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Commentary

Death's Waiting List
Sally Satel, MD, The New York Times, 5-15-06

Satel, a beneficiary of a kidney transplant, inveighs against the U.S.'s ineffective—and therefore deadly—system for matching potential kidney donors with the people who need transplants. She concludes that high–handed moralism—rather than a rational analysis of the costs and benefits of the current system–needlessly kills thousands of patients on kidney waiting lists every year.

Today 70,000 Americans are waiting for kidneys, according to the United Network for Organ Sharing, which maintains the national waiting list. Last year, roughly 16,000 people received one (about 40 percent are from living donors, the others from cadavers). More are waiting for livers, hearts and lungs, which mostly come from deceased donors, bringing the total to about 92,000. In big cities, where the ratio of acceptable organs to needy patients is worst, the wait is five to eight years and is expected to double by 2010. Someone on the organ list dies every 90 minutes. Tick. Tick. Tick.

Until my donor came forward, I was desperate. I had been on the list only for a year and was about to start dialysis. I had joined a Web site, MatchingDonors.com, and found a man willing to give me one of his kidneys, but he fell through. I wished for a Sears organ catalog so I could find a well–matched kidney and send in my check. I wondered about going overseas to become a "transplant tourist," but getting a black market organ seemed too risky.

Paradoxically, our nation's organ policy is governed by a tenet that closes off a large supply of potential organs—the notion that organs from any donor, deceased or living, must be given freely. The 1984 National Organ Transplantation Act makes it illegal for anyone to sell or acquire an organ for "valuable consideration."

In polls, only 30 percent to 40 percent of Americans say they have designated themselves as donors on their driver's licenses or on state–run donor registries. As for the remainder, the decision to donate will fall to their families who are as likely as not to deny the hospital's request. In any event, only a small number of bodies of the recently deceased, perhaps 13,000 a year, possess organs healthy enough for transplanting.

The verdict is in: relying solely on altruism is not enough. Charities rely on volunteers to help carry out their good works but they also need paid staff. If we really want to increase the supply of organs, we need to try incentivesq;financial and otherwise...

Some critics worry that compensation for kidney donation by the living would be most attractive to the poor and hence exploit them. But if it were government–regulated we could ensure that donors would receive education about their choices, undergo careful medical and psychological screening and receive quality follow–up care. We could even make a donation option that favors the well–off by rewarding donors with a tax credit. Besides, how is it unfair to poor people if compensation enhances their quality of life?

Paying for organs, from the living or deceased, may seem distasteful. But a system with safeguards, begun as a pilot to resolve ethical and practical aspects, is surely preferable to the status quo that allows thousands to die each year. As the International Forum for Transplant Ethics put it: "The well–known shortage of kidneys for transplantation causes much suffering and death. If we are to deny treatment to the suffering and dying, we need better reasons than our own feelings of disgust."



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