An ethical market in human organs
=================================

* Charles A Erin
* John Harris

*   human organ donation
*   ethical markets
*   ethics of human organ donation

While people’s lives continue to be put at risk by the dearth of organs available for transplantation, we must give urgent consideration to any option that may make up the shortfall. A market in organs from living donors is one such option. The market should be ethically supportable, and have built into it, for example, safeguards against wrongful exploitation. This can be accomplished by establishing a single purchaser system within a confined marketplace.

Statistics can be dehumanising. The following numbers, however, have more impact than most: as of 24th November, during 2002 in the United Kingdom, 667 people have donated organs, 2055 people have received transplants, and *5615 people are still awaiting transplants*.1 It is difficult to estimate how many people die prematurely for want of donor organs. “In the world as a whole there are an estimated 700 000 patients on dialysis . . . . In India alone 100 000 new patients present with kidney failure each year”2 (few if any of whom are on dialysis and only 3000 of whom will receive transplants). Almost “three million Americans suffer from congestive heart failure . . . deaths related to this condition are estimated at 250 000 each year . . . 27 000 patients die annually from liver disease . . .. In Western Europe as a whole 40 000 patients await a kidney but only . . . 10 000 kidneys”2 become available. Nobody knows how many people fail to make it onto the waiting lists and so disappear from the statistics. It is clear that loss of life, due in large measure to shortage of donor organs, is a major crisis, and a major scandal.

At its annual meeting in 1999, the British Medical Association voted overwhelmingly in favour of the UK moving to a system of presumed consent for organ donation,3 a proposed change in policy that the UK government immediately rejected.4 What else might we do to increase the supply of donor organs? At its annual meeting in 2002, the American Medical Association voted to encourage studies to determine whether financial incentives could increase the supply of organs from cadavers.5 In 1998, the International Forum for Transplant Ethics concluded that trade in organs should be regulated rather than banned.6 In 1994, we made a proposal in which we outlined possibly the only circumstances in which a market in donor organs could be achieved ethically, in a way that minimises the dangers normally envisaged for such a scheme.7 Now may be an appropriate time to revisit the idea of a market in donor organs.8 Our focus then, as now, is organs obtained from the living since creating a market in cadaver organs is uneconomic and is more likely to reduce supply than increase it and the chief reason for considering sale of organs is to improve availability.

To meet legitimate ethical and regulatory concerns, any commercial scheme must have built into it safeguards against wrongful exploitation and show concern for the vulnerable, as well as taking into account considerations of justice and equity.

There is a lot of hypocrisy about the ethics of buying and selling organs and indeed other body products and services—for example, surrogacy and gametes. What it usually means is that everyone is paid but the donor. The surgeons and medical team are paid, the transplant coordinator does not go unremunerated, and the recipient receives an important benefit in kind. Only the unfortunate and heroic donor is supposed to put up with the insult of no reward, to add to the injury of the operation.

We would therefore propose a strictly regulated and highly ethical market in live donor organs and tissue. We should note that the risks of live donation are relatively low: “The approximate risks to the donor . . . are a short term morbidity of 20% and mortality, of 0.03% . . .. The long term risks of developing renal failure are less well documented but appear to be no greater than for the normal population.”9 And recent evidence suggests that living donor organ transplantation has an excellent prognosis, better than cadaver organ transplantation.10 Intuitively, the advantage also seems clear: the donor is very fit and healthy, while cadaver donors may well have been unfit and unhealthy, although this will not be true of many accident victims.

The bare bones of an ethical market would look like this: the market would be confined to a self governing geopolitical area such as a nation state or indeed the European Union. Only citizens resident within the union or state could sell into the system and they and their families would be equally eligible to receive organs. Thus organ vendors would know they were contributing to a system which would benefit them and their families and friends since their chances of receiving an organ in case of need would be increased by the existence of the market. (If this were not the case the main justification for the market would be defeated.) There would be only one purchaser, an agency like the National Health Service (NHS), which would buy all organs and distribute according to some fair conception of medical priority. There would be no direct sales or purchases, no exploitation of low income countries and their populations (no buying in Turkey or India to sell in Harley Street). The organs would be tested for HIV, etc, their provenance known, and there would be strict controls and penalties to prevent abuse.

Prices would have to be high enough to attract people into the marketplace but dialysis, and other alternative care, does not come cheap. Sellers of organs would know they had saved a life and would be reasonably compensated for their risk, time, and altruism, which would be undiminished by sale. We do not after all regard medicine as any the less a caring profession because doctors are paid. So long as thousands continue to die for want of donor organs we must urgently consider and implement ways of increasing the supply. A market of the sort outlined above is surely one method worthy of active and urgent consideration.

