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The Market for Human Organs?

Opening Billboard: Funding for this program is provided by the Bernard and Irene Schwartz Foundation, the Smith Richardson Foundation, and the Lynde and Harry Bradley Foundation.
WATTENBERG: Hello, I’m Ben Wattenberg… What would you do if tomorrow you discovered that you needed a new kidney? What would you pay? Would you wait patiently in line with thousands of others for a compatible donor to die? What would you do if you found out that a friend needed a kidney and that you were a match? Today on Think Tank we are joined by two remarkable women who faced these questions, and now are using their personal experience to question the established culture of organ donation.
Dr. Sally Satel, is a psychiatrist, a resident scholar at the American Enterprise Institute and author of several books including One Nation Under Therapy: How the Helping Culture is Eroding Self-Reliance .
…and Virginia Postrel, is a frequent contributor to the New York Times, The Atlantic and Forbes, and is the author of The Substance of Style: How the Rise of Aesthetic Value Is Remaking Commerce, Culture, and Consciousness
The Topic Before the House: The Market for Human Organs? This Week on Think Tank

WATTENBERG: You are talking to a world class hypochondriac, and I wonder why everybody isn’t. But as we say, I want you to tell your story like it is, as it is. And Virginia Postrel you are also quite a remarkable woman. Welcome to the program.
Sally, why don’t you tell us in brief strokes that a layperson can understand what happened and what you did about it.
SALLY: Well, in August of 2004 I found out that my kidneys were failing. Turns out, this isn’t that uncommon for people to feel healthy, which I did. This was just discovered on a routine physical. And to discover in that context that they have very poor renal function and in fact are heading towards needing a kidney transplant or going on dialysis.
WATTENBERG: Which is very unpleasant even though there’s been a lot of advances. It’s unpleasant.
SALLY: Very true. Technology of dialysis is much better and it certainly saves your life, which is something not available to people with failing hearts and livers, but it is very much –-
SALLY: So I knew that I had to find a kidney because, well, in fact, I did sign up on the national waiting list, which is administered through HHS; everyone should do that.
WATTENBERG: Health and Human Services.
SALLY: Right; because maybe you can’t find a donor. So I did sign up on the list, but I knew if I didn’t find someone, and find someone soon, so first I could avoid dialysis and secondly so then if I went on dialysis I could not stay on it for the 5 to 8 years that I probably would have waiting for a kidney on the list to come up. So to make a long and somewhat discouraging story short, it took quite a while to find someone. I didn’t have a family that could help me out and --
WATTENBERG: You asked a lot of friends and colleagues, I know.
SALLY: I didn’t ask that many people directly, but they knew about it.
WATTENBERG: You didn’t ask me. You can do male/female, can’t you?
SALLY: Yes, in fact, you don’t even need -- you need a compatible blood type. You don’t even need exactly the same one. And it’s quite -– the technology has advanced tremendously. It’s really a triumph of medicine. But had some people say they would do it, and they would back out, which quite frankly, was a lot harder than being declined initially. And so I guess it got to be a year ago this time, I was looking up on the web about transplants and there was a newsletter from Harvard, I think, and it was about something like Matchingdonors.com. Which is a website, as the name implies, links potential donors with potential recipients. And within a week, well, actually within a week about ten people had responded, but there was one person who seemed most promising to me. Seemed very mature...
So, anyway, I thought this gentleman that I met online was going to give me the kidney, and then unfortunately, about six weeks later he just disappeared. And then it was an amazing coincidence, but thank goodness someone was at an event with Virginia who knew me and Virginia had said how’s Sally, and...
WATTENBERG: Had you met her before?
SALLY: Oh, yeah. I had known her since ’97, but we were just talking about it. I don’t think I’ve seen her in person more than five times since then. I’ve always had great respect for her work and loved her when I got to see her but...
WATTENBERG: Well, we have to talk a little bit about libertarianism, which is your guiding beacon. But pick up the story.
VIRGINIA: Well, as Sally said, in late October, I believe, 2005, there was an event for Foundation for Individual Rights and Education, which board I’m on, was having it’s fifth anniversary celebration and Sally’s co-author, Christina Hoff Sommers is also involved with [fire?]...
WATTENBERG: Another wonderful colleague of ours, I must say.
