vendor market would include maintaining a registry, paying

for health coverage for donors and vendors, making up the additional operational costs to

OPOs for identifying and screening vendors, and funding oversight of various incentive

programs to ensure that mechanisms for safe practices and long-term follow-up are in place.

At least some of the surplus (if any) from a vendor program should be set aside to maintain

the solvency of funds dedicated to paying for the long-term medical obligations to vendors.

Create Mechanisms to Ensure Fair Trading

The legalization of organ vending cannot be an invitation to anarchy. Legal organ vending

requires adapting existing infrastructure to ensure “mutual gains through trade,” by

prioritizing the safety of all parties, and to successfully increase the number of available

organs. These goals can best be achieved by legislative and court action affirming an

individual’s property right in their own body and ensuring that fairly executed contracts

for organ vending are upheld. To help ensure fairness, laws might require lifelong health

coverage for donors or at least some direct payments into an individual health savings

account delineated for purchasing comprehensive health insurance only for the designated

vendor. To encourage vendors to follow up with a physician over the long-term, deposits to

the health savings account could be amortized, contingent upon the vendor making follow-up

visits at specified intervals. Such restrictions are justified by the fact that the

government has a direct financial interest in ensuring that vendors are at minimal risk of

developing short- or long-term complications after the exchange. Similarly, tying incentives

for organ procurement organizations and transplant physicians to the correct identification

and assessment of low-risk vendors, rather than to the absolute number of vendors approved,

merges the moral obligations of transplant professionals to minimize harm with the economic

interests of the government to avoid the costs of paying for the consequences of injury.

Let a Thousand Flowers Bloom

Since the constraints on a proposed vendor system in the United States are modest, and the

effectiveness of various incentives must be empirically validated (in the form of both

increasing the number of transplantable organs and documenting long-term outcomes of vendors

and recipients), individual transplant facilities and OPOs should be permitted to fashion

their own vendor systems, subject to modest oversight. There is little reason to suppose

that a given package of incentives offered to residents of New York City will appeal equally

to individuals in Charlotte, Chicago, or Houston. Permitting diversity in structure

encourages innovative approaches, which in turn offer communities and vendors a panoply of

incentive options, though each set of options should include safeguards for all parties. So

long as incentives are successful, and the proper safeguards are in place, the specifics

become less important.

Conclusion: Solutions Instead of Sermons

Despite vast cultural and political differences between Iran and the United States, much can

be learned from the Iranian system. A review of 20 years of experience with a living organ

vendor system in Iran reveals successes, deficiencies, and ambiguities. Each of those

aspects is instructive for demonstrating what an organ market can be, as well as what it

ought to be. If there is a salient irony in the debate over the moral defensibility of the

Iranian system, it is that American critics seem disappointed that the Iranians did not

follow our lead. But carrying this reasoning to its conclusion would entail admitting that

in so doing, Iran would have also incurred our current shortage of organs, our waiting list

mortality, and our consequent moral complicity in sustaining an international market in illegal organ trafficking. If the discussion of kidney

markets in this country can progress beyond preconceptions as to what can and cannot work,

in Iran or elsewhere, to an examination of the example of Iran based on the evidence, that

will be a significant step in the right direction.

[“Organ Sales and Moral Travails: Lessons from the Living Kidney Vendor Program in Iran”](http://www.cato.org/pub_display.php?pub_id=9273 ““Organ Sales and Moral Travails: Lessons from the Living Kidney Vendor Program in Iran””) was originally published as The Cato Institute’s Policy Analysis No. 614. This article has been edited and, for stylistic reasons, references within the article have been removed. To view the article with documentation, please visit the original source.