PBS’ Frontline Roughcut series lives up to its name with its latest on-line film. You might remember that I have linked to their on-line film series before. The latest one tracks the human kidney trafficing business in a slum near Chennai nicknamed “Kidney-vakkam.” The 10 minute film is titled, A Pound of Flesh: Selling kidneys to survive.
Traveling between Bangalore, India’s thriving technology center, and the slums to the south, Grant spoke to government officials, doctors, kidney brokers and donors to try to find out why so many people are still getting paid to give up their kidneys even though a law was passed 12 years ago to heavily regulate the practice. When Grant arrived in the slums of Chennai, about eight hours south by train from Bangalore, someone offered to sell her their kidney on the spot. “I was stunned,” she says.
A New York Times Magazine article recently asked the question, “Why not let people sell their organs?” From an economic point of view, the article explains, demand for kidneys is far outrunning supply around the world. If people could legally sell, economists argue, more people with kidney disease might be saved, and the poor people willing to sell would have a chance to get badly needed funds.
As Grant reveals, the problem is especially acute in India, where demand for kidney transplants is increasing along with the country’s growing numbers of diabetics, a health problem that has been directly linked to India’s recent prosperity and rise in obesity. Those who can afford medical care are much more likely to receive a new organ, often because inside India’s impoverished slums, many are desperate enough to sell a kidney for as little as a few hundred dollars. [Link]
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p align=left>The film points out that as Indians increasingly adopt a western diet they are becoming more susceptible to kidney disease, thus increasing the demand for illegally sold kidneys.
Above all, Grant’s story shows a vicious cycle among India’s poorest — particularly among women, the family members traditionally expected to sell their kidneys. Holding out her original donor card, one woman tells Grant that she has been waiting 17 years for the rest of the money promised her. [Link]
As the film explains, the quickest way to close down this practice is to limit kidney donations to between blood relatives, but nobody seems incentivized to do this.
abhi– thanks for putting this post up. organ donation is a serious matter, and the economic benefits for those who are in poverty can be immense, but as pointed out, the pressure for women to donate and be expected to do so is ridiculous…. the change in diet and new health problems doesn’t surprise me.. (fast food nation–changing and debilitating the world over)..
unfortunately, i don’t see any real solution to this problem…it’s just a cloudy haze..
I heard a story about this on NPR last night. There was a pretty chilling reference to the Indian govt setting up a website to promote “medical tourism” including organ transplants for firangs in India, touting the lower cost and relatively short waiting period for such procedures. Disgraceful.
re: kidney transplants per se, First- diabetes is a big and getting bigger (pun intended, see below) problem in India and it is very much a disease caused by lifestyle. Some populations have a genetic predisposition to this disease and the lifestyle of stress, too little physical activity and diet high in refined carbs (read sugar, white flour, white rice; fat isn’t really the issue, contrary to Grant’s statement in the film) causes obesity and insulin resistance in those susceptible populations.
Second- all over the world, people are having to take a look at the reality of expensive life-saving “heroic” measures. In a nutshell, we’ve created technological fixes that are so expensive they cannot be made available to every person who needs them, the financial resources (leaving aside organ availability) simply aren’t there. Too many people (and more on the way) are having these health problems and this will force us as a society and a world, to allocate the scarce resources. (for more on this: http://healthvsmedicine.blogspot.com/2006/07/biting-bullet.html)
Third- for some reason, I’m having trouble seeing the government regulating this effectively. Bribes, payoffs and backroom deals abound in India. What the potential donors need is education about why kidney donation poses a real risk to their health so they make truly informed decisions. It’s hard to focus on the risks when there’s a big pile of money being offered. But clearly Geeta’s husband in the film knows they are getting the short end of the stick, and not just monetarily. It seems the government, or some organisation to broker the deals would only remove (or place in the shadows) the middleman, not deal with the selling off of future health in exchange for short-term monetary gains.
there are several functional websites/ agencies for medical tourism in india, just google it… i had heard about this for the first a couple of years ago and more recently a few cases were mentioned in the news in toronto. basically people get sick of wait lists in canada and opt to go to india via a ‘medical tour’ agency for treatment. in many cases it is cheaper to fly and get treated there than it is to go across and get treated in the US. some doctors in india think that this is a good way to bring indian medical capabilities to the forefront and that it’s what a great way to capitalize on a public demand. i wonder though, who would get priority? say in a heart transplant surgery for example. the local indian who is finally next on the transplant list and has been able to shell out enough for the operation or the medical tourist who can afford to throw an extra few thousand rupees to get the single precious heart? the bioethics of the whole affair are another story.
in terms of the the organ trafficking situation, it is just a dire one… unfortunately, it will be hard to get a wrap around this one just yet… far too many underlying factors that need to be dealth with first.