## REFERENCES

1.  **UK Transplant**. [http://www.uktransplant.org.uk/](http://www.uktransplant.org.uk/)
    
    

2.  **Cooper DKC**, Lanza RP. *Xeno—the promise of transplanting animal organs into humans.* New York: Oxford University Press, 2000 : 7–17.
    
    

3.  **Beecham L**. BMA wants presumed consent for organ donors. BMJ1999;319:141.
    
    [FREE Full Text](http://jme.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEyOiIzMTkvNzIwMy8xNDEiO3M6NDoiYXRvbSI7czoyNDoiL21lZGV0aGljcy8yOS8zLzEzNy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

4.  **Anon**. Organ donor reform rejected. BBC News Online. 16 July 1999. [http://news.bbc.co.uk/1/hi/health/396430.stm](http://news.bbc.co.uk/1/hi/health/396430.stm)
    
    

5.  **Josefson D**. AMA considers whether to pay for donation of organs. BMJ2002;324:1541.
    
    [FREE Full Text](http://jme.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEzOiIzMjQvNzM1My8xNTQxIjtzOjQ6ImF0b20iO3M6MjQ6Ii9tZWRldGhpY3MvMjkvMy8xMzcuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

6.  **Radcliffe-Richards J**, Daar AS, Guttman RD, *et al*. The case for allowing kidney sales. Lancet1998;351:1950–2.
    
    [CrossRef](http://jme.bmj.com/lookup/external-ref?access_num=10.1016/S0140-6736(97)08211-1&link_type=DOI) 
    
    [PubMed](http://jme.bmj.com/lookup/external-ref?access_num=9654279&link_type=MED&atom=%2Fmedethics%2F29%2F3%2F137.atom) 
    
    [Web of Science](http://jme.bmj.com/lookup/external-ref?access_num=000074464700045&link_type=ISI) 

7.  **Erin CA**, Harris J. A monopsonistic market—or how to buy and sell human organs, tissues and cells ethically. In: Robinson I, ed. *Life and death under high technology medicine*. Manchester: Manchester University Press in association with the Fulbright Commission, London, 1994:134–53. See also Harris J, Erin CA. An ethically defensible market in organs. BMJ2002;325:114–15.
    
    [FREE Full Text](http://jme.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEyOiIzMjUvNzM1Ni8xMTQiO3M6NDoiYXRvbSI7czoyNDoiL21lZGV0aGljcy8yOS8zLzEzNy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

8.  **Tuffs A**. Debate fuels controversy over paid-for live organ donation. BMJ2002;325:66; Hopkins Tanne J. International group reiterates stance against human organ trafficking. *BMJ* 2002;**325**:514.
    
    [FREE Full Text](http://jme.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEzOiIzMjUvNzM1NS82Ni9tIjtzOjQ6ImF0b20iO3M6MjQ6Ii9tZWRldGhpY3MvMjkvMy8xMzcuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

9.  **Allen RDM**, Lynch SV, Strong RW. The living organ donor. In: Chapman JR, Deierhoi M, Wight C, eds. *Organ and tissue donation for transplantation.* London: Arnold, 1997: 165 (original references omitted). See also—for example, Bay WH, Herbert LA. The living donor in kidney transplantation. *Ann Intern Med* 1987;**106**:719–27; Spital A. Life insurance for kidney donors—an update. *Transplantation* 1988;**45**:819–20. In this last study it was reported that in a sample of American life insurance companies, all would insure a transplant donor who was otherwise healthy and only 6% of companies would load the premium. We are indebted to Søren Holm for pointing us to these latter two sources.
    
    

10. **Hariharan S**, Johnson CP, Bresnahan BA, *et al*. Improved graft survival after renal transplantation in the United States, 1988 to 1996. N Engl J Med2000:342:605–12. See also Gjertson DW, Cecka, MJ. Living unrelated kidney transplantation. *Kidney International* 2000;**58**:491–9; Terasaki PI, Cecka JM, Gjertson DW, *et al*. High survival rates of kidney transplants from spousal and living unrelated donors. *N Engl J Med* 1995;**333**:333–6. We are indebted to Aaron Spital for pointing us to these sources.*J Med Ethics* 2003;**29**:138–139
    
    [CrossRef](http://jme.bmj.com/lookup/external-ref?access_num=10.1056/NEJM200003023420901&link_type=DOI) 
    
    [PubMed](http://jme.bmj.com/lookup/external-ref?access_num=10699159&link_type=MED&atom=%2Fmedethics%2F29%2F3%2F137.atom) 
    
    [Web of Science](http://jme.bmj.com/lookup/external-ref?access_num=000085575500001&link_type=ISI)