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Should Donors Get Cash for Kidneys?

It is an idea that tends to generate an immediate and negative response: paying people to give their kidneys to patients who need transplants.

It is illegal in nearly every country to pay someone for an organ. But as the wait-list for organ donations continues to grow, and the black market in illegally-sold kidneys grows along with it, some members of the American medical community are calling on the United States government to start paying people for their kidneys.

Yalemzewd Woredekal is a doctor at King's County Hospital in Brooklyn, New York. Like most physicians, she gets up early to go to work. But Dr. Woredekal's day begins about three hours earlier than her colleagues', because for the last 21 years, she has been dealing with diabetes-induced kidney disease. "I wake up at 4:30 in the morning," she says, "so I can take my dialysis between 5:30 to 8:30, so I'll be ready for work at 9 o'clock."

Yalemzewd Woredekal has already had two kidney transplants: one from her sister, who made a live donation, and another from a deceased donor. Neither procedure worked, and so Dr. Woredekal is back on the kidney transplant waiting list, a group that includes 65,000 people in the United States alone.

Each day, about 17 Americans die, waiting for organ transplants. Amy Friedman, a transplant surgeon at Yale University Hospital, says in the 52 years since the first organ transplant was performed, transplantation has become a very successful procedure -- thanks to improved techniques and medications that prevent rejection. "That means that many people are appropriate candidates, and can (benefit) from organ transplant," she says. "The problem is that so many people are suitable, we've totally outstripped the availability of organs."

The reason the organs are not available is that despite a national effort to get people to become organ donors, most Americans still "take their organs with them," so to speak, when they die. Not only that, but advancements in medicine and automotive safety have meant that fewer young Americans are dying, and while that is certainly a good thing, Dr. Amy Friedman says there is a drawback.

"While we wouldn't previously have used, say, a kidney from a 65-year-old, now we don't really have much choice," she says. "And statistically, a 65-year-old kidney is not likely to work after transplant as well, or as long as a 21-year-old kidney."

In desperation, some patients have purchased advertising, pleading with people to donate their organs -- especially their kidneys, since most people have two of them, and you do not actually have to die in order to donate one. The advertisements are not illegal, though they have raised some ethical issues, since patients who can afford to advertise and find their own donors do not have to wait as long as patients who are poor.

What is illegal is the practice of paying someone for his or her kidney. It is outlawed in just about every country except Iran. Nevertheless, every year hundreds of patients from wealthy nations like the United States and Japan travel to poorer nations like Pakistan and Turkey, where the laws are not well-enforced, and the people are so destitute they will sell one of their kidneys for as little as $800.

It is similar to the Prohibition Era in the United States, according to Eli Friedman, a physician who oversees the Renal Disease Division at the State University of New York's Downstate Medical Center. "Go back to 1920, when the government says, 'You may not have alcohol in the United States,'" he says. "The people continue to drink, and gangsters like Al Capone come along, and America drinks wildly until finally we repeal the law."

Eli Friedman is Amy Friedman's father, and the two physicians recently co-authored an article in Kidney International Magazine, where they suggested it might be time for the federal government to start regulating -- and maybe even financing -- the sale of human kidneys.

The people who are illegally buying kidneys are paying as much as $100,000 for them, but only a fraction of that money ever makes it to people who have sold their organs. If the government regulated the sale of kidneys, the Friedmans say, a standard and just price could be established. And because they would not be sneaking around, donors and recipients alike could have access to the best medical care.

"It's happening now, and people are getting AIDS, and people are getting hepatitis, and they're getting bad kidneys, and they're being exploited," Eli Friedman says. "We cannot just say 'It is bad to sell kidneys, and therefore I'm against it.' The fact is that we have to cope with human behavior."

But if you think the exploitation is bad now, says Delmonico, president of the United Network for Organ Sharing, just imagine what it will be like, if the U.S. government ever lifts the ban on organ sales. "If you have a regulated market in the United States, why couldn't we import people from Mexico, or India?" he asks. "Why can't we outsource that to individuals who, for them, $90,000 (would) be quite a bit of salary for them for a long time to come. Well, think about that from an international public policy perspective."

Dr. Delmonico says instead of trying to expand the list of transplantable kidneys by paying people for their organs, the U.S. government should concentrate on keeping people off the wait-list by financing preventative care. Many patients with diabetes, he points out, developed the disease because they did not receive the proper medical advice and attention when they were young.

So far, none of the major organ transplant organizations in the United States has endorsed the idea of paying people for their organs. But the topic is on the list of issues that will be debated at this year's World Transplant Congress in Boston in July.