Cingles Info

Miami Herald
Posted on Sun, Sep. 22, 2002
With 80,000 awaiting transplants, doctors consider idea amid debate
BY JOHN DORSCHNER
jdorschner@...
Michael Ritchie, 45, has spent two months ''hooked to a lot of machines'' in
a Jackson Memorial Hospital bed, waiting for a new heart. ''I have faith in
the Lord,'' he says, ``and I have faith in my doctors.'' The problem is that
no one has faith that enough people will donate their organs to keep people
like Ritchie alive. The shortage of available organs is so severe that some
experts are proposing a radical solution: paying for organs -- giving money
to the relatives of the recently deceased. The hope is that the move would
help the 80,000 people waiting for transplants. That's up from 20,000 in
1990. Last year, 6,238 Americans died while on the transplant waiting list,
and many more became so sick that they were removed from the list before
they died.
At present, paying anything for organs is illegal, and many transplant
surgeons think payment is morally wrong. But as the waiting list has
lengthened, a growing segment of the medical establishment is willing to at
least explore the idea. This summer, delegates of the American Medical
Association voted to support a study to see whether payments would ease the
shortage. Several bills in Congress propose changing the 1984 law that
forbids payments for organs. ''The organ shortage we are experiencing is not
mandated by nature,'' writes David L. Kaserman, an economist at Auburn
University and the recipient of two kidney transplants. ``Rather, it is the
outcome of a myopic public policy.''
UNMET NEED
While many disagree with him, the United Network for Organ Sharing, which
keeps the waiting list for transplants, says it is an ``undeniable fact that
the current system, despite 30 years of experience based on altruistic
donation, has yet to meet this need.'' Kaserman wants to know what is
un-American about paying for a heart the way one would pay for a car. If
there is a shortage of cars, you give an incentive to manufacturers to
produce more by raising the price. ''I don't tell a surgeon how to
operate,'' says Kaserman, who this summer co-authored a book, The U.S. Organ
Procurement System: A Prescription for Reform. ``I don't know why a doctor
would tell an economist what's right. A shortage is by definition an
economic demand that's not being met -- a difference between supply and
demand.'' Kaserman's book, published by the conservative American Enterprise
Institute, has a two-tiered proposal. The more radical would be a pure
free-market system, in which families could auction organs to the highest
bidder and brokers could then resell them to whoever paid the most --
similar to the black-market system that now operates quietly around the
world.
''The medical community is still very much opposed to that,'' Kaserman says.
It's also opposed to paying live donors for a kidney. The implications of a
poor person endangering his health for a few thousand dollars are too
distasteful. What is gaining support is Kaserman's second proposal: paying a
small fee to the family, with the organs then going to one of the several
dozen nonprofit procurement organizations around the United States. The
nonprofits are tied to the United Network for Organ Sharing, which would
continue to maintain the waiting list based on medical criteria, not wealth
or fame.
Others think it's not that simple. ''The downside is it opens the process to
undue influence, if not downright
corruption,'' says Ken Goodman, director of the bioethics program at the
University of Miami.
Selling organs to the highest bidder could lead to the rich living by buying
up all the available kidneys, livers, hearts and lungs while others die. It
could also lead to the poor being persuaded to risk their health by parting
with a kidney or a slice of their liver -- the two organs that live donors
can part with. ''I can see the slippery slope,'' says Sister Kathleenjoy
Cooper, 61, of St. Raphaela's convent in North Miami-Dade. She has been
waiting for a kidney for four years, but she is opposed to buying organs.
``I don't want the United States doing what they're already doing in other
countries. ''That could lead to the poor being exploited for their bodies.
Or it could lead to that murky line about being brain-dead'' -- speeding a
declaration of death in order to harvest organs.
THIRD WORLD SALES
In fact, in poor countries around the world, including Iraq and India, sales
of organs are already occurring -- generally by poor men willing to give up
a kidney for as little as $1,000. Kidneys are the main black-market organ
because they are needed by more than half the people on the waiting list,
and because most patients don't trust the quality of organs taken from
cadavers.
