What I Am Reading: Free Market Edition

Jul 28 2014 Published by under MedicoLegal Concerns, What I'm Reading

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Sigrid Fry-Revere is a lawyer and a medical ethicist. She has played an advisory role to organ donation organizations in the US. Her latest work explores the kidney "exchanges" in Iran where a very different approach to organ donation has produced a surplus of living kidney donors.

The approach in most of the world has been to use deceased donors for transplantation as much as possible. Kidneys provide a unique opportunity for living donation, since most people have two and can live nicely with only a single organ. Our system requires these kidneys be donated from purely altruistic motives, usually because of relationships between the parties involved: husband - wife, parent - child, or other relations. When relatives or other close parties cannot donate, a donation "circle" can be set up. In this, one party cannot donate to their loved one, but they are a match for someone else whose relatives cannot donate. In the simplest setting, the donor exchange is paired; however, chains of up to 19 donors and recipients have now been orchestrated to give dialysis patients a better life.  While many donor expenses are covered by medical insurance, donating may have unseen expenses, including weeks out of work and the potential for complications of anesthesia and surgery.

Despite harvesting deceased organs, matching services for donor chains, and availability of dialysis, 20 to 25 people in the US die every day awaiting a kidney.

Iran has taken a different tactic to alleviate kidney shortages, namely paying organ donors. The powers that be in the US have assumed that this system is coercive and unfair. Dr. Fry-Revere decides that a program this successful is worth learning about. She spends several months on the road in Iran with an expatriate nephrologist, Dr. Bahar Bastani, a former colleague of mine at Saint Louis University. They bravely recorded video and audio interviews with doctors, nurses, donors, and recipients throughout Iran, generating the first account of this system by Western experts. The resulting book is The Kidney Sellers: A Journey of Discovery in Iran.

In Iran, the national government provides a cash payment for a kidney. Additional compensation varies by region. Most regional centers provide health coverage for a period of time for donors. The donor can then negotiate with the seller through the regional bureau for additional cash; if the recipient has no means to pay, the center can often tap donations for the funds needed.

Procedures vary from region to region. In the best situations, donors are carefully screened to make sure that their financial issues cannot be solved through other routes.  Potential donors interviewed in the book often had a debt to retire or needed capital to start a business; marriage often necessitated a cash infusion. Donors often expressed mixed emotions about the procedure. Many got their money, fixed their financial issues, and moved on with no regrets, but some felt guilt or shame that they had to sell an organ to make their lives better.

Recipients sometimes formed bonds with their paid donors, but for the most part this was a market transaction that ended when it ended. Many stated that they preferred a paid donation to an altruistic one from a relative; the latter would have left them indebted for life, while paying cash let them feel the debt was paid. They could then move on with better health and less guilt.

The book can be a bit repetitive at times, but it paints a wonderful picture of a society and system we know very little of. As I watch my own patients on dialysis, waiting months for a deceased donor kidney, I wonder if the Iranians just might have a good idea. I recommend reading this work for a thought-provoking take on our organ donation system.

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