Posted on Sat, Sep. 21, 2002 Miami Herald
BY JOHN DORSCHNER
[email protected]
http://www.miami.com/mld/miamiherald/4125034.htm
Michael Ritchie, 45, has spent two months ''hooked to a lot of machines'' in a Jackson Memorial Hospital bed, waiting for a new heart. ''I have faith in the Lord,'' he says, ``and I have faith in my doctors.''
The problem is that no one has faith that enough people will donate their organs to keep people like Ritchie alive.
The shortage of available organs is so severe that some experts are proposing a radical solution: paying for organs -- giving money to the relatives of the recently deceased.
The hope is that the move would help the 80,000 people waiting for transplants. That's up from 20,000 in 1990. Last year, 6,238 Americans died while on the transplant waiting list, and many more became so sick that they were removed from the list before they died.
At present, paying anything for organs is illegal, and many transplant surgeons think payment is morally wrong. But as the waiting list has lengthened, a growing segment of the medical establishment is willing to at least explore the idea.
This summer, delegates of the American Medical Association voted to support a study to see whether payments would ease the shortage. Several bills in Congress propose changing the 1984 law that forbids payments for organs. ''The organ shortage we are experiencing is not mandated by nature,'' writes David L. Kaserman, an economist at Auburn University and the recipient of two kidney transplants. ``Rather, it is the outcome of a myopic public policy.''
UNMET NEED
While many disagree with him, the United Network for Organ Sharing, which keeps the waiting list for transplants, says it is an ``undeniable fact that the current system, despite 30 years of experience based on altruistic donation, has yet to meet this need.''
Kaserman wants to know what is un-American about paying for a heart the way one would pay for a car. If there is a shortage of cars, you give an incentive to manufacturers to produce more by raising the price.
''I don't tell a surgeon how to operate,'' says Kaserman, who this summer co-authored a book, The U.S. Organ Procurement System: A Prescription for Reform. ``I don't know why a doctor would tell an economist what's right. A shortage is by definition an economic demand that's not being met -- a difference between supply and demand.''
Kaserman's book, published by the conservative American Enterprise Institute, has a two-tiered proposal. The more radical would be a pure free-market system, in which families could auction organs to the highest bidder and brokers could then resell them to whoever paid the most -- similar to the black-market system that now operates quietly around the world.
''The medical community is still very much opposed to that,'' Kaserman says. It's also opposed to paying live donors for a kidney. The implications of a poor person endangering his health for a few thousand dollars are too distasteful.
What is gaining support is Kaserman's second proposal: paying a small fee to the family, with the organs then going to one of the several dozen nonprofit procurement organizations around the United States.
The nonprofits are tied to the United Network for Organ Sharing, which would continue to maintain the waiting list based on medical criteria, not wealth or fame.
Others think it's not that simple.
''The downside is it opens the process to undue influence, if not downright corruption,'' says Ken Goodman, director of the bioethics program at the University of Miami.
Selling organs to the highest bidder could lead to the rich living by buying up all the available kidneys, livers, hearts and lungs while others die. It could also lead to the poor being persuaded to risk their health by parting with a kidney or a slice of their liver -- the two organs that live donors can part with.
''I can see the slippery slope,'' says Sister Kathleenjoy Cooper, 61, of St. Raphaela's convent in North Miami-Dade. She has been waiting for a kidney for four years, but she is opposed to buying organs. ``I don't want the United States doing what they're already doing in other countries.
''That could lead to the poor being exploited for their bodies. Or it could lead to that murky line about being brain-dead'' -- speeding a declaration of death in order to harvest organs.
THIRD WORLD SALES
In fact, in poor countries around the world, including Iraq and India, sales of organs are already occurring -- generally by poor men willing to give up a kidney for as little as $1,000. Kidneys are the main black-market organ because they are needed by more than half the people on the waiting list, and because most patients don't trust the quality of organs taken from cadavers.