VIRGINIA: And so I saw Christina, and I -- in the course of conversation, just a cocktail party, chatters, I said, “So how’s Sally?” And she said, “Well, she’s okay.” I had no idea. I mean it was very clear she was not okay. And she said, “Oh, I thought you knew. She needs a kidney transplant, and she’s doing all right, but she needs a kidney transplant or she’s going to go on dialysis.” And so that’s what’s wrong with her. And this has been for about a year. And so my immediate thought was well, I knew Sally didn’t have any siblings and her parents are deceased. I knew she didn’t have the obvious family to turn to.
WATTENBERG: What do you have to have just type A, type B, type O?
VIRGINIA: And so Christina told me that in fact you just need a compatible blood type. So it occurred to me that gee, maybe I could donate a kidney to Sally. And so when I went home, I talked with my husband, I did some research on line, because I wanted to make sure that if I said I would go forward, I wouldn’t change my mind. And in fact, it is the case that you can live very healthy with one kidney. So the main dangers are cancer, which is -– kidney cancer is relatively rare, and there’s no history of it in my family, and trauma. You could be in a car accident, or a knife fight or something. And I decided that was not too bad of odds. My main concern was actually the risk of surgery, which those are the real risks of donating a kidney, general anesthesia, and being cut open.
WATTENBERG: You were in and out in a couple of days, is that right?
VIRGINIA: Anyway, so I said I would do it. At that time, Sally had this guy that she had met online and I was the backup. Which proved, as my husband said, a good halfway house for him to get used to the idea of his wife donating this kidney. And yes. So in March we went into the hospital and we had the transplant. Before that, I had to have a lot of tests. My blood was typed a million times.
WATTENBERG: Were you scared by this whole process?
VIRGINIA: -– it’s actually, as sort of good deeds go, it’s the easiest thing in the world ‘cause you basically just show up. At least that was my theory originally. In fact, you actually have to be fairly pushy to donate a kidney. One thing I discovered through the process is, rather than encouraging people to do this, both the system and society tend to discourage people. There’s a -- pun intended -- visceral reaction against the idea of donating an organ. Plus you have to go through all these tests, which means you have to make arrangements for them. There are many, many times that you can quit. But I did go through it.
WATTENBERG: I can see where I would do it for a child, but I mean, with all due respect, I cannot think of a friend I would do it for.
SALLY: That’s why I didn’t ask you Ben.
WATTENBERG: Well...
VIRGINIA: Well, that’s what a lot of people say. Is that they would do it for their spouse, or their child, but not for a friend. And I think everybody has lines that they draw. There are a few people who would do it for a complete stranger. But, I was happy to do this for Sally. All surgery is dangerous. It is the surgery part of this that makes it dangerous. And it is, as surgery goes, not that dangerous and not that difficult. It’s generally done today laparoscopically. So in the old days they used to cut a big hole in your side. And now, my largest scar is “this big” and I have some tiny little ones.
WATTENBERG: About like an appendix scar or something?
VIRGINIA: Yeah, so -– and I was in the hospital for three days. I probably could’ve been out in two, but I live in Dallas, the surgery was in Washington, so I was in Washington for a week afterwards before I was well enough to travel with my husband accompanying me.
WATTENBERG: What did he think of this?
VIRGINIA: He was scared. But, as he said, he knows who he married, so.
WATTENERG: It’s a great thing psychologically to do good deeds. You feel -– gives some meaning to your life. You probably saved Dr. Sally’s life. Now, Sally, you are a psychiatrist, which means you are an M.D. Where’d you go to medical school? College?
SALLY: I went to medical school at Brown University, and college at Cornell.
WATTENBERG: Very good. You have been critical of the medical and psychiatric establishment in your books, one called, PC MD, and another one called, One Nation Under Therapy. From the perspective of a doctor, did you change your point of view as you became a patient moving through the system?
SALLY: I didn’t change my point of view that much, but, in fact, I really didn’t change it at all. I’ve had experiences all my life with colleagues who are physicians and also physicians who were my physicians when I was a patient other times, who really were quite wonderful and very interactive, not so directive. “You will do this; take this therapy,” and there’s no negotiations. So I’ve always had good experiences, and my experiences this time were wonderful. I had superb physicians. But what I was impressed with in a negative way was the paternalism, the intense paternalism of many other surgeons who are involved with transplantation medicine. And that’s where the policy aspect comes in, which we can talk about.
WATTENBERG: Now, Virginia, you are described by others and describe yourself as a libertarian; is that correct?
VIRGINIA: Yes. Or a classical liberal.
WATTENBERG: Classical liberal, meaning let people do what they want to do, let the market rule, with some regulation?
VIRGINIA: I’m in the tradition of Adam Smith, very much.
