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When Altruism Isn't Enough: The Case for Compensating Kidney Donors

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This is a very interesting and very challenging book because its various authors (edited by Dr. Sally Satel) make a case for compensating people who donate kidneys. Why? Because there are not enough kidneys being donated for altruistic reasons and people are dying unnecessarily. This is discussed by Sally Satel in the introduction.

Arthur J. Matas then discusses the risks to kidney donors, which turn out to be minimal. As a reasonable person, this would be my largest concern. But it turns out that most healthy people have plenty of kidney capacity with one and those who have donated over the decades have not hard significantly increased adverse outcomes.

Huang, Thankur, and Meltzer then tackle the cost effectiveness of renal transplants by comparing it to no treatment, hemodialysis, and what this might mean to the valuation of a kidney. Julio J. Elias provides a framework for a compensation system. This is obviously more for providing something reasonable to discuss than as a final proposal.

James Stacey Taylor and Mary C. Simmerling deal with the reasonable objections:
-Will a legal market create a black market?
-People will be coerced into donating.
-People will fake their eligibility for donation to get money.
-The poor will be exploited to save the wealthy.
-Because of subsequent health problems, donors will be actually be worse off.
-Medical conditions.
-Compensation will actually lead to fewer organs becoming availability.

Satel comes back with a chapter dealing with the issues of human dignity, the way money taints donation, and the romaticization of altruism. Richard Epstein also provides a chapter on the uneasy embrace of altruism, markets regulated and not, and quantifying the benefit of a new kidney.

Hippen and Satel then discuss the issue of compensated kidneys suppressing donated kidneys and what impact this issue might have on organ procurement for transplantation. Michele Goodwin discusses the way the federal government has inserted itself in this issue and why it would be better to return to state by state regulation. Dr. Satel then provides the books conclusion.

Appendix A is particularly useful and interesting because it discusses the way legislation has been created to deal with transplantation from 1968 to 2008.

Whatever your own views, you should at least be willing to become informed on this issue and wrestle with serious arguments for and against this idea of compensation. People are dying and this approach might save lives.

Reviewed by Craig Matteson, Ann Arbor, MI

If people were willing to risk their own lives to help others universally, the world would be a better place - but it's not. "When Atruism Isn't Enough: The Case for Compensating Kidney Donors" is a look at the ethical issues around America's organ shortage. When someone needs a kidney, finding a good match is hard, and the good match is not always willing. But throwing money at the problem presents another issue - is it ethical to sell one's organs for profit to save a life? Is it ethical to deny one a kidney if it means their death? Intriguing and a very real issue many doctors face today, "When Altruism Isn't Enough" is a scholarly look at this serious ethical debate.

Dr. Satel's argument fails from the start, and her conclusion that altruism has been tried and failed, is simply not true. There is an organ shortage and people die while waiting, but the fault is not lack of altruism but rather the singular lack of support for altruism in the form of organ donation.

Altruism has worked for 5 decades to provide organ donations both from living donors and deceased donor families, but it simply has not worked well enough. Most people in the field recognize that for the altruism of donation to work, it requires social, legal and cultural support to reduce risk and improve awareness, support that is not currently in place.

Donation, unlike other altruistic social solutions, carries with it burdens beyond the known medical risk. The living donor faces the expense of nonmedical costs, is not protected from insurance discrimination norjob discrimination, not covered under FMLA, etc. Compare this to volunteer firemen, who protect 38% of the US population, but who have legislative and social support in place and it becomes clear that when social altruism is supported, it works very well.

The challenge is to get donation to the same level of support that firemen, blood donors, adoptive parents, military reservists and other altruistic citizens receive. There are new, strong initiatives to address these issues with the goal of taking what works, altruistic donation, and making it more effective.

