Organ Donation Incentives, Cont'd
In response to a post and comments at Marginal Revolution, I wrote the following, which I'm cross posting here:
The objections to incentives fail to adequately consider a) the range of incentives that might be considered or b) the way organ markets, if such things existed, would in fact operate within a system of insurance (including federal programs) and transplant centers. Incentives, for instance, might include tax advantages of interest primarily to the wealthy. One, proposed by my economist husband, would be a one-year exemption from federal income tax. That would result in organs going from the rich to the poor.
If there were a fully open market, organ acquisition would become just another cost of the transplant, like immunosuppressant drugs or transplant surgeons' fees, to be covered through the normal channels. The problem is when you don't make payment an above-board part of the medical system. That's when you get the many problems we currently observe in black markets, ranging from inadequate care and contract/financial protections for those who sell organs to the availability of organs only to those who are willing to break the law and have the means to travel abroad.
I don't believe that permitting payments, whether for organs outright, through tax incentives, or simply to make up for lost wages (which isn't illegal but doesn't happen today in large part because people think it's illegal), would make unpaid donations disappear. Blood donations coexist with blood banks that pay for blood. Volunteer fire fighters work alongside professionals. I would have donated a kidney without compensation even if it were legal. But I am a relatively affluent person who can afford to take such risks, and miss a certain amount of income, without compensation.
Expecting people to take risks and give up something of value without compensation strikes me as far more blatant exploitation than paying them. I don't expect soldiers or police officers to work for free, and I don't think we should base our entire organ donation system on the idea that everyone but the donor should get paid. Like all price controls, that creates a shortage--in this case, a deadly one.
While giving up a kidney has risks, it is no more risky and far less emotionally fraught than being a surrogate mother, something many women receive both money and personal gratifications from doing. I suspect that if, like the people who use surrogates (or egg donors), kidney patients were affluent professionals with political clout, markets in kidneys would also be legal. Unfortunately, the typical kidney patient tends to be a relatively low-income wage earner without the time, education, or social capital it takes to get policies changed.
As for the idea [from an earlier commmenter] that "Most people view the body/life/health as a sacred matter much like religion is," I certainly agree. When people hear that you are going to donate a kidney, they tend to be repulsed, though after the fact they dole out lots of praise. But we don't need everyone to think it's OK to give or sell kidneys. A tiny minority will do. The rest of the world can simply tolerate their odd behavior.
When I write about "organ donors," I am referring to live donors, primarily of kidneys, but many of the same arguments would apply to incentives for families considering donation of a deceased loved one's organs.
The issue of lost wages is a significant one, especially since kidney patients and their friends and families are disproportionately likely to be of lower socioeconomic status. In many cases, people who might be willing to serve as living donors simply cannot take the chance of financial ruin posed by losing a few weeks of pay (and that's assuming their understanding bosses would give them leave).
Addressing this problem does not require changing federal law--or any government policy. It can be done on a local level by voluntary donations. A philanthropic fund at a major transplant center like Washington Hospital Center, where our surgeries took place, could be established to cover documented lost wages of living donors, presumably with some income cap. Churches could do something similar for members who serve as living donors, presumably for relatives or other church members. This would be particularly valuable in the African-American community; black Americans make up about a third of the people who need kidney transplants.