Monday, March 29, 2010

Organ markets

The Sunday Star Times (unfortunately, not online) notes that Israel now gives organ donors priority in receiving transplants. There were apparently a few ultra-orthodox folks who figured 'twas better to receive than to give, so the legislation puts folks on a more equal footing. This is of course now a bit old news, but nice to see it being reported here.

The piece nicely notes Andy Tookey's tireless work trying to improve New Zealand's policy framework. Andy heads up the local branch of LifeSharers: a club for potential organ donors and recipients who wish that their organs, should they become available, be offered in the first instance to other members of the club. If no club members are suitable matches, then the organs are released to the general pool. A few ethicists hand-wring endlessly about some more medically desperate folks perhaps being passed over, but absolutely nothing stops those folks from joining the club as well, and I'm enough of a hard case not to be overly worked up if folks who wouldn't be willing to give me an organ if they died and I needed one are passed over for first call on mine.

An economist's first best is a free market in live and cadaveric organs, appropriately regulated to ensure that all parties involved weren't coerced into the transaction. There are lots of options between here and there that would improve outcomes:
  • allowing compensation for cadaveric donors to encourage donation;
  • allowing compensation for live donors;
  • restricting transplants to folks who sign their organ donor cards (and banning any familial veto post-death);
  • restricting the set of people who are allowed to veto your expressed choices (right now, in NZ, pretty much anybody can veto your choice about being an organ donor);
  • presumed consent for cadaveric donation.
The Maori Party seems likely to veto any potential changes to New Zealand's organ donation regime: while Maori have higher diabetes rates than others, and consequently are more likely to need a transplant, some Maori view the harvesting of organs after death as being tapu and consequently forbidden. If the Maori Party views beliefs about tapu as wholly price insensitive and broadly held across the community, then they'll reckon that changes prioritizing donors over non-donors would disproportionately adversely affect Maori.

I'd tend to expect instead that a change in regime would induce folks to lay aside more costly beliefs; I'd further expect that the increase in donation rates that could be achieved by giving preferential treatment to donors could be sufficient to ensure that even registered non-donors could be made better off by the change. Is it better to be at the bottom of a very short queue or in the middle of a very long one?

23 comments:

  1. It is easy to succumb to the ‘No give/No take’ rhetoric of recipient lobbyists that presume low organ donor rates stem from selfishness, rather than ignorance. It also overestimates the rationality of grieving families.

    Admittedly, culture plays a part but name-calling ethnic groups ‘freeloaders’ is hardly encouragement for them to reframe their mindset.

    It is a dangerous trajectory if we start placing an ethical loading on organ recipients. Then we are only a few steps away from donors leaving instructions to exclude recipients on the basis of race, age, religion, socio-economic class etc

    Organ donors and their families are the ultimate heroes. Their overwhelming generosity should not be undermined by caveats, coercion and conditions which will pervert the ethos of ‘unconditional gift of life’. If whipping up populist hysteria changes the perception of organ donation from altruism to mean-spiritedness, it could well decrease the number of donors even more. First, Do No Harm.

    Anita

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  2. @Anita:

    First, where did I say freeloaders? I thought I was rather careful to avoid any kind of name-calling.

    Second, if some donor will only donate an organ on condition that his liver goes to somebody who hates lima beans, loves peas, and has a goat, that's one more organ in the system and all the folks behind that guy who love lima beans, hate peas, and have sheep move up one place in the queue. A life gets saved that otherwise wouldn't and everybody else moves up a spot. It's a Pareto move: at least one person is made better off and nobody's made worse off. The only way it's not a Pareto move is if some folks who would have been unconditional donors switch to being only conditional donors, and if there are enough of them that the total increase in number of donors is outweighed by substitution. I find that pretty implausible (there just aren't that many racists out there). It could be reason for banning such donations later on if it proved to be a huge problem, but I can't see it as reason for banning those donations ex ante. Would you really prefer that a racist's organs rot than that they save a life?

    And, when Iran allowed donation with compensation, they saw no decrease in altruistic donation. It's plausible that money donors could induce altruists to exit, and in sufficient numbers that it would outweigh the benefits coming from the for-pay donors, but the empirics just don't back it up. Moreover, since altruistic donation rates in New Zealand are so tiny, it would be shocking if we'd lose more altruists than we'd gain folks who'd consider it for some compensation.