The shortage exists because transplants have become much safer -- and therefore possible for more people -- since the first successful transplant in 1954.
Much of the success is due to improved drugs that stop the body from rejecting another person's organ. More than 85 percent of patients now survive the first year. For kidney and pancreas patients, it's 95 percent.
Last year, 24,000 transplants were performed in the United States, and while the number waiting for transplants has increased 400 percent since 1990, donations from cadavers have increased only 32 percent, according to the United Network for Organ Sharing.
The problem is that only 1 percent of the dead are potential donors.
Those whose bodies have wasted away slowly with disease can't be used. Surgeons need people who die suddenly, as in an accident, and have healthy organs.
It used to be that cadaveric donors had to be younger than 50. Then the limit was raised to 55, and finally removed. ''There's no cutoff in age,'' says Andreas Tzakis, director of liver and gastrointestinal transplants for the University of Miami. ``We've used the liver of an 87-year-old.''
MULTIPLE BENEFITS
Theoretically, a single body could save up to seven lives -- two kidneys, two lungs, one heart, one pancreas, one liver -- but the practical maximum is three or four.
That makes organ donating a huge gift, and for years, the medical community has tried to drive that point home while urging people to put ''organ donor'' on their driver's license and explain their decision to relatives.
Still, only two out of five eligible cadavers are used as donors.
''Americans don't want to think about dying,'' says Anne Paschke, spokeswoman for the organ sharing network, ``so they don't think in advance about donating.''
''It's not against the tenets of the major religions,'' says Goodman, the bioethicist. ``But a lot of family members think of it as yucky.''
Kaserman thinks money would help focus families' attitudes. ''I've been preaching this sermon for 10 years now. . . . When I first started writing, the medical community was extremely opposed.'' But as the number of deaths of people on the waiting list has grown -- it's now 17 a day -- the medical community has become more receptive.
`MENU OF OPTIONS'
Offering money doesn't have to be crass, Kaserman says. 'You should do this in a sensitive way, with a menu of options. You say, `You are giving the gift of life. . . . As an additional inducement, we can make a contribution of $500 or $1,000 to your favorite charity, or help with funeral expenses, or as a cash payment.' So they can make a contribution or take a vacation.''
The crucial issue is how big the payment should be. Kaserman thinks it doesn't need to be astronomical. He believes that families will be willing to donate for as little as $1,000, based on a poll he did of Auburn students. That's not much of a survey, he acknowledges, and that's why he supports better surveys.
That's precisely the American Medical Association's position.
Leonard Morse, a Massachusetts physician who chairs the AMA ethics council, says the group supports a limited study, involving only cadaveric donors, offering incentives of ''moderate value,'' such as partial payment of funeral expenses.
The board of the organ sharing network also favors such a study examining the usefulness of ''small amounts paid directly to a funeral home, or a token thank you,'' Paschke says.
So far, no group has launched a pilot project, at least partly because it might first have to seek a federal waiver from the 1984 law.
`IMPLIED CONSENT'
An alternative to payment is the ''implied consent'' system of several European countries, including Spain. Doctors there assume that a patient is willing to have his organs donated unless he is carrying a card that says he does not want to be a donor.
Most U.S. experts doubt that such an attitude would work in this country. ''Americans have a suspicious nature about authorizing a government to do that,'' says Tzakis, the Miami surgeon. ``It's just a blank check.''
Goodman, the bioethicist, would rather spend the money on education than funeral expenses. ``If a family thinks it's yucky to remove organs and desecrate a loved one, are you going to surrender the loved one for a few shekels? I think we're better off educating people about what a valuable gift they're giving.''
Meanwhile, the waiting list grows.
Bruce Modlin, 49, a former bar owner who lives in Weston, has been waiting for a liver for four years. ''It's an emotional roller coaster,'' he says.
He has no opinion about how organs are obtained. He just knows he needs a liver. ``I'm getting progressively worse.''
