Hi. I'm Art Caplan at the Division of Medical Ethics at the NYU Langone Medical Center.
Why are we facing continued shortage with respect to organs for transplant? Many people have conversations with their doctor. Sometimes the doctor brings it up and asks, "Have you signed an organ donor card? Is it something that you've thought about?" I think this is something that, if there's time and you remember, you should raise with patients. We need to try to encourage people to sign those donor cards.
Shortage is a chronic condition. It has been a huge problem in organ transplantation for a long time despite improvements in outcome and despite better use of immunosuppressive drugs. We just don't have nearly enough organs to transplant, particularly for children. Many, many people die on waiting lists without getting a shot at transplant. The biggest obstacle is getting organs to give patients, and that has led to a discussion about what to do.
Some people, myself included, say that maybe we should shift away from laws that say you can opt in to become an organ donor, to a system that says you can opt out. You still get to consent, but you will say that you don't want to do it as opposed to saying that you do want to do it. There might be evidence from Europe that says that some countries that have followed so-called "presumed consent"—or as I like to refer to it, "default donation"—have had better results.
Still, there have not been huge improvements, because doctors and other healthcare personnel still tend to treat organ donation as an opt-in area, trying to get family permission.
Your patients may ask you, "If I sign that card or I register, can my family override it?" Legally, no. That has been true for decades. Morally, yes. Transplant teams and intensive care unit personnel tend to listen to families. They don't want a headline that says, "Widow Cries in Hall While Transplant Team Removes Liver Despite Her Objections." It's just bad publicity, and people want to be sensitive to the bereaved and those who've suffered a loss.
What about buying and paying for organs? That is an approach that no country has really tried except Iran. Some people point to them and say that it seems to have worked. I have no idea. I will say, however, that if your test case is going to be Iran, I don't think you're going to get far in American public-policy debates about whether we should try to buy organs. One limit that is serious is that you can only do this for kidneys. You still need hearts, you still need lungs, and you still need livers. We're not going to have markets for those organs.
Let's say that we try to market kidneys from living persons. There are two major problems here. One is that there are many major religions in the United States that don't approve of the sale of organs. They don't believe that you should sell your body, whether it's prostitution or selling organs for transplant. You're going to encounter their opposition if you do that. The Catholic Church has said that many, many times.
Whether you agree with those religions or not, you still have to deal with the reality that you don't want to get into a fight about it. We don't need to reenact the abortion controversy over something like organ donation.
The other difficulty with selling organs is that, in a relatively rich country like the US, you're going to have to pay a lot of money to get people to say, "Yeah, I think I'll sell a kidney." It's not going to be thousands of dollars; it's going to be tens, if not hundreds, of thousands of dollars. Even on a bad day, I don't believe that many Americans are going to say, "Yes, I'll sell my kidney." There are concerns about safety issues, time away from work, loss of income from missed work, and long-term loss of function in the remaining kidney.
If making a kidney available were so easy, then there wouldn't be so many ethicists and transplant surgeons around with two kidneys. It's a major decision, and I don't think people are going to be lured in unless there were huge sums of money changing hands. If those huge sums of money change hands, then you're wondering, "Is the person really consenting, or are they just blind to the risk because the money offer is so good?"
If that were to happen and somebody died, I think the whole practice would be quickly ended. People would say, "I didn't really understand what I was getting into. I was just lured in by the big bucks."
I think there may be ways to get more organs. Interestingly enough, gene editing is starting to be used in animals like pigs. We may be able to engineer animals that have organs that are more useful in humans without getting rejected. In addition, there are ideas floating around about possibly asking the families of people who die outside of hospitals for permission to bring the deceased to the hospital and see if we could procure kidneys or other body parts at the hospital.
Those ideas have some merit. They are going to occasion a lot of debate in and of themselves. As for the endless going around and around about whether we should buy organs, I think it's time to put that to rest. Major religious groups won't support it, there are too many people who are wary of exploiting people who might be willing to sell, and the overall cost of convincing healthy people to sell an organ to a stranger is probably more than we can afford.
I'm Art Caplan at the Division of Medical Ethics at the NYU Langone Medical Center. Thank you for watching.
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Cite this: Should You Be Able to Sell Your Kidney? - Medscape - Jun 30, 2016.
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