    The current system does ample harm. First, stop the harm we're doing by forbidding transactions that save lives.

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  3. Sorry, I don’t understand the Pareto stuff- it’s above my head.


    I do understand the frustration and desperation of those on transplant waiting lists, and the pressure to increase donor numbers. But I still think promoting organ donation as a positive, ethical, feel good issue is a better way of raising organ donation profile; more time, effort and money put into nationwide campaigns to encourage discussion, elevating organ donors and their families to hero status, fighting ignorance with education, and supporting positive attitudinal change within cultures rather than negative incentives, coercing grieving families and legislation.



    Academic and principle arguments aside, no organ donor regulation is workable without the cooperation of physicians.



    In New Zealand, there are only about 100 ICU deaths/year suitable for organ transplantation. About 2/3s of the grief-stricken families can be appropriately asked; last year, there were 42 donors. (90% of families respecting the deceased wishes agree to donation).



    Low organ donor rates are the flipside of our world class ICU system.

    Intensivists fight to save the lives of their ICU patients. This is reassuring for all of us. As far as organ donation, intensivists must preserve their moral neutrality or risk the gross perception they may consider seven potential recipient lives are more important than saving one ICU patient’s life.



    Next, the transplant physician team have less than an hour to decide ON CLINICAL PRIORITY who next on the waiting list to receive the available organ- usually the next person closest to death. There is a critical time factor involved whereby organs and recipients are rushed to hospital from any part of the country.



    Is it these doctors’ responsibility to decide conditional donor and recipient factors as well? Collating details on lima beans, peas and goats is going take precious time.

    How do you enforce compliance? How will you penalise these physicians? …… without doing any harm.


    Anita

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  4. I had to jump in here. I didn't see Eric suggest coercion as a viable ethical means of increasing organ donation rates. In fact knowing Eric as I do I suspect he would be fundamentally opposed to such a means, although he may prove me wrong ;)

    My reading of it is simply that consideration be given to some measure of financial recompense for those cases where the individual (or his/her family in the case of post-mortem donation) are undecided. I suspect that most of us who are altruistic enough to wish our organs be put to good use upon our death are already listed as donors - I know I am.

    I think Eric is suggesting that we may see a greater return on investment in offering compensation for organs from those not already donors than by a warm fuzzy advertising campaign targetted at those folks who are probably already donors anyway. Again, I am prepared for him to disagree with me here.

    My guess is that physicians are already assessing other suitability factors for organ donations (blood types, etc - note I've received no medical training so am assuming here) so it should not be impossible for a few extra fields be added to the database for those individuals who choose to restrict the possible recipients of their organs. It may be distasteful to some but where possible we should respect the wishes of the donor in these situations, and if it means an overall increase in the number of organs available for transplant then this is a good thing. I can conceive of a situation where a donor would only donate given certain conditions - say, for example, that he/she doesn't wish his/her liver given to a alcoholic, or lungs to a smoker. I have no problem with that, it is still an extra organ in the collective pool.

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  5. @Anita:

    Pareto gives the nicest guiding criteria in welfare economics: if compared to state of the world X, state of the world Y has at least one person who's better off and nobody else is worse off, then Y is preferable to X. So if a horrible racist wishes only to donate organs if he can guarantee that no white folks get the organs, then the donor's made better off, the recipient is made better off, other folks on the list move one step up the queue if they're behind him and nobody above him in the list is made worse off because the organ otherwise would have been buried. That's a Pareto move.

    I agree with you that it would be helpful if we did more here to encourage organ donation. Those initiatives have done some good in other countries. But they haven't done enough good relative to the scale of the problem.

    I can understand the transactions costs arguments. I'd be very reluctant to go and pester a grieving family for permission to make a transplant absent some pretty strong incentives too.

    On your specific ICU points, I understand that current practice is that terminally ill folks near death with harvestable organs are not put into ICU beds in preparation for transplant even if surplus beds are available on grounds that it's more expensive and that the beds may become needed later on. If that's the case, then there are more options we could use to increase current transplant rates.