The shortage exists because transplants have become much safer -- and
therefore possible for more people -- since the first successful transplant
in 1954.
Much of the success is due to improved drugs that stop the body from
rejecting another person's organ. More than 85 percent of patients now
survive the first year. For kidney and pancreas patients, it's 95 percent.
Last year, 24,000 transplants were performed in the United States, and while
the number waiting for transplants has increased 400 percent since 1990,
donations from cadavers have increased only 32 percent, according to the
United Network for Organ Sharing.
The problem is that only 1 percent of the dead are potential donors. Those
whose bodies have wasted away slowly with disease can't be used. Surgeons
need people who die suddenly, as in an accident, and have healthy organs. It
used to be that cadaveric donors had to be younger than 50. Then the limit
was raised to 55, and finally removed. ''There's no cutoff in age,'' says
Andreas Tzakis, director of liver and gastrointestinal transplants for the
University of Miami. ``We've used the liver of an 87-year-old.''
MULTIPLE BENEFITS
Theoretically, a single body could save up to seven lives -- two kidneys,
two lungs, one heart, one pancreas, one liver -- but the practical maximum
is three or four.
That makes organ donating a huge gift, and for years, the medical community
has tried to drive that point home while urging people to put ''organ
donor'' on their driver's license and explain their decision to relatives.
Still, only two out of five eligible cadavers are used as donors.
''Americans don't want to think about dying,'' says Anne Paschke,
spokeswoman for the organ sharing network, ``so they don't think in advance
about donating.'' ''It's not against the tenets of the major religions,''
says Goodman, the bioethicist. ``But a lot of family members think of it as
yucky.'' Kaserman thinks money would help focus families' attitudes. ''I've
been
preaching this sermon for 10 years now. . . . When I first started writing,
the medical community was extremely opposed.'' But as the number of deaths
of people on the waiting list has grown -- it's now 17 a day -- the medical
community has become more receptive.
`MENU OF OPTIONS'
Offering money doesn't have to be crass, Kaserman says. 'You should do this
in a sensitive way, with a menu of options. You say, `You are giving the
gift of life. . . . As an additional inducement, we can make a contribution
of $500 or $1,000 to your favorite charity, or help with funeral expenses,
or as a cash payment.' So they can make a contribution or take a vacation.''
The crucial issue is how big the payment should be. Kaserman thinks it
doesn't need to be astronomical. He believes that families will be willing
to donate for as little as $1,000, based on a poll he did of Auburn
students. That's not much of a survey, he acknowledges, and that's why he
supports better surveys.
That's precisely the American Medical Association's position. Leonard Morse,
a Massachusetts physician who chairs the AMA ethics council, says the group
supports a limited study, involving only cadaveric donors, offering
incentives of ''moderate value,'' such as partial payment of funeral
expenses. The board of the organ sharing network also favors such a study
examining the usefulness of ''small amounts paid directly to a funeral home,
or a token thank you,'' Paschke says.
So far, no group has launched a pilot project, at least partly because it
might first have to seek a federal waiver from the 1984 law.
`IMPLIED CONSENT'
An alternative to payment is the ''implied consent'' system of several
European countries, including Spain. Doctors there assume that a patient is
willing to have his organs donated unless he is carrying a card that says he
does not want to be a donor. Most U.S. experts doubt that such an attitude
would work in this country. ''Americans have a suspicious nature about
authorizing a government to do that,'' says Tzakis, the Miami surgeon.
``It's just a blank check.'' Goodman, the bioethicist, would rather spend
the money on education than funeral expenses. ``If a family thinks it's
yucky to remove organs and desecrate a loved one, are you going to surrender
the loved one for a few shekels? I think we're better off educating people
about what a valuable
gift they're giving.'' Meanwhile, the waiting list grows.
Bruce Modlin, 49, a former bar owner who lives in Weston, has been waiting
for a liver for four years. ''It's an emotional roller coaster,'' he says.
He has no opinion about how organs are obtained. He just knows he needs a
liver. ``I'm getting progressively worse.''