Hammad Akbar

HSS 404 – Biotechnology and the Law

Introduction

Medical technology involved in the transplanting of organs has improved drastically over the last one hundred years. The effectiveness and success rate in organ transplant procedures has continued to improve. What was believed to be impossible to accomplish is now highly possible with minimal complications. Many people are in need of organs every year but will be put on wait lists that can take up to 5 years to receive an organ. According to a national database made available by the Organ Procurement and Transplantation Network (OPTN), it is stated that in

2018, there were 124,732 people on the wait list for an organ in the United States alone. Only

17,555 donors were available to meet the demands of this huge wait list (OPTN 2018). This

“small” concern is becoming a huge issue that needs to be solved. The United States of America should inherit the Iranian model of a market system that allows the sale of non-vital organs, so that organs can be bought and sold by all American citizens. Using this method, the amount of people on the transplant lists and the amount of deaths that result from waiting on these lists will be reduced drastically.

The continued success of organ transplants allows it to be an option available for anyone in need. The problem with organ transplants however is that the demand far outstrips the supply.

There are simply not enough organs to meet the needs of all those who need them. Due to this shortage people will travel to various parts of the world to obtain organs, a phenomenon called

‘transplant tourism’. In 2008, the World Health Organization estimated that out of the 660,000 people in the world that required any type of transplant, only 10 percent of patients received one every year. Of those ten percent, ten percent of them received their organs through ‘transplant tourism’ (Major 2008, 1). These organs however are sold on the black market and are obtained illegally. There is a great danger in gaining an organ this way. These illegal operations are performed by unqualified professionals and will result in a poor transplant which can cause further complications. If complications do occur, the recipient will then have to undergo further surgery when he or she returns home (Delmonico 2009, 1). In order to prevent problems like this from occurring, the United States must abandon the current system in place for organ transplants.

When an organ fails, a transplant is the only option to live an enjoyable life and not be wired to machines. The most common transplants that occur are kidney transplants, as most people are capable of living with only one kidney and liver transplants since the liver has the capability of regenerating itself. In the United States, for transplants such as a kidney, liver, pancreas and intestinal, a living donor must be found and if none can be found then that person is put on the national transplant waiting list. In the case a donor is found, doctors will check for compatibility. They will examine the size of organs, body of both donor and recipients, condition of organs and also the blood type of the donor and the recipient (Erin 2003, 1). Both parties must be a match in all categories in order to minimize the risk of rejection. Due to the need of similar blood type between the two people involved, family members often donate a kidney or part of their liver to the patient in need.

If the patient is in need of a heart, double lung, pancreas or cornea transplant then a cadaverous donor must be found. An acceptable cadaverous donor in these cases are those who are brain dead. This means that the brain is unable to function but their body and all other organs will continue to function with the help of life support (Miranda 1999, 1). Since organs deteriorate very quickly after death, the organs of a deceased person would be unusable. However, since there are very few generous living donors, the transplant waitlist is ever- growing. This is a fault in how America conducts transplants. Since the supply is unable to meet the demand, an increase in supply is necessary. One way to increase the supply would be to allow a free market in which people are able to directly sell their organs to those in need. Using this financial incentive many will feel far more generous with their organs.

A Market to Sell Organs in Iran

A market to sell organs has already been implemented and has been successful. This legal and government regulated market to sell kidneys was established in 1988 in Iran. Iranian citizens were able to have access to renal transplants with great success. The number of transplants completed had increased so drastically that in 1999 the waitlist for renal transplants was completely eliminated (Ghods 2006, 1137). The market originally functioned where donors would go to offices run by volunteers. The prospective donor would receive medical testing conducted by the Dialysis and Transplant Patients Association and then get matched with a potential recipient who has the same blood type. Further testing is still required but if successful, the kidney donation will proceed. The government assumed the costs if recipients were unable to pay and surgeries were performed in established hospitals or universities (Yanklowitz 2015). The market today is a free market with little government regulation and funding so that transactions can be done with minimal complications. With this market those who donate will also receive one full year of free healthcare paid by the government (Khosroshahi 2012, 3). Male donors are also granted exemptions from military service (Yanklowitz, 2015). Foreigners are banned from paying for transplants to avoid exploitation. Using this financial incentive many will feel far more inclined to sell their organs. There are however several flaws with this system. A lack of funding by the state has inhibited the transplant program. High inflation has caused government payouts to be drastically reduced and in some poor rural areas, due to depleted funds, donors lack proper follow-up care.

In a country that has a larger amount of available funds were to implement this system, these flaws would be reduced.

In the United States of America, the sale of organs is illegal. Donors must be voluntary and recipients are forced to wait on a waitlist in order to receive their desired organ when it becomes available. If America were to follow Iran’s model, the number of people on waitlists will reduce drastically. A proposed plan for allowing the sale of organs must first include a bill to allow the legalization of sale. After legalizing it, hospitals will perform the operation and reimburse the donor, and in turn be reimbursed through Medicare or private insurance

(Yanklowitz 2015). The organ donated will then be supplied to hospitals which will deal with the transaction for the recipient. There will be set prices for each organ which will not change in order to prevent exploiting the recipient of the organ. The organs that can be sold will include one kidney, portions of the liver and intestines and even one lung. In adopting such a system, the problem of waiting lists can be reduced.