WATTENBERG: The invisible hand. Did your political outlook change as you went through this process?
VIRGINIA: As the editor of Reason magazine, which is a libertarian magazine, which I edited for many years, I published articles on this subject, occasionally, on the subject of there’s an acute shortage of particularly kidneys for transplant. And many people, particularly libertarians, have argued that if you were allowed to compensate people, which you are not, by federal law, if you were allowed to pay people...
WATTENBERG: Which you both regard as crazy, not to be able to pay people, right?
VIRGINIA: I think it’s wrong, and let me explain. I had this sort of libertarian view. If you had asked me -- if you’d come up to me on the street three years ago and said, “Virginia, what do you think about paying for organs?” I would have said in good libertarian fashion, “Well, you know, people own their bodies, they should be allowed to do with them as they will, as long as it doesn’t harm somebody else.” And this certainly would not harm somebody else. This would help somebody. They should be able to have this transaction. But it was a purely sort of, philosophical conviction. I had not really engaged with the issue. And I certainly didn’t have the deep knowledge I now have of what the transplant system is like. What I now find is that this is the kind of issue that drives those of us who are sort of bleeding heart libertarians crazy. Because you both have the government saying that consenting adults cannot engage in a mutually beneficial transaction. And you have thousands and thousands of Americans needlessly suffering and dying.
WATTENBERG: I did a lot of traveling around the world over the years. I was in Calcutta in a --which is no garden spot. And across the river from Calcutta, I guess the Ganges or something, is a place called Halara (ph). And I have never seen such a dry, dirty, dusty, parched, beggars in the street, where -- this is unbelievable -– they would break the limbs of their own children to make them better beggars. I mean, now, if such a person, and they loved their children the way I do and the way most everybody in the world does, if they were able to donate a kidney and get ten thousand dollars or whatever, which is a goldmine, wouldn’t that be more humanitarian?
VIRGINIA: Well, I would say yes, it would be more humanitarian. But I think when we talk about -- this is one thing that I came to understand from going through the process, there’s a kind of an abstract philosophical debate that takes place about selling organs and it frequently involves very poor people in the third world. In fact, the transplant system in the United States is quite complex and it involves all the other entities that health care involve. So you’ve got insurers, both private insurers and the federal government. You’ve got hospitals, you’ve got transplant surgeons, all within a certain kind of rule of contract and torte law. So when I talk about being able to sell kidneys within the United States, it’s all within that system. So, you’re basically talking about something that is very similar to, for example, young women selling eggs or something like that. It’s conceivable that somebody from India could come and do that. But probably what you would find is, young, healthy college students. Because what happens today is exactly what you alluded to. There is an overseas trade in what’s called “transplant tourism”.
Where people from -- affluent people from affluent countries go to poorer countries and often there’s multiple countries involved, and people sell their organs. But the problem with this is not that there’s something inherently wrong with selling organs, the problem is there are very few protections for the donor, either medical protections or contractual protections, or even financial compensation.
WATTENBERG: How does the organ donation system in the United States work? Cadaver donors are regulated by a united sharing list, is that right?
SALLY: Well, there’s something, you know, called the United Network for Organ Sharing. And this non-profit has the contract, monopoly contract, as Virginia always cautions I call it, with HHS, the Department of Health and Human Services, to maintain a huge database of these cadaver kidneys. And as they come in, they are allocated mostly at first by geography, because one very important dimension of this is, it’s true, technology is getting better and better for preserving these organs, but they don’t have that long a half-life. So, for example, a heart isn’t going to, even in the best cooling fluid, isn’t going to make it across the country, necessarily. A kidney is a little more resistant. But nevertheless, they are getting much better in terms of all these methods. But the point is, you want to do it as quickly as possible. So that’s why it’s done regionally. And basically it is largely a first-come-first-serve for kidneys. For livers and hearts, there is actually a rating of illness. So if a person is close to death, and also has a good chance of benefiting from this organ, I mean, there are people that are close to death and if they got the organ, they wouldn’t survive the surgery or wouldn’t last much longer anyway, so they’re not good transplant candidates anyway. But someone very sick who’ll make use of it for livers and hearts gets it next. For kidneys it’s very much the waiting list and who comes to the top.
WATTENBERG: But as I understand, both of your positions, you would be for allowing a reasonable and humane free market system to work. That if a person wants to donate an organ, he or she may do so. And they get compensated.
SALLY: Right. A cadaver and living, for both.
WATTENBERG: Our colleague is a wonderful doctor, Leon Kass, I gather he’s very much against this, isn’t he?