    There are, of course, systems that could be in place to ensure separation of the ICU physician's incentives from those of the transplant agent to avoid the moral hazard problem to which you allude. Some of these, I believe, are detailed in work by Barnett, Saliba and Walker, but I'd have to double check.

    Would it really be so difficult to have a donor registry that allows various tick-box options? I know the current driver licence version is currently non-binding, but we can readily imagine a more robust system involving actual informed consent, via a website, where folks could register as donors and, if they wished, put specific restrictions on things. Physicians could check the donor's details rather quickly on the computer system if it seemed likely the organs were to come available, then match the conditions with the existing queue of potential recipients. They already have to check for organ / recipient genetic compatibility, so it's not like they're simply rushing it to the next person on the list - they have to check which recipient is a good match for the donor. I'm not sure that the incremental increase in transaction time is that large relative to the potential increase in donor numbers, especially with systems like LifeSharers that make donating a dominant strategy.

    Your questions on compliance are indeed interesting. I've also heard that transplant physicians here would sooner that organs rot in the ground than that they be allocated with priority to other LifeSharer members, or in accordance with any other donor wishes, regardless of whether the new system could save dozens of lives by increasing donation rates.

    Why should we presume that a surgeons ethical qualms about saving a particular life should outweigh that that life be saved? You might as well ask what we should do with a surgeon who refuses to operate on black people because he's a racist. How would you enforce compliance against the racist surgeon? The same way we enforce compliance in any other employment situation, really.

    @Lats:

    You're right that I'm no fan of coercion, but Anita's coercion worries seem more about coercing surgeons to do things about which they have ethical qualms.

    I would expect that if the standard deal were that the hospital had a fund covering funeral expenses for folks giving organs, donation rates would increase. It would be a small move to save lives. A bigger move would be towards Lifesharers. An even bigger move would be a market in organs. All of these would save lives.

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  6. A couple of random observations/comments.

    LifeSharers does not target ethnic groups in any way. Everyone is welcome to join LifeSharers, no matter who OR their medical condition.

    LifeSharers does not discriminate on race, religion etc. Giving organs say to only catholics does not produce more catholics, giving organs to only women doesn't produce more women, but giving organs to registered organ donors first produces more organ donors and that saves more lives which should be the goal of our organ donation system?

    LifeSharers is not about mean-spiritness it's about personal responsibility and is incentive based - and remember anyone can join...(It's Free!)

    Altruism is a fine thing but is it worth the many lives lost each year due to a lack of it?

    "First do no harm"? The recent decision of the organ donor service to reject perfectly good organs because 'they' do not subscribe to the same morals as the donor means that another 6 people may die as a result of their 'holier than thou' attitude and supposed higher and better morals than everyone else.

    First do no harm?

    I agree with raising the profile and more education and so on. In fact that has been the mainstay of my 8 year long campaign. But that will only go so far, we need to think outside the square if we are to increase donor rates.

    "In New Zealand, there are only about 100 ICU deaths/year suitable for organ transplantation. About 2/3s of the grief-stricken families can be appropriately asked; last year, there were 42 donors. (90% of families respecting the deceased wishes agree to donation)."

    I have a concern on these figures (And so to will the Auditor General soon if I feel the need to progress this.)

    There are as you say around 100 suitable donors per year. (Not including all the missed ones/those denied access to ICU as potential donors.) But only 42 donors last year, with I believe another 3 families declining. So are you saying that there has been some magical new cure in ICU in the past 2 years that has given patients an extra 60% survivable chance? Why has this amazing figure not been reported in the international media? A cynic may wonder why this incredible 60% 'extra' cure rate very timely fits in with the new audit that has been running for how long? Oh yes I remember, about the same length of time...

    Other things - I am not going to re-litigate LifeSharers. the website (www.lifesharers.org.nz) is there for people to make up their own minds and judging by the amount of people signing up they agree with our philosophy. Of course all publicity is good publicity and the article about me in the Sunday Star Times saw another surge of registrations.

    The organ donor bods can do all they like to ignore it or impose their own ('mean-spirited'?) rules to try and block it but... with the continuing number of registrations it won't be long before they get a LifeSharers member as a potential donor.

    2 things can happen here.

