By contributor
updated 6/25/2008 5:02:55 PM ET 2008-06-25T21:02:55

Need extra livers hearts or  kidneys to transplant because the demand is greater than the supply? The answer, say proponents, is simple. Put a price on kidneys and livers and people will be falling all over one another to sell them. Set the price high enough and hordes will amble into hospitals, sign binding agreements to let themselves be sawed into transplantable bits for cash upon their demise, the thinking goes.

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In fact, the American Medical Association recently called for pilot studies on financial incentives for organ sales.

Sounds good, right? Not so fast. Despite the AMA’s enthusiasm for testing a cash-for-parts scheme, it will never work in America.

The market of supply and demand has its place. When it comes to things like cars and paperclips, what we pay for them goes, in part, to helping make more. But when it’s impossible or difficult to create more of the item that’s in high demand, markets simply hike prices to ration access to whatever resource exists. If you don’t believe me, visit a gas station or a ticket scalper.

The supply of transplantable organs is very limited. Despite the AMA’s hopes, we are not going to get a lot more simply by putting a price tag on them.

Not so easy
Becoming an organ donor when you die is actually a very difficult thing to do. About 2.5 million people died in the U.S. last year. But only about 25,000 transplants were done using cadaver organs. While it may seem like there’s plenty of potential to get more organs if the price is right, which is what the AMA apparently is thinking, getting a big boost in the supply from cadavers would be very hard.

You can only be an organ donor if you die in a hospital on life-support. Very few of us do. And you need to be in fairly good shape except for a traumatic injury to your brain. Add to that the fact that donors cannot have any serious communicable diseases and the number of possible donors in that 2.5 million pool shrinks to a fraction.

Many of those who haven’t already signed up to be a potential donor probably have little interest in doing so. The prospect of legally auctioning off their useful remains to the highest bidder when their number is up is not likely to change their minds.

Money and body parts don’t mix
Whether for religious or cultural reasons, some Americans don’t like mixing money and body parts. Some just don’t trust the health care system and fear being rushed off to their maker prematurely if they indicate a willingness to be a donor — a fear not likely to be assuaged if paying for organs makes people worth more dead than alive. Others think markets in body parts smacks of treating bodies as property in a way akin to slavery — something this nation fought a horrendous war to eliminate. And still others know their religion does not permit treating the body as property — what is a gift from God cannot be sold but only stewarded.

If this country were to allow financial incentives for organs, the money would presumably go to the family or the deceased’s designee. But if these people have their hand on the life-support plug and know they stand to make good money as soon as the owner of the valuable body parts is dead, how hard are they going to try to keep that owner alive? While offering money for organs might persuade a few more to donate, it is more likely to turn off those now willing to consider giving out of fear or knowing there’s a reward for their death. Net result: A loss in the overall number of organs available.

The same story applies to using money to encourage living donations. Unless things take a really unethical turn, we are only talking about kidneys and parts of liver or pancreas. But having surgery to remove those organs, and living without them, carries real medical risks. Are there really lots of Americans who are going to line up to sell their parts knowing that potentially nasty complications and even a slight risk of death will follow? I doubt it. And even if some are willing, it won’t be long before prices start to inch up, opening a bidding war for scarce organs and leaving all but the richest with no shot at a transplant. Add in the incentive for potential sellers to lie about their health status as prices begin to climb and you have created a mess, not a solution.

A better way
Perhaps the best argument against markets is that there is another option that has yet to be tried in the U.S. In Spain, Italy and Belgium, laws creating presumed consent or what I prefer to call “default to donation” have been enacted. In those countries, people who don’t want to be organ donors upon their deaths have to register on a computer, carry a card or tell their loved ones they don’t want to donate. Otherwise, the presumption is that you want to be a donor.

No, this is not a socialist plot to give the state control over your body. Under “default to donation” no one’s rights are taken away. You don’t want to donate? Just say so. Default donation is basically the same system we have now except that instead of opting in using a card or drivers license you have to opt out using a card or a driver’s license.

Based on the European experience, we’d likely see a significant jump in the number of organs available to dying Americans. Spain has donor rates two times higher than in many parts of the United States. The default plan could bring a boost in organs for transplant without creating the headaches, fears and misdistribution of a financial market. Doesn’t it make more sense to try a low cost plan that has a chance of working then a high priced market that won’t?

Arthur Caplan, Ph.D., is director of the Center for Bioethics at the University of Pennsylvania.

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