What Would Happen if We Legalize Kidney Trade?
You have two, but would you rather share or sell?
While the nature of this topic is actually universal, we will be frequently quoting from Indonesian sources.
My friends and I, as a proper middle-class clique, frequently lament the fact that we can’t afford stuffs that people from the upper class may. God may have forbid you to covet what belongs to your neighbor, but you can’t help but drool at their new Omega (and maybe, their spouse too).
My friends and I may come from different beliefs (or lack of thereof), but we more or less believe in the same thing. That everything can be more or less be bought with money.
But we can never have enough of everything, that’s why we covet what is our neighbor’s. So we tend to feel that we need more money so that we may acquire….what is theirs. But how?
“Just sell your kidneys”
- my genius friends
It indeed provides the much-desired money. There is only one problem. That it’s not exactly legal in….pretty much everywhere, bar Iran.
But let’s say I’m…considering it anyway. How does kidney transplant work in Indonesia anyways?
The Current State of Kidney Transplant Process in Indonesia
We will refer to PMK no. 38/2016 (Indonesian Law) about Organ Transplant.
Suppose this one guy, let’s call him “Willie”, needs a kidney. Willie has got to wait for a willing kidney donor with a compatible kidney to come. Now how do we procure this kidney donor?
If we are playing by the rules, in Indonesia, the standard case is from a brain-dead individual. So, you have another guy got into an accident, got knocked around, and lose his brain function or brain dead. His head might be mushed, but his kidney, incidentally, was intact. This fresh kidney will go to the guy in the top of the queue. So if Willie is number 5 on the queue, he better hope there are 4 more happy accidents.
Or you can have a willing and living donor. This is where it gets difficult.
According to the regulation, a living donor must be both willing and voluntary. Voluntary meaning, not receiving compensation of any kind. A donor must also pass interview, then health screening.
Interview, according to Rumah Sakit Dr. Cipto Mangunkusomo (RSCM, a State-Owned Hospital), is done by a Forensic Psychiatry to ascertain that the donor made the decision to donate the kidney while is “cognitively, intellectually, and emotionally able” and without external pressure. In short, to determine whether he is getting paid for or coerced into it or not.
Then comes the health screening, where they run tests to see if the donor is a match or not to avoid health complications due to incompatible organ. Amongst other things, it usually can’t be spouses (mother with a child develops antibody for proteins inherited from the father, or something along that line), people of different blood types, or people with different body builds.
Note that according to study by Nemati et al. (2014), although the short term survival rate for live donor and cadaver donor is pretty much the same, there is a higher chance of survival for those receiving a kidney from live donors than cadaver donor. In another publication, it is mentioned that live kidney donors allow for more extensive testing that allows a better match rate. Hence, ideally, we should strive for more live donors.
Alas, it is very hard to find a living, compatible, AND voluntary donor.
Supposedly, there are other several sources to look for kidney, the black market let’s say. You can do it the hard way using sketchy brokers. Or, you can browse through several Facebook Groups offering sale of kidneys. The process would be so murky that even if Willie stated that he would give IDR 1 billion to the donor, the donor would only receive IDR 300 million and the rest goes to the intermediary. If Willie is lucky, he can find his own donor and broker the deal on his own.
So, what is so bad about the current process? Let’s look at both sides.
For the recipient, Mr. Willie. Finding a donor is hard. There is always a long queue for kidneys. In the current state of affair, there are a lot of Willies dying while waiting for the donor that never arrives. The demand for kidney always outstrips the supply. If Willie is rich, he may have a better chance since at least he can afford the kidney and the operation (the operation itself costs IDR 300 million at RSCM). If Willie happens to be poor, he might have a tougher (and shorter) time. The kidney, after all, in accordance to the law of supply and demand, is very expensive due to its scarce nature. People who can afford the kidney is more likely to be price inelastic (they don’t really care about the price as long as they got the kidney). The black-market participants knew this and may charge higher price for the kidney since people are going to buy them anyways.
How about the prospective donor, Mr. Indra?
First, since this is not exactly legal, there is no proper channel for the kidney donor to match with the recipient. If we want blood, we can request to PMI (Palang Merah Indonesia, some Indonesian volunteer organization) and pay a “blood quality maintenance” fee, but for kidney there hasn’t really been any organization championing this.
Interestingly, the regulation mentioned that all donors and recipients must be registered by the National Transplantation Committee (Komite Transplantasi Nasional), but a quick Google Search returns…nothing. Only a piece of news stating that “Indonesia is going to establish a National Transplantation Committee” with no further news or mention of it actually being established. There is, however, one piece where it was mentioned that while the committee has been established since 2016, there is yet to be any regulation to their name. We can conclude that this topic is currently not properly regulated yet.
So, they go through various black-market intermediaries, who we can safely assume will claim their very handsome cut on the transaction.
Brokering a deal, with or without broker, can be bad too. Since they may not have a formal agreement (remember, it’s illegal), all parties can easily cheat. Say Willie agreed to pay IDR 500 million for Indra’s kidney after the procedure. The procedure is done, Willie pays half of the agreed amount and promises to pay Indra the other half later.
Now Willie can easily refuse to pay the other half. Indra would not be able to sue Willie since what he’s done is not exactly legal.