Where are all the free-market wallahs to explain how this system is “very efficient” and can match the supply with demand beautifully?
SP
Why is medical tourism disgraceful? India should be proud that it provides quality care at much lower costs. No one is forcing people to sell their kidney. This notion that the poor should make sustantive economic decisions is as class biased as they come. Are the poor too childish to make these decisions? Obviously their circumstance makes it sad that some may sell their kidney, but it should be their choice not people who feel bad that it goes on. If a system were in place to regulate it, then that poor woman wouldn’t have had to wait 17 years. As for proving the free-market wallahs point, I think in the absence of any such a donor program, it’s pretty clear there is a supply problem. I would suggest reading Richard Posner’s article on this.
Here I will even give you the link:
http://www.becker-posner-blog.com/archives/2006/01/organ_salesposn.html
Medical tourism for organ transplants is disgraceful because it preys on those who are weakest – there is a supply problem, as you put it, for a very good reason, which is that donating an organ comes with serious health risks. If you are poor and desperate enough, you might go ahead and make the short-term rational decision to sell your kidney even if you are weak and undernourished yourself and will face health risks in the long term by doing so. What the government should be doing is to give people the requisite information to make the right decision, not creating financial incentives for people to dodge medical and safety guidelines.
The organ trade is problematic for all sorts of reasons (I recommend watching the film Dirty Pretty Things about this, btw), and the reason that folks who want transplants go to poor countries is that they can get away with less stringent safety checks and procedures there, and pay their way around health safeguards. It’s the same with drug trials in poor countries.
If donating your kidney makes such good sense and if there is such a supply shortage, as you put it Vikram, why don’t you go donate your kidney tomorrow? Why aren’t people jumping up to do so in the US?
SP
You write “What the government should be doing is to give people the requisite information to make the right decision”. Very well. Then let them make that decision, but you seem to want to make that decision for them. By legalizing organ sales, the government is not itself providing financial incentives, but it allowing people to weigh short term fiancial gains against long term potential health risks. Again this is a decision that should be in the hands of the individual.
Regarding this issue of why I don’t sell my kidney, again you seem to fail to understand basic economics here. I have financial means commensurate to support my lifestyle. I don’t need to, but if I ever were to fall into the poor house, I certainly would want to be able to make that decision. People aren’t jumping to do it here, because we also have our share of intellectual lightweight beauracrats.
So Vikram, you’d be quite happy in a world where the poorest of the poor walked around with one kidney apiece so that moneyed Westerners didn’t have to wait more than a few weeks for their new kidney…and health considerations be damned, as you know they will be, because who can blame folks for preferring to take a year’s income or more even though they know there may be consequences down the road (hell, I’d do it). There are times when basic supply and demand do not produce optimal long term outcomes, and health is one of the areas in which a pure free market approach could well result in huge numbers of poor people dying because they have financial incentives to sell their organs and there is no financial incentive to give them proper healthcare. We can’t brush aside this issue just because we think it only affects the poor and will never affect us. This isn’t about paternalism, it’s about basic empathy.
Enough with blaming bureaucrats for not allowing enough organ trading (though I share your general disdain for the species of babudom) – the reason people aren’t selling their organs in the US, and the reason you don’t particularly feel the need to consider the risks of making that decision, is that you don’t need the money and never will, and so you can affort to not think about it.
SP
There is also the argument that by regulating the process, the health risks can be minimized. You ask if I would be happy in a world where the poor walk around with one kidney and the rich pay for the aforementioned kidney. I wouldn’t happy or sad, becuase it is none of my business. It is a private contractual interaction between consenting adults. Your all emotion and very little reason. Just becuase it upsets you or the majority of people does not invalidate it as a reasonable exchange. Again, if the government were to legalize it and provide the proper counseling before the operation so that the poor would understand the risks, and if the procedure were to be done in proper hospitals, it would be preferable to the back alley unregulated system we have now. There is both a practial and intellectual argument for it. Happiness or sadness of the majority nothwithstanding.
