From the WSJ Opinion Archives
ECONOMIC MEDICINE
Have a Heart. We'll Send the Bill.
The case for selling human organs.
Last weekend American moviegoers shelled out $23.6 million to watch John Q. Archibald, played by Denzel Washington, hold an emergency room hostage because his HMO wouldn't spend $250,000 for his dying son's heart transplant. One wonders how many hearts could have been purchased for that $23.6 million if the supply of organs for transplant were expanded through monetary incentives.
Sound ghoulish? Bear with me. The standing American policy of the distribution of transplant organs can be summarized in one proposition: It is divine to give, but evil to sell. Altruism is chic; individuals are encouraged to give their organs at death and even during life. And they do, chiefly to close family members. But trade is verboten: It is a criminal offense to sell organs, either during life or after death, to strangers.
Unfortunately, altruism to strangers is in short supply, especially for invasive procedures that carry with them palpable discomfort and some small risk of death. So the queues predicted by the classical economic theories continue to grow. Now that transplant techniques have improved, about 79,000 people are awaiting organ transplants; about 5,500 die each year in part because price is not allowed to rise to bring supply and demand back into equilibrium.
Now there are glimmerings that all this might change. The American Medical Association's Council on Ethical and Judicial Affairs may stick its small toe into the rushing waters of voluntary markets. Stories in this newspaper and elsewhere suggest that the learned delegates may overcome their moral qualms about organ transplants and propose, cautiously and on an experimental basis, a program that will allow the payment of small sums in the neighborhood of $300 to $3,000 for cadaveric organs in an effort to overcome the current acute organ shortfall.
Francis Delmonico, who heads the AMA Committee, has opined that these small payments are merely designed to offset funeral expenses. Yet even this modest proposal generates a fierce reaction. Thus Dr. Mark Fox, who heads the ethics committee at the United Network for Organ Sharing, wants to keep the ban in place because the payment of money could be "unduly coercive to certain segments of the population."
Yet in many cases compensation would actually reduce the coercion exerted on family members to make live organ transfers. Less social muscle is needed if some cash could be paid so as to offset the real costs that these transplants require. We should not care whether the proceeds are spent on funerals or potlatches.
There is, moreover, lots of room to maneuver, given the enormous gains from trade. Take some ballpark estimates: Before a kidney transfer, the healthy "donor" has a life expectancy of 50 happy years; the recipient, on the other hand, a miserable 18 months. With the transfer, the donor reduces his life expectancy by, say, two years, but the organ recipient increases his by, say, 10 years or more. The payment in cash or kind generates the mutual gain that allows the transplant to go forward.
This simple economic (and moral) logic does not answer all questions about how organ markets should be structured. It is highly unlikely that direct sales between donor and recipient make any sense. The difficulty of securing matches between two individuals requires the use of intermediaries to collect the organs from one group of individuals and distribute them to another. In addition, it is probably necessary to give full disclosures before individual organ donations are allowed. Notwithstanding the dangers of paternalism, informed consent should be the applicable norm here, as it is with other forms of surgical treatments.
Finally, it is not clear whether the state or individuals should purchase these organs. I believe that individuals should be able to use their own wealth to purchase organs, and that public agencies and charitable organizations should be allowed to use their funds to supply organs, as desired, to the needy. Others may disagree and prefer to continue the metaphor of organ sharing that is part of the United Network for Organ Sharing's name. But even the release of "John Q." should not provoke the unwise response of requiring HMOs or employers by law to cover organ transplants.
For the moment, however, these disputes are details. The first item on the agenda is to increase supply. No matter how these questions are answered, that won't happen so long as we keep the creaky set of policies that are now in place for "ethical" reasons. Rather, we should summon the courage to denounce as immoral any high-minded policy that forces needless deaths by constricting the supply of organs.
In time, perhaps, we may develop a stable source of animal organs that will eliminate all doubts about organ transplants. But in the meantime we should enact, not repeal, the law of supply and demand.
Mr. Epstein is a professor of law at the University of Chicago and a senior fellow at the Hoover Institution. He is the author of "Mortal Peril: Our Inalienable Right to Health Care?" (Perseus, 1997).
