An article popped up on my google alerts recently regarding an Indian (dot, not feathers as Robin Williams’ character would say in “Good Will Hunting”) who answered a solicitation for a kidney, sold said kidney and has now been screwed and abandoned by his recipient/buyer.
A couple of days later, another article appeared, this one about a seventeen year old Chinese boy sold his kidney to a black market broker so he could afford to buy an ipad 2. As per the first story, once the kidney was safely in the hands (er, body) of the recipient, the broker has disappeared – with the payment.
Other than one being governmentally sanctioned and the other not, these are incredibly similar tales. Both illustrate the dangers of commodifying a living person’s body, as well as the dehumanization of living organ donors*. They also reveal how organ sales take advantage of the disadvantaged, vulnerable and desperate, regardless of legal status.
Some folks would dismiss these two experiences as anecdotal, extreme examples, or emotionally inflammatory. Except that they confirm what all published studies on organ sales have concluded:
Selling living donor organs benefits everyone (surgeon, transplant program, recipient, broker, govt) except for the living donor her/himself.
Naqui compared kidney vendors and kidney donors in Pakistan:
Of the vendors 67% were bonded laborers earning less than %50 month as compared to controls where 68% were skilled laborers and self-employed earning greater than $100 month. History of vendors revealed jaundice in 8%, stone disease in 2% and urinary tract symptoms in 4.8%.
Post-nephrectomy findings between vendors versus donors showed higher BMI and almost twice the level of hypertension in vendors, serum creatinine (mg/dL) of 1.17±0.21 versus 1.02 ± 0.27, an almost 20 point lower GFR (kidney function) in vendors, urine protein/creatinine of 0.150 ± 0.109 versus 0.10 ± 0.10, Hepatitis C positivity in 27% versus 1.0% and Hepatitis B positive 5.7% versus 0.5% (p = 0.04), respectively.
In conclusion, vendors had compromised renal function suggesting inferior selection and high risk for developing chronic kidney disease in long term.
Danovitch had this to say about Naqvi’s study:
The study adds an important element to the growing body of empirical evidence not only from Pakistan but also from Egypt, India, Iran and the Philippines (2–4) suggesting that the outcome for kidney donors who sold their organ is worse that that of those who donated it without financial gain. Worse, not only from a strictly medical point of view, as Rizvi et al. have shown, but also from a psychosocial one.
The donation transaction is primarily a commercial one and the donor likely does not have the benefit of a trustworthy advocate to care about his or her interests. Neither is there good reason for the donor and the recipient to care much about each others welfare since there is no mutual interest in a good outcome.
And even if we were to accept the dubious ethical and practical arguments in favor of commercialization we would be left with the complexities and uncertainties of ‘regulating’ a system which would undoubtedly engender a destructive schism in the professional transplant community; a drop in noncommercial living donation; and possibly also of deceased donation. Commercial and noncommercial organ donation do not cohabit well together.
Goyal, after interviewing kidney vendors in India (refer to first news article at the top of this post):
Sixty percent of female participants and 95% of male participants worked as laborers or street vendors.
Ninety-six percent of participants sold their kidneys to pay off debts. The average amount received was $1070. Both middlemen and clinics promised on average about one third more than they actually paid. Most of the money received was spent on debts (60%), food and clothing (22%), or marriage (5%).
Average family income declined by one third after nephrectomy. The percentage of participants below the poverty line increased from 54% to 71%. Of the 292 participants who sold a kidney to pay off debts, 216 (74%) still had debts at the time of the survey.
About 86% of participants reported a deterioration in their health status after nephrectomy.
Seventy-nine percent would not recommend that others sell a kidney.
Broumand said, of the Iran experience of creating a legal kidney market, which has eliminated Iran’s waiting list:
…we have paid an expensive price for ?rst reversing the percentage of LRD [living related donation] in favour of LNRD [living non-related donation]. Because of the rush for donation of kidneys there are occasions in which HIV, HBsAg [Hepatitis B], HCV [Hepatitis C], CMV [cytomegalovirus, one of the herpes family], and tuberculosis are donated with the kidneys…I personally have observed two patients expiring within the ?rst 3 months of kidney transplantations with miliary tuberculosis (TB).
I personally interviewed 32 donors in our Department. Of these 32, just one person claimed that he wanted to donate a kidney with true altruism. It was shocking when a husband, just discharged from the hospital after donating his kidney, brought his wife to donate her kidney as well because the payment for his kidney was not enough for them to repay their debts. Another person wanted to sell his kidney to be able to buy drugs, and asked if he could sell both of his kidneys and start on maintenance dialysis, as dialysis anyhow was free…sadly, because donors are in a hurry to ?nish the business, there is no time to check if they are really mentally competent or not. I had a case in which the donor killed the recipient’s son during the course of work-up when he understood he could not donate the kidney.
Finally, as these paid donors are too involved to think about the future, almost 95% of them receive no follow-up visits after donation.
And finally, Zargooshi who spoke with hundreds of Iranian kidney vendors:
Poverty prevented 79% of vendors from attending followup visits, and vending caused negative effects on employment in 65%. Of the families 68% strongly disagreed with vending, which caused rejection of 43% and increased marital conflicts in 73% of vendors, including 21% who divorced.
There were 70% of vendors isolated from society, and 71% had severe de novo postoperative depression and 60% anxiety. Vending caused somewhat (20%) to very (66%) negative financial effects.
It also had negative effects on the physical abilities in 60% of vendors who were mainly unskilled laborers, and 80% were dissatisfied with postoperative physical stamina, which was decreased mostly by depression.
Of the vendors 37% concealed the truth of kidney sale from anyone, 14% disclosed it only to spouses, 43% to first generation relatives and 94% were unwilling to be known as donors.
The mental preoccupation with kidney loss was usually (30%) to always (57%) present and interfered negatively with vendor life, and 62% reported negative effects on sense of being useful. Effects on general health were somewhat (22%) to very (58%) negative. When thinking about vending, the majority cited negative feelings.
They responded that if they had another chance 85% would definitely not vend again, and 76% strongly discouraged potential vendors from “repeating their error.” Half the vendors were ready to lose greater than 10 years of life and 76% to 100% of properties to regain kidneys.
Consider all of this when some individual or organization proposes a government sanctioned living organ (usually kidney) market. It might be beneficial (financially and otherwise) for some, but it’s always a losing proposition for the person relinquishing the kidney.
*A lengthy discussion could be had regarding which aspect arrives first, but we’ll leave that for later.
Broumand, B. (1997). Living donors: the Iran experience Nephrology Dialysis Transplantation DOI: 10.1093/ndt/12.9.1830
Naqvi, S. A. A. (2008). Health Status and Renal Function Evaluation of Kidney Vendors: A Report from Pakistan. American Journal of Transplantation DOI: 10.1111/j.1600-6143.2008.02265.x
Danovitch, G. M. (2008). Who Cares A Lesson from Pakistan on the Health of Living Donors American Journal of Transplantation DOI: 10.1111/j.1600-6143.2008.02290.x
Goyal, M. (2003). Consequences of Selling a Kidney in India. JAMA: The Journal of the American Medical Association DOI: 10.1001/jama.289.6.699-a
Zargooshi J (2001). Quality of life of Iranian kidney “donors”. The Journal of urology, 166 (5), 1790-9 PMID: 11586226