Sell Your Body, Save a Life By Richard A. Epstein 04/16/1998 The Wall Street Journal A22 (Copyright (c) 1998, Dow Jones & Company, Inc.) Each passing year, public health organizations beg for more people to donate organs when they die. Yet the transplant waiting list continues to grow longer as surging demand outpaces a static supply. Now, Secretary of Health and Human Services Donna Shalala is poised to make the current transplant system even more ineffective. Instead, she should consider a few market-oriented reforms that would make more organs available for transplants. The federal law on organ transplants stems from a belief that human organs should not be bought and sold. It curtails the supply of this life-saving resource while denying donors any benefits. Some 55,000 individuals anxiously wait for organs on national lists maintained by the United Network for Organ Sharing, a quasipublic agency operating under a federal mandate. Individual organs cannot be "shared," as UNOS's name suggests; they can only be given to one person or another. Since the government has banned markets in organs, UNOS must create its own allocation rules. Until now, these factored in medical compatibility, the severity of the recipient's condition and the locations of the donor and recipient. At present, organs are collected by local institutions, which get first dibs on them. But new techniques of organ preservation now give cadaveric organs a longer useful life. This emboldened Secretary Shalala to call last month for a single national recipient list under uniform criteria. Organ queues will no longer depend on the happenstance of where a person lives or on how quickly he can fly to some remote transplant center. But Ms. Shalala's proposed regulation would only exacerbate the grave flaws of the current regime. The comprehensive national list is supposed "to allocate organs among transplant candidates in order of decreasing medical urgency status," so that sicker people get the organs first. This is a risky policy, since extremely sick people have poor prospects even if they receive new organs. A higher survival rate can be achieved by having healthier individuals get transplants, as is currently done with livers (it is harder to quantify the severity of other organs' dysfunction). Ms. Shalala has publicly denied any intention of altering the present practice, but the language of the proposal, quoted above, clearly amounts to a major change. Ms. Shalala also says that the proposed national regime would remove quirks that benefit some regions more than others, so that patients in Boston will no longer have to wait in longer lines than those in Fort Worth, Texas. But by trying to redistribute the organs more "fairly," the proposed regulations would likely reduce the total number of organs collected nationwide. Fort Worth's short waiting lists stem in part from its successful local LifeGift organ collection program. A centralized system would discourage such ingenuity because the industrious region would not reap the rewards of its labors. Moreover, people are more inclined to donate their organs to benefit their neighbors. Ms. Shalala's high-minded statements conceal the bitter struggle between local and national transplant centers. The latter have long waiting lists, and therefore will garner a greater share of organs under the proposed pooling arrangements. Already, to keep their supply high, local centers delay reporting their organ inventories until it is too late for them to be shipped out, several doctors and transplant network workers have told me. A fully nationalized system would see an increase in such withholding, jeopardizing the effectiveness of the national program. All these proposed reforms -- now pending in Health and Human Services administrative proceedings -- are really beside the point. Ms. Shalala herself observes that "the real answer to the problem of scarce organs is to increase the number of organ donations." Markets know only one way to increase supply: raising prices. But since the government sets the price for organs at zero, shortages will remain and worsen. At the very least, the government should be allowed to pay donors for organs donated upon death, and then allocate the increased supply according to the clumsy UNOS procedure. But we can do even better at saving lives. Right now, two-thirds of people on the waiting list need kidneys. Kidney transplants from live donors accounted for nearly 30% of the 11,000 kidney transplants performed in 1996. A price system would not only increase the supply of cadaveric kidneys, it could induce healthy individuals to sell one of their kidneys. Live transplants yield better kidneys because the donor and recipient can be operated on side-by-side on a prearranged schedule. The huge gains to the recipient should dwarf the risks and inconvenience to the donor; cash is the solvent that splits the gain between them. Any non-vital organ, like eyes, could be bought and sold under such a system. Live donation might create the practical problem of criminals coercing people to sell their organs; the brokers who would run the process would have to institute a rigorous screening process to ensure that live donations are truly voluntary. But the net benefits of an organ market would be great. Fewer patients would spend expensive and painful years on dialysis waiting for kidneys; the pace of improvements in surgical techniques would increase as transplants became more common; and increased safety and reduced red tape would lead to lower prices and broader access. Most important, fewer people would die because of a government-created organ donor shortage. --- Mr. Epstein, a professor at the University of Chicago Law School, is author of "Mortal Peril: Our Inalienable Right to Health Care?" (Addison-Wesley, 1997). Copyright © 2000 Dow Jones & Company, Inc. All Rights Reserved.