Here’s a draft of a piece I’m working on. Would love any suggestions for improvement or other thoughts. The more critical the better!
Also note that it’s just a draft, so I may make dumb points or say things in stupid ways. Wait till it’s final to hold it against me.
I Wanted the Government to Buy Kidneys: Then I Changed My Mind
Four years ago, when I donated my kidney, I was a passionate believer that the government could pay people for their kidneys, save a great deal of money and rescue tens of thousands from a grueling death. So in 2013, I left my job at a corporate law firm (and my home in Boston), moved to Toledo, and joined the transplant field so that I could enact this change.
A year after that, I co-authored a letter in favor of incentives signed by hundreds. By that June, I’d received a grant from a major foundation to plan a nonprofit to bring incentives to the transplant field. But then I changed my mind.
I didn’t change it all at once or entirely. I still think donors should be treated better than they are. A lot better. But what’s different is where I used to think kidneys could be an item to be purchased by the government, now I think it’s a bad idea to treat them as just another commodity up for exchange. Instead, for kidney donation to be respected, our society needs to treat it like an act of public service and honor donors accordingly.
Here’s how I got there.
Why I Liked Incentives
The kidney transplant shortage might be the most underrated public health problem in America. The current waiting list is a hundred thousand names long. Each year, twenty thousand more people go on the list than receive a transplant. That number represents 50% more than all the homicides committed in the nation last year. Each living donor transplant saves a decade or more of life. Year after year, this shortage crisis represents a truly massive number of lives lost.
Kidney donation is a safe, laparoscopic procedure. Most donors are out of the hospital after a couple nights and off prescription painkillers after a week. Donors lead normal, healthy lives. As with any surgery, there are risks: about 1% of donors will develop kidney failure over their lifetime, which is 0.9% higher than if they hadn’t donated. By comparison, the lifetime risk in the general population is 3.2% (kidney donors need to be healthier to start with). Like any surgery, donation can have complications, but the chance of dying is just 3 in 10,000. And there is uncertainty—people have been donating kidneys for sixty years, but ascertaining exact health effects decades down the line for an unrepresentative population is an epidemiological struggle– one that is necessarily imperfect.
But what is clear is that kidney donors remain as healthy or healthier than the general population after they donate.
Moreover, kidney donation saves the government a great deal of money: Medicare guarantees coverage for patients with kidney failure regardless of age, and averaged over the first five years, transplants costs $60K per year less than dialysis. Since live donor kidneys last for fourteen years on average, a cost savings of $300K is conservative.
That means the government could easily afford to pay $50K or $100K to donors to undergo a surgery that is safe and saves another person’s life. If you persuaded one in two thousand Americans to take that deal, you’d end the shortage tomorrow. No more waitlist: a hundred thousand lives saved; a hundred thousand families rescued from tragedy. Seemed like a no-brainer.
And while we may reasonably worry that the people incentivized to donate would be disproportionately poor, the shortage itself primarily affects people of color and the impoverished. The primary causes of kidney failure are obesity, diabetes, and hypertension, which each share a racial bias. Minorities make up 38% of the American population but 63% of the kidney waiting list. Access to living donation is also racially skewed. Only 29% of living kidney donation comes from minorities, and a white person in the top income quintile is three times more likely to donate than an African American in the bottom quintile, despite African Americans needing kidneys at three times the rate of whites.
Whatever negative racial pattern incentives might have for donors would be dwarfed by the extraordinary health improvement it would achieve for vulnerable communities.
The Problem with Incentives
When I joined the transplant field, I wanted to understand the best case against incentives (so I could beat it). Since I’m a philosophy geek, that meant reading authors like Elizabeth Anderson, Margaret Radin, Lewis Hyde, and Michael Sandel to better understand commodification and the philosophy of market exchange.
To vastly simplify, commodification is when you take something that’s sacred and sell it like it’s scrap. Prostitution takes something intimate and reduces it to something more empty. Selling organs could turn our very bodies into a mere repository for parts (“Kidney Depot”). Even though the seller can rationally consent, she might not be able to avoid being in some way worse off.
Mortifyingly, the example that best illuminated this for me was my time as a corporate lawyer. Like many such, I was all at once unreasonably well-paid, extraordinarily lucky to have the job, and absolutely miserable. Though it may have been completely rational to sell years of my life for money, in some real way it left me diminished.
So how to weigh this risk of commodification against the benefits? I’m honestly not sure, but I do know the lives saved by incentives don’t just erase the problem. A society that looks down on kidney donors as desperate and unclean – as mere human vending machines – would be unspeakable no matter how much healthier it was than our own.
Moreover, diminishing the value of donation could also have bad consequences. Living donors currently give 5,500 kidneys a year; deceased donors 11,500 more: will people still be so generous if the status of organ donation were to decline?
And then there’s the risk. Market incentives would be a drastic change to a national regime of organ donation whose creation was hard-fought and which relies on only the public’s good will to survive. Jeopardizing that system through drastic change could sacrifice people who definitely receive transplants today for the mere potential of lives saved tomorrow. We should avoid that risk if at all possible.
Transplant support was my way of trying to get the benefits of incentives while avoiding their pitfalls. Transplant support treats kidney donation as a public service: making donation an act of community support rather than individual heroism.
In practice, respecting donors as public servants means offering them lifetime health insurance to alleviate and offset the risks of donation; it means providing annual research stipends to donors to encourage participation in follow-up study and care; and it means removing disincentives to donation by paying donor expenses like lost wages and making the experience of donating as convenient and easy as possible.
This GI Bill for kidney donation isn’t stingy, but it also avoids the problems inherent to incentives. Far from commodifying donors, transplant support honors them. Instead of crowding out generosity, support nourishes it. It builds from the current system and sets an example that we would want the rest of the world to follow.
I admit that the idea isn’t perfect and the details need to be worked out. If you told me there was a button I could push that would immediately install incentives and end the shortage, I’d still have a hard time saying no. The lives saved would weigh too heavily for me to honestly prefer the status quo.
But that’s not the best system we can create. Transplant support can end the shortage by treating donors with respect—by transforming a system that demands a patient beg for her life to one where transplant is supported by the community.