Thanks to ever increasing medical capabilities, organ transplantation has become an established life-saving therapy. However, demand for organs exceeds supply because altruistic donations are the only legal source in most countries. This means that in this chain of transactions the original supplier, the organ donor, must not profit.
People die because of flawed systems
At 31 March 2018 there were 6,044 patients on the UK transplant waiting list, 3,404 suspended, 411 dead and 755 removed mainly due to physical deterioration. In the USA approximately 100 patients on the waiting list die each week.
Only one-third of the UK population is listed on the Organ Donor Register. A US national survey in 2012 revealed that despite 95% theoretical approval for donations amongst the population, only 60% of respondents had granted permission on their driver’s license.
In conclusion, the current system of altruistic organ donation is insufficient to meet demand.
Organ markets exist
WHO Guiding Principle 5 requires donations to be made “freely, without any monetary payment or other reward of monetary value”. However, it allows for reimbursement of direct expenses and “tokens of gratitude” that cannot be transferred to another party. By design, this prevents any tangible gratitude for cadaveric (after death) donations. Even funeral and other costs are born by the bereaved. The internationally endorsed Declaration of Istanbul calls for national self-sufficiency in organ supply to counter organ trafficking. Albeit, no solution is provided and financial neutrality also demanded, i.e. “donors and their families [shall] neither lose nor gain financially” from organ extraction. EU member states compensate living donors to varying degrees, mostly in form of expense reimbursements. Whilst immediate expenses for travel or lost working hours in case of living donations can be measured, long-term costs are difficult to assess such as loss of work, lowered quality of life, enhanced healthcare needs and insurance costs. None of this increased risk is being compensated, making living donation a net-negative transaction for the donor. Strictly, current systems make financial neutrality unachievable.
Since medical service providers in the transplant supply chain are paid to operate profitably, the question is not whether a legal commercial organ market exists, but why the initial transaction must be altruistic by law. Even though costs are monitored, service providers can inflate prices to turn a profit legally. Because hospitals are not allowed to sell organs, they may be inclined to retain them locally by expanding waiting lists to generate returns from operations. Even without payment to donors, the human body has economic value due to undisputed practicalities of existing processes.
Even without payment to donors, the human body has economic value due to undisputed practicalities of existing processes.
Legal European organ exchange programmes are largely underdeveloped. Thus, illicit organ trafficking is spawned by the shortage in home countries and absence of legal trade. Small surveys of physicians in the UK and Ireland reveal liver and renal transplant tourism even though data gathering is difficult due to the legal grey zone for patients and clinicians. Evidence suggests that treatment abroad is often suboptimal, which ultimately strains domestic healthcare systems.
Notably, off-waiting list barter-type markets are allowable within legal boundaries. If patients have sourced incompatible donors, they can swap those to provide matching donors for each other.
Altogether, the only transaction partner in current legal organ markets who is not adequately rewarded is the party bearing the greatest burden, the donor and their family.
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