HEALTH CARE/Joan Retsinas

Shifts of Right and Wrong

Think of a moral paradigm as a kaleidoscope. Click once, and the pieces fall into a pattern. Re-click, and the pieces yield a radically different pattern.

Most of us adhere to an implicit moral pattern, with clear notions of right and wrong. Religious creeds, our sensibilities, life-experiences–all may undergird our ethical sense. Whatever the genesis of moral codes, most people have one.

Those codes are not uniform. Different people view the world through different kaleidoscopic settings. Consider abortion: Some abhor it as infanticide; others pragmatically accept it. Stem cell research, using embryos discarded after in vitro fertilization, similarly draws divided reactions.

The buying and selling of organs, though, repulses most Americans. We—a nation not prone to substitute government for the private sector—have outlawed the sale of organs. Governmental rules control the distribution of kidneys, livers, hearts—whatever physicians can harvest from the living (or dead) to implant in the living. From an economist’s vantage, those organs are scarce commodities; but the notion of marketing them sparks a moral shiver among the most zealous private market enthusiasts.

Sometimes people change their moral paradigms–shift their kaleidoscopes. In the new paradigm, what was evil is OK, if not good.

Often science propels the shift. More than a century ago, “blood” was sacrosanct, not to be transfused. And the transplantation of organs from one person to another was anathema.

Throughout the world, people are shifting their perceptions of organs-as-commodities. What was repellent is starting to be seen as pragmatic, if not beneficent.

The Economist’s report on “Organ transplants: The gap between supply and demand” (10/11/08) describes the changing paradigm.

Demand for organs (heart, lung, pancreas, kidney, even penis) is soaring in part because of medical advances, in part because of aging populations.

The supply, though, has lagged. (Ironically, declining traffic fatalities have contributed to the dearth.) Countries have tried a variety of stratagems to bolster donations. Some have “presumed consent” rules (Sweden, Greece, France, Spain, Italy): Unless a patient has said “no” to organ donation, the transfer is allowed. ln other countries (Canada, the United States, Britain, Australia, Ireland) people must expressly decide to donate an organ. Some nations have embarked on massive advertising campaigns, urging people to sign “donor” cards. Spain has established organ-transplant teams in all hospitals. No country in the developed world has closed the gap.

In fact, the United States has a higher rate of donation from living donors (20.8 per million) than most of the world, including Canada (16.5), Sweden (13.9), France (4.0). It also has a higher rate of “cadaveric” donations (26.6), compared to Canada (14.8), Sweden (14.5), France (25.3).

Yet the gap widens. More than 100,000 Americans are on waiting for a kidney; each month 4,000 more sign on. In Britain, the waiting list has risen 50% over the past decade. The World Health Organization estimates that 10% of people on waiting lists will get kidneys.

The United States has set up a rational, equitable system of distribution, weighing age, life expectancy, region, and compatibility with donor. So have many other countries. The World Health Organization, along with developed nations, bans trafficking in organs.

But the bans have spurred creative end-runs. “Transplant tourists” from the developed world travel far afield, searching for willing (or unwilling) donors. In the United States, unscrupulous funeral homes have sold organs from cadavers, without consent.

Perhaps the rigid prohibitions against paying donors warrant reconsideration. Desperate patients, their physicians, their families—and, most crucially, governments—are reconsidering payment, asking: Why not? Arguably, even altruistic donors deserve payment for time lost from work, for medical care post-procedure, indeed for comprehensive medical care for the rest of their lives.

At the same time, governments are recognizing the costs of keeping organs scarce. The 341,000 patients on dialysis in the US cost Medicare up to $21 billion a year. Every addition to that waiting list will up Medicare’s tab. An Australian health care expert suggested that the government pay each kidney donor $47,000–yielding a net savings to the state.

One country allows payment for organs; and the developed world might look to its experience. Iran started paying donors for kidneys (unrelated donors) in 1988; by 1999 nobody was on a waiting list. The country’s protocol marries philanthropy, family ties, and respect for the donor. A person must first seek a donor within his family, then wait on a queue for a deceased donor. If those steps don’t work, the patient can apply for an organ from a paid-volunteer. The government will give health insurance for one year and $1200 to the volunteer; the recipient will give an agreed-upon sum. Some charities will pay the sum (the Economist cites a range from $2300 to $4500). The country also allows private transactions. Iran’s Islamic citizens often donate as an act of religious duty.

Americans may want to reset their kaleidoscopes. Compensation to donors may save both money and lives.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, Jan. 1-15, 2009

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