Last year, a local quiz show was having an anniversary, and was promising many prizes for the studio audience. The crowds lined up, and alas, several hundred people were killed in the stampede to enter the theatre.

You see, unlike in the US, where if you work hard, you have the hope your children will be able to get an education and live comfortably, here too often there is little hope for advancement. So lotteries are seen as a blessing, the only way for a poor person to get rich.

What does this have to do with paying for organ donations?

The libertarian argument for organ donations insists that we are free agents, and that paying for organs will increase the supply with minimal problems for the donor.

Yet the reality is that poor people, who see no way to support their families, are open to be exploited by the rich who offer them huge sums of money for their organs.

Yet the promise of wealth is illusionary. A JAMA (journal of the American Medical Association) report found that if you went back and checked the donors, few actually benefitted from the windfall of wealth, since often their poor health afterward made it impossible for them to work.

Ah, but it could be regulated, could it not?

But a Frontline investigation shows how India, confronted with ethical lapses in the organ transplant industry, passed a law to regulate it…but in the 12 years since that law was passed, not one doctor/clinic had lost their license.

Ah, but that is the third world, isn’t it. Such things would never go on in the United States, since we don’t have such severe destitution.

In the USA, perhaps we could have a scheme that would pay friends and relatives to compensate their donation. That would be “ethical” since the idea of altruism still applies.

We see such altruism in students donating plasma, sperm, or eggs: They need the money, but there is an altruistic reason for them to chose to do this.

Yet some of us are old enough to remember blood banks paying for blood.
Some of my fellow medical students gave blood or donated plasma regularly, again for both money and altruistic reasons.

But it was also well known that blood banks in the slums didn’t always screen their clients, taking blood from alcoholics and addicts: the result was hepatitis B and hepatitis C. Indeed, selling Plasma from Arkansas prisoners probably resulted in 42,000 cases of hepatitis C, and several thousand cases of HIV in Canada, a scandal that almost brought down the Canadian government, but was little covered in the US since it involved the then governor Clinton’s Arkansas cronies…

This brings out the dirty little secret of any ethically questionable program, from cloning to IFV to selling organs.
When the ethics is questionable, thoughtful ethical people hesitate to do the research or procedure, and although most involved with the action are good ethical people, it opens the research or procedure to the ethically challenged.

In Arkansas, the prisoners received $7 a pint. Yet those running the program made large amounts of money.

Similarly, many in India who donated organs found they were not paid the fee that they were promised, and often pre op screening and post operative follow up was minimal.

Once organ donation became associated with “big bucks”, expect the con men to come in. Most Americans are not poor, but one could forsee that a black market on smuggled organs– or smuggling in poor people to donate organs— would quickly arise.

But there is another side effect that is more ominous to the supply of organs.

Once taking organs becomes profitable, there will be a growing suspicion that doctors, or one’s family members, might let a person die so that their organs might be donated for profit.

The previously cited Frontline article mentions that this is already a problem in India. But what about the USA?

Well, when I lived in Western Pennsylvania, every weekend some good old boys would wreck their cars driving home from the bars…those with head injuries were sent to Pittsburgh, which at that time was a major transplant center.
The Helicopter and ambulance driver cyncially called these transports “Body runs”, because everyone knew the person was brain dead, but if they died in Pittsburgh, the organs could be donated, and often were. The families often were religious, and saw this as a way to make sense of the death.

Yet once money became involved, such trust might not continue. Even back then I was told by two separate nurses about a person declared brain dead who woke up and had to be rescued from the transplant team…both nurses swore the story came from a friend of a friend, and the identical story occured at two hospitals, so I am sure it was merely an urban legend. Yet the show “Law and Order” has already had an episode on a similar scenerio.

Yes, these are urban legends, but as the inevitable money scandals start about the lucrative organ trade, expect voluntary donations to plunge, especially among minority groups who already have a distrust of the medical system.

A medical system that allowed the Tuskegee study of the 1940’s, the Red Lake study of the 1960’s that withheld Penicillin from patients with kidney damaging strep infections, and the early 1980’s Oklahoma City Children’s Hospital program that withheld treatment from babies according to a “quality of life” scale that resulted in mainly children of minorities dying, and the Arkansas blood scandal cited above may still be trusted by upper class libertarians, but those of us who work with Blacks and Indians in Pittsburgh, Minnesota, and Oklahoma recognize that these actions still have a negative effect on our patient’s trust of the medical system.

Niebuhr’s essay that the children of light underestimate the ingenuity and aggressive tendencies of the children of darkness holds true here also.

Helping a person who freely donates an organ from altruism is probably fine. But experience shows that the adverse effects on society will soon outweigh the benefits to those suffering from end stage renal and liver disease.

–Nancy Reyes is a retired Physician living in the Philippines with her husband. Her website is Finest Kind Clinic and Fishmarket

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