A Historical Argument Against Paid Organ Donation: Plasmapheresis and HIV

Alex Tabarrok of Marginal Revolution links to a very compelling case for paying organ donors, made by Alexander Berger in a New York Times op-ed. The counter-argument has always been that this will lead to the exploitation of people, especially the poor. What I find striking is that the debate, as I have seen it, has rarely if ever referenced the best example of this actually happening. In Chapter 12 of the excellent The Origins of AIDS, Jacques Pepin highlights paid plasma donors as a crucial vector in the early spread of HIV-1. A few potent excerpts:

In rural areas [of China],  poor farmers were recruited by ‘plasma pimps’, to sell plasma to increase their meagre income. They received $6 per donation, which could be repeated twice a month in theory, more often if donors attended more than one collected centre. [...] In the most-heavily affected provinces [...] approximately 250,000 paid donors (a quarter of a million!) acquired HIV.

[...]

What do these stories have in common? Poor people looking for a quick source of income and willing to sell their blood repeatedly. Profit-driven blood collection centres where a small number of entrepreneurs try to make as much money as possible by cutting costs, re-using needles, syringes, and tubings, while being unaware of or not caring about the risk of transmitting blood-borne viruses. A lucrative market for these blood products, either locally or internationally. Finally, a ‘patient zero’ who introduces the pathogen.

Pepin also cites incredibly dangerous practices such as the pooling of blood from multiple (ABO-matched) donors for plasma separation, with the cell matter divided among all of them for return to the bloodstream. The system was ripe with abuses. Strikingly almost all of this appears to have been driven by blood collectors or donation centers, rather than risk-taking by actual donors. And of course all organs and blood donations are always sold, often at a substantial profit, by the extractors – we are arguing only over paying the donor him- or herself.

The lesson here is not that paid organ donation is a bad thing – all of Berger’s points are entirely valid ones, and any risks can be controlled. But we should address the strongest arguments against this option, to see how to deal with them. In particular, careful regulation of the extraction of donated organs is always important but becomes moreso the more that high prices for organs induce potential entrepreneurs to enter the market. We have a handle on HIV transmission now, but need to be on guard for the next potential disaster. The danger is that the case for paid organ donation seems so obvious that, in bringing it about, we (perhaps willfully) ignore the risks associated with it.

About Jason Kerwin

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3 Responses to A Historical Argument Against Paid Organ Donation: Plasmapheresis and HIV

  1. Dave Undis says:

    As the death toll from the organ shortage mounts, public opinion will eventually support paying organ donors in the United States. Changes in public policy will then follow.

    In the mean time, there is an already-legal way to put a big dent in the organ shortage — allocate donated organs first to people who have agreed to donate their own organs when they die. UNOS, which manages the national organ allocation system, has the power to make this simple policy change. No legislative action is required.

    Americans who want to donate their organs to other registered organ donors don’t have to wait for UNOS to act. They can join LifeSharers, a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at http://www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

    Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. Non-donors should go to the back of the waiting list as long as there is a shortage of organs. Everyone can offer to donate their organs when they die, no matter what their medical condition or history is.

    David J. Undis
    Executive Director
    LifeSharers

  2. The population of the United States will have to consider financial incentives for organ donation because there are not enough organs from deceased patients. Last year an estimated 13,000 patients died from brain death and only 8,000 families said yes to donation. Even if all 13,000 families said yes there would have only been 39,000 transplants (about 3 organs recovered per donor). The waiting list was 110,370 which means that even if all brain dead patients were to be donors, there would have been 70,000+ patients not getting a transplant. These patients are either on dialysis (renal patients) or they are dying. Therefore the medical community has to look to living donors for the needed organs.

    Almost every living donor is doing so because a mother, father, brother, sister, son or daughter needs a transplant. That’s understandable – love of family motivates them. Last year these family members totaled 6,565. So where will we get the remaining 65,000 donors? There has to be an incentive to encourage strangers to donate. Why should they forego three or four weeks worth of pay checks and be out of pocket for their travel, food, lodging and miscellaneous unreimbursed expenses related to living donation?

    Altruism hasn’t EVER covered the need for organ donation – since 1988 when OPTN/UNOS started collecting statistics on this. In the first year (1988) there were 5,000 patients who didn’t get a transplant because of a lack of organs available. In 2010 there were 81,000 who didn’t get on.

    We ave to come up with some appropriate financial incentives to motivate living donors to come forward.

  3. Alexander Berger says:

    Hi Jason,

    Thanks for the comments. I hadn’t seen this particular example before, but it fits the general story typically attributed to Richard Titmuss, who wrote a famous book arguing against compensating blood donors in 1970.

    I’d really recommend you check out a book by Duke sociologist Kieran Healy called Last Best Gifts: Altruism and the Market for Human Blood and Organs. It tells a similar story about HIV, but the punchline goes in the opposite direction: in the U.S., organizations that paid blood donors reacted much more quickly to news of the HIV outbreak in the 1980s, compared with organizations that collected blood from volunteer donors, which were afraid to alienate their volunteer donors. It’s also just an outstanding book.

    Anyway, the underlying problem in both the Titmuss example and the one from Pepin is that there was no way to test the blood for the relevant diseases. Broadly speaking, that’s not the case with kidneys. Donors undergo a bunch of tests to determine the health of their kidneys; although there may be some important health factors that can only be assessed by asking the donor, none come to mind. So the worry that unhealthy people will lie in order to be able to sell their kidneys doesn’t strike me as too overwhelming, though of course it is a concern.

    Best,
    Alexander Berger

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