    1- they accept the organ and it is offered FIRST to another member. If this happens the publicity will be so huge that the LifeSharers registration database will exceed the driving licence system and will force change (for the better.)

    Or 2- the self appointed moral high ground brigade will decline the organs, therefore condemning several other people to death ('First do no harm' comes up again.)

    The resulting publicity from them declining will again be so huge that change will be inevitable.

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  7. Thinking outside the square..... hmmm--- Okay, instead of just increasing the number of available donors, why don’t we also shorten the waiting list by excluding alcoholics and smokers? Also exclude the obese and drug users. How about criminals and white collar fraudsters? Then, those who no longer contribute economic benefit to society- the old, unemployed, the weak ..... Now everyone else moves up considerable places.


    Then, on the personal conditional donor database, we can start checking the human rights tickboxes- Eric trusts there aren’t many racists but combined with homophobes, religious and political bigots, misogynists etc …. . . I am sure we can up the numbers.



    And payment for organs by recipients is the most obvious step to increase donor numbers.





    This trajectory is the fear of ‘moral high-grounders’. Once expediency trumps the primacy of organ donation being 'an unconditional gift of life', then appealing to people’s better angels is no longer an option.


    In the 'ends justifies the means' argument, I would say you guys win.
    Regrettably, losing sight of some humanity is the price we pay.


    Anita

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  8. "Okay, instead of just increasing the number of available donors, why don’t we also shorten the waiting list by excluding alcoholics and smokers?"

    Why don't we try my way first? :-)

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  9. @Anita: If you really can't see the difference between those kinds of proposals, I'm not sure what else to say...

    The "means" we're suggesting entirely respects donors wishes and is consistent with the idea that we own our own bodies. It's worrying that folks finding those means repugnant run our transplant system.

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  10. Also Anita... All your posts talk of excluding various categories of people (Religion, smokers etc) and punishing them for being what they are.

    LifeSharers excludes no-one and rewards people. Once you have read thoroughly (and understood) the LifeSharers scheme (did I mention you can see it here? http://www.lifesharers.org.nz) I am sure you will leap at the chance of joining. (I'll even send you a free LifeSharers keyring!)

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  11. As the article wasn't online I've scanned in the print edition here's the link to it.
    http://www.lifesharers.org.nz/pressreleases/sst28april.JPG

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  12. Professor Crampton is correct when he says that the best way to increase the supply of organ is a free market in live and cadaveric organs. But in a world where paying for organs is is illegal, non-financial incentives are the next best option.

    Giving organs first to registered organ donors creates an incentive for non-donors to become donors. More donors = more organs = fewer people dying waiting for transplants. Shouldn't saving the most lives possible be the goal of the transplant system?

    LifeSharers offers the only legal non-financial incentive to donate. Please sign up at www.lifesharers.org.nz (or at www.lifesharers.org in the United States). LifeSharers gives you a chance to help yourself as you're helping others.

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  13. I wasn't aware lifesharers register was legally binding/
    It must a recent law change.
    Please give link to legislation.

    Dr Mckay

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  14. Who said it was legally binding? In fact it says in the article that it is 'not' legally binding.

    (http://www.lifesharers.org.nz/pressreleases/sst28april.JPG)

    However it 'is' legal.

    For doctors to reject organs because they don't agree with the decisions of the donor is not legally binding either...

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  15. Andy

    So what you are waiting for is the first big TEST CASE; where a tranplant doctor by-passes several acute patents who are weeks away frm death, to givnig an organ to a Lifesharers patient who may have years to live on a chronic condition?

    Then joining Lifesharers is huge incentve.

    I'm not usually into this type of queue-jumping, but if it is my life at stake, I'm all for it.

    pierre

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  16. @Pierre: Every single person on the current wait list can join life-sharers, for free; they just have a short waiting period before they're eligible for life-sharers organs to give folks stronger incentive to sign on while healthy.

    The hopeful end result is no queue jumping at all but rather everyone being a member of Life Sharers and organ donation rates jumping considerably higher than they are now.

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  17. The real queue-jumpers are the non-donors on the transplant waiting list.

    They can refuse to be donors, but if they ever need a transplant they'll expect to be right up there with registered donors. The irony being though they will expect a transplant where do they think the organs are coming from?