Moral and Ethical Implications

This discussion of a legal market in which organs can be bought and sold revolves around the morality and ethicality of implementing such a system. The ethical arguments regarding organ sales is centered around the issue of justice (Coro 2016). Arguments are linked to the long standing social paradigm in which ‘the rich get richer and the poor get poorer’ (Shelley 1965,

33). The implementation of a free market in which organs can be bought and sold would cause the poor to be exploited and the rich to benefit. Those encouraged to donate due to a compensation fee would be those who are in need of money. Allowing the sale of organs would be placing an “organ tax” on impoverished and desperate people. In the legal market established in Iran, 70 percent of kidney donors are economically disadvantaged (Hippen 2008, 7). Poor people would essentially be paid to take a permanent and increased health risk in order to reduce the health risk of another person.

The group of people who would be most at risk to being exploited by potential purchasers are those who are economically disadvantaged, illiterate, bonded laborers and criminals sentenced for execution. These people are seen in a lower standing to the rest of society and therefore will be the target audience to create an organ supply.

Another system to incorporate the sale of organs is a single payer market. In this market, there would be a single purchaser of the organs, some type of agency, and this agency would buy and distribute organs as needed (Erin 2003, 1). There is however an ethical issue with this type of system. Having a single entity distribute organs to the whole populace would cause an uneven distribution of organs across multiple class lines (Coro 2016). There are also issues in which compensation for donors would be uneven as well. This type of market system does not mitigate the disparity between the poor and rich but in fact enhances it as it gives a single agency the power to give organs to who they please and allows them to control the amount of compensation given.

It is important to analyze the ethical and moral issues regarding an organ market. Proper ethical and moral behavior is important because it helps to make society better (McCartney

2015). Therefore, any potential market that would be devised by the United States would have to be a benefit to society. While there are ethical risks where certain populations would be exploited, it is worth taking this risk to because it would benefit society as a whole. When the program to buy and sell kidneys was implemented in Iran, within 11 years the waitlist was cleared (Ghods 2006, 1137). By having this system in the United States, there is potential to drastically reduce the amount of people on the waitlist for transplants. A survey experiment conducted by economists at the American Economic Association was able to determine the support for paid transplants. 3,417 United States residents were surveyed and it was found that

52 percent were in favor of paid transplants. That number however rose to 71 percent when further information was provided on how a paid transplant system would function (Elias 2015,

361). These numbers are indicative of an increased approval of paid transplants when a proper program is presented. If America were to create a program and properly inform the public of its function, support for an organ market may increase.

Religious and Cultural Views on Organ Transplantation

Religion and culture play a significant part in the ethics surrounding organ transplantation. In Islam, the human body is seen as a creation from God. This body belongs to

God and as a human you are simply borrowing it. The body should therefore be returned in the condition received unless changes to the body are unavoidable. Examples of unavoidable changes to the human body can be cases where the change is necessary to extend life or if these changes are a result of an accident. With respect to organ donation, certain scholars in Islam oppose donating organs as it is destroying God’s creation. An opposing view to this however is that organ donation should be encouraged but only if it is the result of the Muslims altruism

(Collins 1997). In Christianity, some scholars believe living organ donation should happen between only Christians (Bruzzone 2008, 2). However, a general view is that organ donation is capable of saving many lives and therefore is encouraged. In Judaism, there are three principles that govern the treatment of a deceased body. The cadaver should be respected and treated with dignity, someone should not benefit from the corpse and the body must be buried immediately

(Solomon, 2001). Despite these principles which would prohibit organ transplantation, saving a life through organ donation supersedes these rules. Transplantation does not desecrate the body or show a lack of respect. Despite some objections, overall every religion has accepted organ donations as it is seen as a lifesaving operation.

It is important to look at the religious views on the act of organ donation. In the United

States, religion is a fundamental part of the nation. Citizens have the power to practice religion freely as stated in the first amendment of the Constitution. “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof…” (U.S. Const. amend. I). The U.S. must then create a system in which religion is expressed and that the act of donating an organ will not impede on an individual’s right to practice religion.

Economic Implications

Another facet of an institutionalized organ market is the economic implication it has, for both donors and governments. Kidney sellers are worse off a year after selling their kidney

(Scheper-Hughes 2016). Most sellers are poorly educated and unskilled laborers who rely on their body to do work. After their operations, many are excluded from their previous work due to the liability of the operation itself. Their day to day work requires the lifting of heavy objects and essentially to be someone capable of doing rigorous work. While they are paid a lump sum for selling a kidney, they are out of work for an extended time period. The economic toll of organ impairment is immense on a patient and diseases which can be treated by organ transplantation causes a disproportional strain on healthcare infrastructures.