SALLY: He’s not in favor of this. He has invoked the eloquent phrase, “the wisdom of repugnance” in reaction to the idea that one would be paid for an organ. He seems to feel that this violates human dignity. It commodifies the body.
WATTENBERG: It’s weird, and I really respect Leon, he’s a wonderful human being, but it’s the most humane thing you can do.
SALLY: Well, I certainly agree. And I think it’s far more of an affront to human dignity to allow so many people to languish on dialysis and die. Four thousand people a year die because they didn’t get a kidney in time.
[TAPE CHANGE]
WATTENBERG: Just as a matter of fact, are there enough healthy organs available, assuming we had a free market, to provide for the need?
SALLY: I think we probably do. There are sixty seven thousand people waiting for kidneys. There are two hundred eighty million Americans. Obviously only a fraction would be compelled by this offer, but I would think enough. But the point is, we have to do pilot experiments. We have to do pilot testing to see whether or not this will prove to be an incentive. And the other important part of this is that we’re already paying so much for dialysis, because most of the sixty seven thousand people are already on dialysis.
WATTENBERG: Special legislation specifically for dialysis that pays for.
SALLY: Only socialized medicine.
VIRGINIA: Well, Medicare.
SALLY: And, as I said, most of the sixty-seven thousand people who are on it, at a rate of sixty-six thousand dollars a year. And if you do the math, you can see that a one time cost for a transplant is about seventy-five thousand dollars for the surgery, and then some maintenance. The medications do cost some money. You have to be on amino suppressants forever -- about ten to twenty thousand dollars a year. But when you do the math, the amount that the transplant and subsequent medication and follow-up cost is dwarfed by the amount spent on dialysis. WATTENBERG: You know Sally, This is a thirteen trillion dollar economy and growing rapidly. This seems to me like a no-brainer, I gotta tell you.
SALLY: I would agree with you. The two main objections are as we alluded to before, as Virginia says, this visceral response to the commodification of a body. We just, you know, organs are so valuable that they’re beyond valuation.
The second kind of objection is more practical and is something that one could address, especially through pilot programs, which is the concern that donors will be exploited in some way. And in fact, we’re working on a book for AEI now about how a market would work and how you can build in all kinds of very, very needed protections. But, for example, lengthy education. Make sure people are very well-informed. They know what they’re getting into. Perhaps at least six months. More cautious than what you might do for a regular donor. And they could be a certified donor. You could become a certified donor after you pass a test. And then of course, people can back out at any time that they want. And then what kind of compensation might they get? What I was alluding to before, the enormous savings that Medicare would enjoy if there were more transplantations and get people off dialysis. Some of those funds could go to the renumeration of the compensation that Virginia and I have been alluding to. For example, a contribution, it’s been estimated at perhaps forty thousand dollars, might be the appropriate prize. That money could go into someone’s 401K. Or it could be given to them for a scholarship voucher so that a child or...
WATTENBERG: If I can give you some, which I’m happy to do, I think psychologically the greatest thing for human beings is to feel that they did something good for other people. I mean, what you did for Sally is beyond belief. If you can say to people, if you want to, compensated or not, if you donate an organ part or a transplant, you are going to get such a psychological bonus that you are going to live longer, and I think everything that we know about my body which has come to fascinate me is probably correct.
VIRGINIA: Well, one thing, since I’ve gotten involved in this issue I’ve bonded with a number of people who have been moved to do this not out of knowing a specific person who needed it, but just wanting to do something good for the world. And for whatever reason, they settled on this. And they’ve met, and they’ve gone to matchingdonors.com, or they’ve gone to, there’s a bulletin board called livingdonors.org and you can find people who are desperately pleading often for a donation for a loved one. “My daughter needs an organ,” or “my mother” or whatever. And people are moved to do this. And unfortunately some transplant centers, not most, not all, but some transplant centers actually discourage donations to somebody that you’ve read about an identify with, or feel that they’re a good person, or whatever. There is an assumption that if you’re not donating to your child or to a very close friend, that there must be something wrong with you. So if you are motivated, by religious motives, or humanitarian motives, you have to go through all kinds of really intrusive psychological probing and distrust, that I think is very insulting to the donors.
Virginia Postrel, many thanks for joining us on Think Tank. Sally Satel, once again, thank you for joining us on what we think is a wonderful program, Think Tank. And thank you as always. Please remember to send us your comments via email. We think it makes our program much better. For Think Tank, I’m Ben Wattenberg.
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