The book ignores obvious successes of altruism and jumps right to proposing providing a profit to the donors. To counter the arguments about the ethics of this, the book proposes a wide and confusing series of government administered programs of deferred compensation and never addresses whether or not an elaborate government bureaucracy is a good idea. At some points, even the benefits of private contracts are touted. In fact, the proposals are all over the place often with nothing in common among them except that all of the proposals gloss over that purchasing an organ for profit would require a revolution in medical, religious and social ethics, something not likely to happen.

By ignoring other solutions and by falsely stating that altruism has reached its limits, this book fails as an honest intellectual evaluation of this real problem. The false dichotomy put forth in this book is that only market solutions have the ability to solve the organ shortage yet real life experience shows us from other endeavors that altruistic solutions are the most effective route for these types of problems.

It should also be noted that none of the essays included are by living donors. Living donors certainly signify in this debate, and while they should not be the final arbiters, people who have already been through this process surely have some insight to offer. This lack is probably deliberate as living donors are not likely to agree with the concept that the real barrier to more living donation is lack of altruism but to point out that the shortage is more likely the fault of suppressed and ignored altruism. For any theory to be accepted, it must be falsifiable and ignoring the important information from those who have lived this is at best careless. The need is real and deserves better consideration than put forward here.

Over the holidays, I finished "When Altruism Isn't Enough," which lays out the case for compensating living donors and describes a couple of possible systems for doing that. I had an interest because I was an "altruistic" kidney donor in June of 2009.

As the book notes, the issue for kidney transplants is this: If everyone in the United States donated his/her organs at death, it wouldn't make all that much difference for people waiting for a kidney transplant, because less than 1 percent of all deaths yield usable kidneys. So organ donor cards are important, but not for kidney transplants. Living donors are key to saving lives.

The book explores the economics of kidney transplants, and how expensive dialysis is, compared with transplant, even if we included donor compensation. It also offers two models for compensating living donors. One is a government incentive, and the other is a little more free market. Both seem workable, if properly regulated. All the screening for whether someone was physically and mentally fit to donate would remain in place.

Look, about 100 people like me come forward in the U.S. each year to donate a kidney to a stranger. I'd love to think we could get that number up to where it would need to be to retire "the list," but it's unlikely. Is paying donors unethical? No. Letting kidney patients die when there is a way to get them a needed organ is unethical.

This quote from the book's editor, Dr. Sally Satel, hits the nail on the head: "... the critics [of donor compensation] have a far greater allegiance to abstract ideas about dignity and the visceral wisdom of queasiness than to actions that could avert needless misery."

There's so much more to this book, such as a look at whether family members or altruistic strangers would be less likely to donate in a compensated system, what human dignity means in a system where one can essentially sell a body part ... it's all very thoughtfully presented and documented, and worth a read if you wonder about compensating donors or about what is wrong with the current system.

I came looking for honest debate on the issue and I left feeling cheated. There is nothing new presented, just the same old unproven theory that the authors' good intentions will solve the problem of deaths due to the lack of transplantable organs. The authors (and there are many) address many issues, but they fail to prove the only one that will support their conclusion - that this radical idea will help save lives. In fact, the little evidence that is presented would appear to disprove their theorem.

The arguments presented are both one-sided, and short-sighted. The authors come from various perspectives, a `health economist' an `ethicist', a `medical doctor', a `transplant surgeon', and `legal scholar' among them. The arrogant attitude of "we are right and everyone else is wrong" becomes tiring. It is hard to imagine that any of them would donate a kidney if compensated, yet they universally assume that others will do so. The evidence? Sadly there is none of that.

The book argues that Congress should change federal law to permit states to experiment with incentives that `might' help increase donation. Fifty states each opening a different version of Pandora's Box opens the door for massive abuse and failure, but it is exactly what is advocated here.

Despite the system that saved Dr. Satel's life, she insists the current system is a failure - tell that to the more than 28,000 people who receive life-saving transplants each year. The current system is not perfect by any means, but we cannot risk those thousands of lives that rely on altruism for a chance at life. There are many proven opportunities to improve the transplant system - none of which are presented in this book.