    Nobody has a right to an organ transplant. Transplants exist only because people are willing to donate their organs. If we take away the right to determine who gets our organs, fewer people will donate and more people will die waiting for transplants.

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  18. The real queue-jumpers are the non-donors on the transplant waiting list.

    There are many who would refuse to be a donor, but if they ever need a transplant they will expect to be up there with, or ahead of a registered donor in the same circumstances. Where do non-donor think the organs that they need are coming from?

    Nobody has a right to an organ transplant. Transplants exist only because people are willing to donate their organs. If we take away the right to determine who gets our organs, fewer people will donate and more people will die waiting for transplants.

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  19. Now its getting confusing.
    So 'donor' on my drivers licence is altruism- and not legally binding. But Lifesharers register is not legally binding either, but will get me higher on the priority list?

    How many people have 'donor' on their drivers licence? Compared to How many on lifesharers register?
    Is it wise to be on both lists or will it confuse the doctors?

    pierre

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  20. @Pierre: Neither system is legally binding. The drivers' licence may provide your next of kin some idea about your preferences if they didn't otherwise know, but they get to veto your preferences when asked by the doctors.

    LifeSharers membership similarly gives folks an idea about your preferences - a much stronger one, as it's far more likely to satisfy "informed consent" than the simple tick-box for the driver's licence. If you're in an accident and your organs come available, your doctors would still ask your next of kin. They, and the card in your wallet, will hopefully inform the doctors that you're a member of LifeSharers and that you prefer that your organs go first to an organ donor on the LifeSharers list. At that point, the transplant surgeon can either respect your wishes and find the first person on the transplant list who is a member of LifeSharers (and, if no LifeSharers member who's a decent match is on the list, then release your organs to the remaining list), or ignore your wishes and refuse to make the transplant. In the latter case, there then will be a lawsuit in hopes of making the system binding in future. At least that's my understanding.

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  21. Anita, nobody can object to your personal feelings about commercial organ transplants. The bit that I object to is where you cross the line and insist that everybody else also operates according to your feelings on the matter.

    The simple fact is that the price of the current system is so needlessly unsuccessful that it can be measured in hundreds or thousands of lives lost here in New Zealand alone. Your justification as presented here is the usual hopeless mish mash of generalisation, non-sequitur and illogic.

    How does it follow that because racists might express their preferences in organ donation that it is better to ban such trade? Can’t the same be said of all trade? Lives will still be saved.

    How would the presence of commercial organ transplants pervert the (extraordinarily unsuccessful) donation model? Do supermarkets in any way pervert the work of charitable food banks? Do clothing stores pervert the Salvation Army’s good work?

    You say you “understand the frustration and desperation of those on transplant waiting lists”, but it is not frustration that is the problem. It is all the lives lost that is the problem. Those lives lost are the price of you and your ilk satisfying your sad desire to see that everybody, however sick and desperate, conforms to your values and not their own.

    Organ donation, when it is to the exclusion of commercial arrangements, is coercive, human-hating, unethical and therefore evil. It does not feel good to watch loved ones needlessly die. Your excuse that it “feels good” to enforce such a system grossly trivialises the suffering, and in fact makes explicit your unbelievable selfishness.

    You are exactly wrong on coercion. Coercion is forcibly preventing thousands of consenting adults from writing an agreement. That is the current system thanks to people like you. Coercion is intrinsic to the raising of taxes to pay for the campaigns and education (read: indoctrination) you promote to bring more people around to your anti-human world view.

    Your comments on physician compliance and, even more ridiculous, on smokers and drinkers, is the usual bait and switch non-sequitur non-argument that is all too common. Really, I’d have thought killing so many people would come with a better justification. I simply can’t believe that anyone would actually mount an argument that because organ donations might give homophobes a means to express their homophobia, nobody – however gay-friendly – should be allowed to participate.

    Your comments here reveal your own lack of humanity. People die because you and your ilk want to feel good. How repugnant.

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  22. Why don't we take this issue to the Human Rights Commissioner?

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  23. Why don't we take this issue to the Human Rights Commissioner?

    And let commenter Matt be lead the submissions - please.

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