‘Dirty Pretty Things’ is an excellent film on the subject, though it covers more ground than just transplants.
Vikram-
I note that the blog post you cited compared the repugnance factor of organ donor sales to “gladitorial contests in which they fight for the death, to sell themselves into slavery, to agree to have their knees broken if they default on a loan, to buy certain mind-altering drugs, to buy or sell sex, or to sell their parental rights.” The point Posner is making is that there is no “inherent” rational reason to limit these activities, although he admits “a certain plausibility” to these limits. I do not think that selling organs falls into the realm of selling your first-born child. And I think such comparisons weaken Posner’s argument, at least for those to whom say slavery, is repugnant. I do think there should be protections in place when the financial incentives (as in abject poverty) tend to outweigh the ability to correctly assess future risk.
I would also argue that your position is all reason and no sentiment. Our capacity for empathy is one of the defining traits of humanity.
SP-
The reason people aren’t selling their organs in the US is partly because it is illegal, but also partly because the system is highly regulated. The rules and system for allotment of available organs are largely based on medical realities of donor tissue compatibility. One reason a person might wait 17 years (which I find dubious as the average life expectancy after beginning dialysis in the US is only 5-6 years) is that they have a very hard to match tissue type. Other factors are the health of the donor: IV drug use (current or prior), infection, cancer and age over 50 all limit or exclude donors.
gitanjali
Thanks for being so sanctimonious. As if you have a corner on empathy and knowing nothing about me except from a few blog posts. I never stated that I thought organ selling should be the only or primary way to help the poor, only that it makes very little sense to keep it in the shadows with unsavory characters and procedures. Swtich your supposed empathy for the poor with say “protection of the unborn” and your argument is no different from someone who wants to ban abortion becuase it violates their moral sensibilities. If abortion is a private choice, i.e. keep your laws off my body, then why shouldn’t organ sales be as well.
That last post should be under my name.
I have $10.. is that enough for a kidney from India?
On paper, kidney donations are limited to “between blood relatives.” However, as with many other laws in India, this one too is difficult to implement. It’s a law that makes little sense anyway. My father died of complications related to kidney failure a few years ago. He was on dialysis till the end because he could not get a close enough donor match from a relative. We tried and abandoned the third-party donor route precisely because it was illegal, unregulated, and open to abuse from both parties. There is no way to check that the recipient will pay the donor an agreed-upon amount. Similarly, there is no way to check that the donor will not emotionally and financially blackmail the recipient later. Very often, both donors and recipients cut short the proper testing process so the deal can progress quickly. It’s a murky world that involves a lot of moral compromises. If third-party kidney donations are made legal, things may improve.
Vikram,
Please read your own comments with an open mind and notice how sanctimonious you are being… You write as though you are the only guy who thinks while others are being “emotional”.
1) “Just because it upsets you…” –
You are making an assumption that the people who are campaigning for banning organ sale are doing so in order to ensure that they are not upset in the future – you are insinuating this without presenting any evidence and ascribing low motives to people who have a point of view that does not agree with yours. This is a backhanded way to win arguments – claim that the people who oppose your point of view hold are weird!
2) “Swtich your supposed empathy for the poor with say “protection of the unborn” and your argument is no different from someone who wants to ban abortion becuase it violates their moral sensibilities. If abortion is a private choice, i.e. keep your laws off my body, then why shouldn’t organ sales be as well.”
Here you seem to assume that abortion is a settled issue in the minds of people involved in this discussion. Implying that, surely, since you agree that abortion rights should hold, so should organ sales rights. Whether because of empathy or otherwise, we as a society determine our boundaries and encode them into laws. In a democratic situation, there is no room for evaluating my position based on whether I used my mind or heart to come to a decision — how can you define these things any way. And really, is a baby just a part of the mothers body before being born?
Accusing others of being emotional does not win you arguments, who is obsessed with emotions here?
A market is simply one method of trading an object or service between people who have the object/service and people who need it. The kidney “market” is one such – this “market” may offend our sensibilities but it deserves to be noted that this market exists only because there are people on both sides of this market. And if Economics teaches anything, it is that suppressing a market only leads to it appearance in less benign forms elsewhere. The “need” which is being fulfilled by the kidney market is not going to disappear.
