Organ market debate
a regulated organ market?
Since the organ trade was first prohibited, an ongoing debate has been dominating the discourse on whether or not to allow payments for organs. Already in 1997, the Bellagio Taskforce wrote that international declarations against commercialism are “put forward in one or two terse sentences with no supporting arguments.” Its authors further stated that “the grounds for condemnation are not as obvious as declarations imply” (Rothman et al., 1997). The overarching question in this discourse is whether allowing government-controlled payments for organs would increase organ donations, reduce patient mortality on transplant wait lists and whether it would reduce the harms on the black market.
Those who are critical of prohibiting payments for organs under all circumstances have been proposing experiments and trials on a so-called 'monopsonistic market'. Such a market designates a central government-run body to reward/pay organ donors and allocate organs. All organ donations would be anonymous and payments between donors and recipients would be strictly forbidden (Erin & Harris, 1994; Matas et al., 2012; Hilhorst & Van Dijk, 2007). Because of the worldwide ban on payments for organs, it is currently not possible to test whether government-incentivized organ donations would be an effective and ethical solution to the organ scarcity and black market abuses.
In the absence of this data, we do not favor one model above the other. Rather, our view is that experiments on incentivizing organ donations would generate data that enables comparative research with current prohibitionist systems. This, in turn, would help evaluate the efficacy, ethics and impact of different models towards organ scarcity and black market abuse.
In 2017 the ELPAT Working Group on Organ Trade and Trafficking wrote a paper advocating for separation of 'trade' (payments for organs) versus 'trafficking' and for the decriminalization of organ sales in order to better protect organ sellers and enable them to safely report abuses without risking conviction:
- Columb, S., et al., (2017. "Re-conceptualizing the organ trade: separating 'trafficking' from 'trade' and the implications for law and policy" . Transplant Int. 30(2): 209-213
Selected articles on the pro/con debate
- Sterri, A. B. (2021). "Why States Should Buy Kidneys." J. Appl. Philos. 38(5): 844-856.
- Danovitch, G. M., et al. (2021). "The True Meaning of Financial Neutrality in Organ Donation." Am J Kidney Dis 77(6): 967-968.
- Delmonico, F. L., et al. (2015). "Living and Deceased Organ Donation Should Be Financially Neutral Acts." American Journal of Transplantation 15(5): 1187-1191.
- Koplin, J. (2014). "Assessing the likely harms to kidney vendors in regulated organ markets." The American Journal of Bioethics 14(10): 7-18.
- Working Group on Incentives for Living Donation. (2012). Incentives for organ donation: Proposed standards for an internationally acceptable system. American Journal of Transplantation, 12(2), 306.
- Radcliffe Richards, J. (2012). The ethics of transplants. Why careless thought costs lives. Oxford: Oxford University Press.
- Hilhorst, M. T., & Van Dijk, G. (2007 ). Financial incentives for organ donation. An investigation of the ethical issues. Available at www.ceg.nl or here.
- Radcliffe-Richards, J., Daar, A. S., Guttmann, R. D., Hoffenberg, R., Kennedy, I., Lock, M., Tilney, N. (1998). The case for allowing kidney sales. The Lancet, 351(9120), 1950-1952.
- Rothman, D. J., Rose, E., Awaya, T., Cohen, B., Daar, A., Dzemeshkevich, S. L., Smit, H. (1997). The bellagio task force report on transplantation, bodily integrity, and the international traffic in organs. Transplant Proceedings, 29(6), 2739-2745.
- Erin, C. A., & Harris, J. (1994). A monopsonistic market: or how to buy and sell human organs, tissues and cells ethically. In I. Robinson (Ed.), Life and death under high technology medicine (pp. 134-156). New York: Manchester University Press.
Empirical studies on allowing payments for organs
- Held, P. J., et al. (2018). "Would government compensation of living kidney donors exploit the poor? An empirical analysis." PLoS ONE 13(11).
- Elias, J. J., Lacetera, N., & Macis, M. (2019). Paying for Kidneys? A Randomized Survey and Choice Experiment. Am. Econ. Rev., 109(8), 2855-2888.
- Elias, J. J. (2017). The role of repugnance in the development of markets: The case of the market for transplantable kidneys. Social Economics: Current and Emerging Avenues, The MIT Press: 234-244.
- Hoeyer, K., Schicktanz, S., & Deleuran, I. (2013). Public attitudes to financial incentive models for organs: A literature review suggests that it is time to shift the focus from 'financial incentives' to 'reciprocity'. Transplant International, 26(4), 350-357.
- Kranenburg, L., et al. (2008). "Public survey of financial incentives for kidney donation." Nephrol Dial Transplant 23(3): 1039-1042.
organ payments in iran
Iran is currently the only country with a running kidney donation and transplantation program that claims to have eliminated its kidney transplant wait list. The country is internationally condemned for having achieved this by paying living kidney donors. The laws and regulations that underlie Iran’s decentralized, semi-regulated payment system differ between the country’s various states, which leads to differing, even conflicting outcomes and reports. These cross-country variations, in conjunction with the limited available data and the absence of a data-driven dialogue, has led to speculation and a poor understanding of the Iranian model within the international (transplant) community.
The Iranian model is not entirely government-controlled. In many regions, the country tolerates side payments between recipients and donors besides the fixed government fee. While problems are reported that are associated with these unregulated organ transactions, emerging evidence suggests that the reported exploitation of kidney sellers in Iran is less severe than the harms reported on the black market.
Empirical studies about Iran's payment schemes
- Moeindarbari, T. and M. Feizi (2022). "Kidneys for Sale: Empirical Evidence from Iran." Transplant International 35: 10178.
- Fry-Revere, S. (2014). The Kidney Sellers. A Journey of Discovery in Iran. Durham, North Carolina: Carolina Academic Press.
- Fallahzadeh MK, Jafari L, Roozbeh J, Singh N, Shokouh‐Amiri H, Behzadi S, et al. Comparison of health status and quality of life of related versus paid unrelated living kidney donors. American Journal of Transplantation. 2013;13(12):3210-4.
- Feizi, M. and T. Moeindarbari (2019). "Characteristics of kidney donors and recipients in Iranian kidney market: Evidence from Mashhad." Clinical Transplantation 33(10): e13650.
- Feizi, M. and T. Moeindarbari (2019). "Donor Willingness to Accept Selling a Kidney for Transplantation: Evidence from Iran." J Urol 201(2): 235-236.
- Heydari RA, Mahdavi MM, Zamyadi M. Compensated living kidney donation in Iran donor’s attitude and short-term follow-up. Iranian Journal of Kidney Diseases. 2009;3(1):34-9.
- Zargooshi, J. (2008). Iran's commercial renal transplantation program: Results and complications. Organ Transplantation: Ethical, Legal and Psychosocial Aspects - Towards a Common European Policy. W. Weimar, Bos, M., Busschbach, J.J. : 80-92.