The editors of the Wall Street Journal invited me to review two new books on the topic of kidney donations, and my review appears in today’s edition. The first book, When Altruism Isn’t Enough by Dr. Sally Satel, gives readers a step-by-step academic analysis of the costs and risks associated with current methods of handling end-stage renal disease (ESRD), the profound shortage of transplantable kidneys, and the benefits of incentivizing live donors in order to reduce the overall costs in ESRD maintenance, ie, dialysis. Those costs are extraordinary, and borne directly by Medicare:
Compensation would dramatically increase the number of kidneys available, the writers argue, saving lives not just because more transplant operations would be possible but also because live-donor organs perform better than those from cadavers. Another advantage of paying for kidney donations would be a radical reduction in costs to Medicare and thus to American taxpayers. Estimates of the annual costs for dialysis treatment and care for end-state renal disease approach $20 billion.
How would a compensation system work? Dr. Satel considers both government and free-market options, but she and her contributors clearly favor the former. The federal government has the means and the incentive to drive down costs through compensation, either with cash or in-kind allotments such as college tuition or tax deductions.
Readers of Captain’s Quarters will recall that my wife has had three kidney transplants. The first of these came from a cadaver donor, which lasted nine years, about the average at the time of that transplant. Live donor kidneys usually last for 25 years or more. We found a friend willing to donate a live kidney in 2004, which should have sufficed, but unfortunately a viral infection in 2006 killed the kidney. Another friend from the same organization then volunteered to donate another in 2007, and she has been healthy ever since.
Unfortunately, unrelated live donors are rare, and dialysis is a poor substitute. The wait time now for a cadaver donor stretches as long as seven years, which is a death sentence to many on dialysis. Half of the 250,000 ESRD dialysis patients aren’t even on the transplant list, for a variety of reasons, and the 7,000 cadaver kidneys available each year probably doesn’t keep up with the additions to the list. Eventually, stem-cell therapies might end the need for transplants, but that’s a very long way off, and people die in the meantime — at least 1,000 patients on the list each year. Dialysis for most people is a prolonged death, not a strategy for managing long-term survival.
Satel’s proposal for compensation prompts two major questions: does kidney donation prove harmful to donors in the short or long term, and would compensation exploit the poor and desperate? The studies Satel and her essayists (which includes the director of the transplant center the First Mate uses) shows that live kidney donors have as good or better long-term health as the general population. Of course, they are chosen for their good health, so that should be taken into consideration, but clearly the data show that they don’t show any long-term trends towards a degradation in health. The “do no harm” ethic, critical for this question, seems very well established already — and our two friends have shown no ill effects at all.
Exploitation is another question. That happens in other countries that employ a compensation system; Satel uses India as an example, where the poor do not get enough information on the surgery, get compensated poorly, and do not get good follow-up care. Having seen the current live-donor system from the inside on three occasions — I was almost finished with the tests to donate the kidney the first time when the cadaver kidney trumped me in 1995, and by 2004 my Type II diabetes removed me from consideration — I can say that we already have protections for live donors in terms of disclosure and care.
Given that the government absorbs all the cost in the current ESRD maintenance system, a government-run compensation system probably makes the most sense, which would also hopefully structure payments across a long term to keep the acutely desperate from trading a kidney for momentary relief. A government system would also get built in a “blind” method, where donors and recipients never meet or know each other’s identities, to avoid the appearance of the rich buying organs from the poor. A free-market system might provide better compensation levels for the donors, but it also would be harder to ensure that the ethical considerations remain paramount, and government is already for better or worse a major stakeholder in the transaction.
The second book, Larry’s Kidney by Daniel Asa Rose, shows what happens when money talks. I’ll refer you to my WSJ column to get the entire sense of the book, but I’ll boil it down to this: It’s a gripping read, but you’ll feel morally compromised before you get to the halfway mark. Rose is a talented writer in a bad cause in this book, although it gives a very interesting view of modern China.
Update: Sally Satel responds on AEI’s Enterprise Blog, with some sympathy for Rose as well.