From a policy perspective, the question is whether to suppress the market (which leads to it going underground, thus less regulated and potentially harmful to the very persons – the poor – whom the ban is supposed to protect) or whether to legalize it and make it better regulated. I think the case can be made that the second option – even though offensive to many sensibilities including mine – is preferable. The choice is not between a good option and a bad one, rather it’s between a bad one and an even worse one.
As an Indian, it hurts that people in my country are poor enough that they are willing to sell their kidneys. Unfortunately, no end to this is in sight at the moment.
“your argument is no different from someone who wants to ban abortion becuase it violates their moral sensibilities.”
If one were to re-read my first comment, it might be noted that I did expressed doubt that the government, or any organisation, could effectively regulate a trade which has already been established on the “black” side of the market.
My response to Vikram was intended to compare the free market theory position with a position that takes into account the human side of things- esp. the vulnerability of the poor when faced with an exchange that has significant potential for bad outcomes.
And as abortion has been used as an example, I would suggest rather that a pregnant woman who (in some future world where fetal stem cells can provide life-saving treatments) is offered money in exchange for the “fetal tissues” removed in the abortion process. One can easily see that this presents many ethical problems. Similarly, I believe selling one’s organs is a thorny issue that encompasses more than economics.
ok guys, first off, medical tourism is not only for transplants, it is a much bigger industry that offers a vast range of treatments/ surgery… so to call it disgraceful only on account of the transplant issue is not accurate at all. i think it is a good thing for india right now, with it’s own iffy points, but something like this is needed at the moment for the field’s growth in relation to global health practice. india is making some remarkable strides in medical/biotech.
and with regards to organ transplants, NOT ALL organs come from trafficking… there are also ‘organ priority lists’ in larger institutions and affiliated hospitals. the lists can seem iffy at times in india, but let’s keep in mind that there ARE good and ethical doctors in india who care about doing things right. the good and bad mix can be found in any part of the world.
the ‘market’ is an issue primarily because it is illegal, then one can add ethical/moral judgements if they want. but the fundamental issue is that it is done illegaly therefore without any control or monitoring, which is why the donors are not given the appropriate compensation or post-operative care.
besides, organ traficking has been happening for decades and is going on in mexico, several south american countries, african countries, eastern europe and russia…. and maybe more places…. just google ‘organ selling’… there are way too many sites to link. there are also interesting views for and against organ selling floating in web space.
key difference is between selling and trafficking. selling implies a regulated process with standard pricing, ‘quality testing’ (i.e. do u want an organ from an HIV+ person who didn’t know they were infected?), monitored surgical procedures and care. trafficking implies organ pimping… and a lot of downstream mess.
people are also forgetting that you don’t just shop around for the best looking kidney! there has to be HLA-type matching for an organ, for it to be accepted by the recipient, who also has to be on immunosuppressive drugs to prevent organ rejection and remain healthy. matching probabilities outside a family are extremely low. the whole process is much more complicated that first impressions. even if the market exists, it’s use is limited by other practical factors. if the process is not regulated/monitored, both donors and recipients could be mislead into a surgical process by a middle man who only wants the money and doesn’t care for the health of either party. however, a properly regulated process can benefit the donor by compensating them appropriately and by ensuring their well being also… and obviously benefit the recipient by giving them a properly matched organ.
if we rely on a market-driven organ transplant policy, the poor will also lose out. as you all correctly point out, demand is outpacing supply – don’t forget that the poor also live on the demand side. When the rich can pay for kidneys, what happens to the poor?
What makes you think that the poor don’t lose out in a “non-market driven” policy? This is a wrong but unfortunately all-too-typical argument — the fact that the market has flaws does not mean that the alternatives are any better.
No one wants to sell their kidneys. If some people do it, it only means that their other options are even worse. Banning the “kidney market” will do nothing to overcome the basic problem, namely, that the poor in India have very few options to earn a reasonable livelihood. For this, all Indians must share the blame. The only long term solution is to improve the opportunities for the poor so that they don’t have to resort to selling their kidneys. In the short run, perhaps, the idea is to manage the “market” better, so that those who sell their kidneys at least make informed decisions rather than be duped by scoundrels (as currently happens).
IIRC, in India, kidney donations are banned unless it is from a blood relative, precisely to fight these kind of money-for-kidney deals. If what I remember is correct, PBS is plain wrong about this story.
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