“In 2014, more was spent by Medicare on renal disease treatment than all cancer treatments combined. The cost of end-stage organ disease is also tremendous at the global level, with more than $1 trillion spent over a decade globally on renal disease treatment alone” (Ward 2018). With further advancement in making transplants more successful and an established organ market to make transplants more accessible, healthcare costs can decrease overall. The cost of organ transplantations can be broken down into three categories, operation costs, post operation costs and chemical costs. Technological advancements and more frequent transplant operations can help to reduce the costs accrued during the operation process. In having an organ market, organs can be more readily accessible and complications can be reduced because the best possible match can be located. A supply of organs would enable immune tolerance induction and better matching between organ and recipient thus reducing the costs of immunosuppressant drugs

(Ward, 2018).

Over an extended period of time, transplantation is also shown to be a cost effective method to treat end stage organ disease. For example, one treatment method for end stage renal disease requires patients to be wired to dialysis machines which can cost up-to $89,000 per patient annually. The only other method to treat kidney disease is through kidney transplantation which costs about $32,000 for the operation and then a further $25,000 per year. Over a five year period of time, the more readily available dialysis treatment costs $445,000 as opposed to transplantation which would cost $157,000 (UCSF 2013).

Policy on Organ Trade, Markets and Donations in Other Countries

Israel and Pakistan have been two of the most prominent participants in what is known as the “global organ trade.” This phenomenon is when organs are trafficked and citizens would go to different countries to have transplantation operations performed, a method also called transplant tourism. Israel and Pakistan are countries that have facilitated transplant tourism in different ways. With a severe organ shortage in Israel, patients from Israel would undergo transplantations in several countries worldwide (Efrat 2013, 1650). Israel’s primary health insurance providers would reimburse transplantation patients. Pakistan played an opposite role to that of Israel, in which it was the destination of transplant tourism. In 2007, out of 2,000 transplantations to occur in Pakistan, 1,500 of them were performed on foreigners (Rizvi 2010).

The failure of Israel and Pakistan to have proper legislation caused a general acceptance of transplant tourism as an effective method to combat the organ shortage.

Both of these countries however enacted laws aimed at regulating transplant activity.

Israel enacted the Organ Transplantation Law in 2008. This law defined what brain-respiratory death is and also provides benefits to living organ donors. Organ trafficking is also strictly prohibited (Berzon 2018). Pakistan enacted the Transplantation of Human Organs and Tissue

Ordinance in 2007 which later became an act of parliament in 2010. This law prohibited the donation of organs or tissues by a living person unless they are genetically or legally related

(Raza 2012). Transplants must also be voluntary and without coercion. Israel and Pakistan had enacted laws in order to combat transplant tourism to varying degrees of success. In Israel, the number of Israeli transplant tourists had dropped from 155 in 2006, to 35 in 2011 (Efrat 2013,

1652). In Pakistan however, the effect was not seen over the same time period. There was an immediate effect in 2007 when the ordinance was put into effect with a decrease in the number of commercial transplants, yet in 2010 when the ordinance became an act of parliament, the organ trade regained momentum (Efrat 2013, 1653).

Currently, Spain is the leading country in organ donations worldwide. While prohibiting the sale of organs, Spain has implemented a system in which the time spent on waiting lists can be as short as 20 days (Baraniuk 2018). In 1979, in order to improve the rate of organ donors,

Spain implemented their current presumed consent legislation, otherwise known as the ‘opt-out’ system (Fabre 2010). Under this system, all citizens are presumed as organ donors from the day they are born. If someone wishes not to be an organ donor then they must fill out the proper paperwork and classify themselves as not an organ donor. Donors are only considered when they are relatively young and healthy as determined by a doctor and must be brain dead (Miranda

1999, 2). Brain death is defined as the total and irreversible loss of brain function. A patient can only be considered brain dead when two doctor and one neurologist confirm it as such (Goila,

2009). Once determined, the family of the deceased is contacted and the family has the final decision as to whether the organs be donated. In many cases organs are stored as a cadaverous donor’s organs would deteriorate quickly. This system in combination with a centralized organ donation agency, donor rates improved. In 2017, Spain had the highest donor rate in the world with 47 people per million. This number compared to the United States 32 people per million shows an improved effectiveness in the presumed consent system implemented by Spain to insure higher donor rates (IRODat 2018).

Conclusion

The organ donor shortage in the United States has presented itself as a problem which impacts the lives of over 120,000 people (OPTN 2018). A feasible solution is to have an organ market which allows organs to be bought and sold. This market would be modeled after Iran’s program. Such a solution however faces scrutiny because of the many ethical and moral issues.

There is a possibility that impoverished people will be exploited due to being most in need of money. However, with strict regulation, this can be prevented. Having such a market has the potential to reduce the aforementioned waitlist. The economy and healthcare industry would also benefit as a whole. As more organ transplants occur, people would generally be more healthy and would require less alternative medicine. An alternative to having an organ market would be the implementation of a program similar to Spain’s, “opt-out” system. By having this system, the entire population of the United States would be considered organ donors unless one explicitly fills out paperwork saying otherwise.

There is potential to implement a successful organ market. Iran is one example of this and if the United States adopt such a system, there is hope to save many lives.

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