Doctor Sally Satel has an editorial in the NYPost promoting giving payment to those who donate organs, or to their families.

She tells a variation of the usual spin: by allowing money to enter into the decision on whether to donate, we would increase organ donations. Ergo, it would help save the lives of many people.

Ah, but would paying for organs actually increase the number of organs donated? Or would it only increase the suspicion in the minds of some families that they would be paying for doctors to kill their loved one to get organs, which would probably go to a rich person?

The very example she uses makes my point.

She points out that Steve Jobs, the rich founder of Apple Computers, needed a liver, so he moved from California to Tennessee, where the chances of getting an organ is much better. This discriminates against the poor.

Ergo, if we pay for organs, more people in California would donate, and poor people would have a better chance of getting organs if they live in the “wrong state”.

What Dr. Satel did not ask is the very important question:

Why are people in Tennessee more likely to donate organs? Because they trust the system, and often know someone who knows those involved in the transplant process.

Scenario: a good old boy in rural Pennsylvania spins out his car. He is “Life Flighted” to the nearest Trauma center. Three days later, his brain is dead, and the family is asked if they want to donate his organs.

Chances are they know someone who knows someone who works at the hospital, and so they trust the doctors. They also know someone who knows someone who got an organ transplant at the hospital. So they say yes.

Scenario two: A Native American in Minnesota spins out his car on the ice. He is “Life Flighted” to the nearest Trauma Center. Three days later, his brain is dead, and the family is asked if they want to donate his organs.

But Native Americans would need the entire family to approve the donation, and there is some suspicion of the doctors and nurses, not only because of subtle and not so subtle experiences of prejudice from white medical personnel in the past, but because they remember when the same University made their tribe “guinea pigs” back in the early 1960’s.

So they say no.

Scenario three: A black man is beaten to death, and take to a Trauma center in western Pennsylvania. Three days later, he is declared brain dead.

His mother says yes when they ask if his organs could be donated to save lives. And so his organs are not given to a minority person waiting for months on the list, but to the governor, who has been waiting only a few weeks. The governor is rich and white, and a lot of folks wonder if he had been given preference for the organs. (He didn’t get preference: The donors heart was too large to fit in the chest of many of those needing a heart).

Dr. Satel then goes on to tell this story:

In 1994, the late Gov. Robert P. Casey, who received a heart-and-liver transplant a year earlier, signed a law that would enable a bereaved family of an organ donor to get a burial benefit of up to $3,000 paid by the state directly to the funeral home.

But then Pennsylvania health officials got cold feet. They feared that the law flouted the 1984 National Organ Transplant Act (NOTA), which makes giving something of material worth in exchange for an organ a felony punishable by up to five years in jail and/or a fine of up to $50,000. In the end they did not implement the funeral benefit.

Yes, and one reason was that the number of people signing Yes to organ donations on their drivers license took a plunge.

Dr. Arthur Caplan argues that most average Americans would oppose “mixing money with body parts”.

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.

Caplan’s ideas are not always popular among those in the ivory towers who only want to save lives. Yet there is a class and racial aspect to organ donation, and those bringing up money seem to imply if you are poor (or a minority) if we wave money in your face, you’ll agree to donate your kidney, or the kidney of your loved one.There is indeed a racial factor in organ donations.

One 1999 study showed that not only were white families approached more often to donate organs than black families (79% vs 67%), but that the rate of donation was lower in black families. (52% in white families, 31% in black families). I suspect that distrust of the medical system is part of the reason for that distrust.

Another reason is that those working in California hospitals often come from outside the community, so there is less trust in these large impersonal hospitals than in a rural state.

News stories about a California physician who hasten the end of life of a disabled patient who was Hispanic, in order to get organs probably didn’t help increase the donation rate in California.

Ironically, Satel’s editorial isn’t the most radical suggestion on how to increase organ donations.

An editorial in this week’s NYTimes. suggest  to mandate organ donation from someone who has died. The rationale is that most people in polls say they would donate their organs, so why not just allow physicians to take organs from anyone who doesn’t have a paper saying no.

That scheme got a 7% approval by the public, but we still hear voices promoting it.

Then come the “non brain dead” organ donations, where a person is taken off the machines and his heart allowed to stop before taking the organs.

That idea ended up on Sixty Minutes:

One of the first and few public discussions of NHBD in the media occurred in April 1997 when the CBS television program 60 Minutes aired a segment on NHBD, which began with the case of a young woman who was shot in the head and, although not brain dead, was judged to be fatally injured and a perfect candidate for NHBD. However, the medical examiner that conducted a later autopsy said that he believed the gunshot wound was survivable. This led narrator Mike Wallace to question the little-known NHBD policies at some hospitals that would allow taking organs for transplants from persons who could be, in Wallace’s words, “not quite dead”.

The practice, however, continues, and many in the disability community worry that families will be encouraged to “pull the plug” after being told their loved one would only be a “vegetable”, and sign that the not-dead- yet patient could become an organ donor, even though such a prognosis is sometimes wrong.

Non Heartbeat patient donation criteria varies greatly from hospital to hospital.

The President’s Council on Bioethics independently evaluated the issues surrounding deceased organ donation and procurement.[10] The President’s Council on Bioethics has expressed major concerns about several issues pertinent to cardiac or imminent death organ donation that have not been addressed explicitly by the bodies that have made recommendations for reforming or expanding that type of organ donation in the United States. The debate on organ procurement in imminent or cardiac death has come to the forefront because of doubts about its ethical appropriateness and acceptance within the medical profession and the community at large.(italics mine).

Full discussion on the implications of taking organs from someone with brain function is found HERE.

Finally, it should be noted that the person who wrote the NYTimes editorial cited above helped his cousin buy a kidney in China.

Yes, if you are rich, you not only can move to Tennessee to get an organ, but you can buy an organ from a poor tricycle driver in Manila or you can get an organ from an executed prisoner in China.

Executed prisoners are a major source of organs used in transplant surgery in China…. A lack of transparency about the use of the death penalty in China and the considerable sums of money involved in the sale of organs, particularly to recipients from outside of the country, raise serious questions about whether the authorities are fully ensuring that organ donations and transplants from executed prisoners occur in strict observance of their legal right of consent for such operations.

A lot of the best organs come from the prisoners in China, because Chinese, unlike Filipinos, are reluctant to donate voluntarily, even for money.

At least the New York Post’s editorial is by a physician active in libertarian causes. I think she is naive about the possibility of abuse, but she is not proposing killing people for profit.

However, one has to wonder about the ethical standards of the New York Times, to allow a person who happily admits being involved with such human rights violations to write an editorial.

Let’s have an agreement here. Donating a kidney is a good deed.

Taking a kidney from a brain damaged person by arranging his heart to stop, bribing a poor family to donate their loved one’s organs, or buying a kidney from a poverty stricken tricycle driver in Manila or from a prison official who will chose a Falun Gong prisoner to match your DNA is not justified in ethics.

And every time these stories hit the news, more people refuse to check the box for organ donation when they get their drivers’ license.

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Nancy Reyes is a retired physician living in the rural Philippines. She has worked in Minnesota and in rural Pennsylvania. She writes medical essays at Hey Doc Xanga Blog.

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