Second, is the health aspect. Normally, kidney transplant follows a strict procedure where donors must be tested to see if they are a match that they are compatible with the intended recipient. Prospective donor must also be interviewed by a forensic psychiatry to ensure the prospective donor is able to make decision on his own free will without coercion.
Ideally, a donor will have to do regular check-ups to monitor his health post-transplant.
Of course, all the above won’t happen if Indra went through the black-market. It is unlikely that the donor is going to receive post-transplant treatments to help his/her body adjust with only one kidney. So, it’s very risky health-wise for the prospective donor. There is also nothing to ensure the prospective donor is making the decision on his/her own free will.
In short, doing it the legal way consists of waiting for a donor that never come (living/brain dead, compatible, and voluntary, but it’s free!) and that causes shortage of kidney supply. Doing it the illegal way opens risks to fraud by either side, health risk due to unsupervised practice, and intermediaries jacking up the price. Also note that not every kidney offered can be sold. Only kidneys that match with a patient can really be sold. This drives down the effective supply even lower.
Gunning for More Kidneys
The problem we are facing is a shortage of kidneys. How, one may ask, do we remedy this situation and stop people from dying waiting for a kidney that never comes? So very simply, we increase the supply. How do we increase the supply then?
One way is by making it legal for people to sell their kidney.
Before you start pointing out how immoral and what a bad idea that is, let us at least try to entertain the notion.
Right now, we have a shortage of supply because of two things:
1. Procuring kidneys legally is hard. Only a fraction of cadavers can be a kidney donor (like, not all freshly-dead can become a donor). While living, willing, and voluntary donor is hard to find. Finding a kidney through cadaver is a matter of pure luck to have a cadaver that can still be harvested for kidneys, while finding a live donor is a matter pure luck to find someone altruistic enough to donate a kidney to you.
2. Even if you somehow manage to get a kidney or someone willing to give you one, the kidney must pass several medical tests to be assessed if compatible or not.
If one country is to legalize sales of kidney, it is thought that it would alleviate cause number one by expanding the pool of supply. Becker and Elias (2013) argued that when the donor or their heir is entitled to compensation, supply of donor is likely to increase. Monetary payments would increase the total cost of transplant, but higher price would elicit higher number of organs.
Note that legalizing kidney sales will only address cause number one by expanding the pool of potential supply (kidneys offered). It does not necessarily increase the effective supply rate (kidneys offered that is a match with a patient). Remember cause number two? Legalizing the kidney market might indeed let more people to sell their kidney, but that does not guarantee that the kidneys being offered will be a match with the patients.
Of course, it wouldn’t make much sense to legalize something and not regulating them properly. For the donors, in a properly regulated market they would undergo proper testing to ensure compatibility and receive proper post-transplant treatment to ensure control over the health of the donors.
When a legalized, safer system of kidney trade exists, it is hoped that prospective donors would opt-out the black market and switch instead to a safer and better regulated legal kidney market. A legal market also offers an assurance of a fair compensation to the donor. Since it would be legal, it would be possible to take legal action for non-payments. It is also hoped that there be set up a robust system to properly track the source of kidneys to avoid illegal kidneys acquired through less proper means coming into play. Thus, serving as a deterrent against black market and kidnappers
Theoretically, a legalized kidney market would also drive down the price for kidney. One may argue that what makes kidney particularly valuable is because it is illegal to be sold. Thus, by the added risk of operating outside the law, donors or organ brokers are able to jack up the price since not everyone will be comfortable enough doing business outside the law. In economist-speak, the when the supply is low (due to the risk that comes with operating outside the law) and the demand high, the supplier will be able to charge high price for the goods. But when it’s legalized, the price will go down due to increase of suppliers, making the market less attractive for black-market participants.
But nevertheless, the logic is simple. Increase the supply, less queue for kidney, less death while waiting for kidneys, the donor gets appropriately compensated and post-transplant care.
If it’s so great, why haven’t all countries consider legalizing the kidney market?
Consider Iran, the only country to legalize the kidney market. This is largely due to not having access to decent dialysis equipment and too many end-stage renal disease patients, hence the government legalized the kidney market. The Iranian government claimed that the kidney queue is practically gone.
Turns out the legalized market didn’t really eliminate the black market. According to one account, there is still queue for kidney, and people are trying to get around the legal queue by….offering their kidney in the black-market.
What legalized market has done to Iran goes way more than increasing the supply of kidney.
True, if we are to take the Iranian government’s claim at face value, the legalized market has done its job to lessen kidney queue and save more patients. When the kidney market is legal, such operation would also be covered by social security (such as Obamacare, or in Indonesia, BPJS) so theoretically the benefit of a well regulated organ market would be felt by patients from all SES. But we would take care to assess the unintended consequences it may have. By legalizing kidney market, the government may unwittingly normalize the act of selling of organs. It becomes a viable option for getting more money. Looking at Iran, the legalized market also didn’t eliminate the black market. It is worth remembering that it’s almost impossible to fully eliminate black market, as people will always look for ways to get around regulations to get more profit normally unattainable under the legal market.
Consider for a moment, who are the players in the kidney market should it become legalized.
The donor (supply side) would consist of mostly of low SES (Socioeconomic Status) individuals. Potential “altruistic” donors would be crowded out since donating an organ voluntarily is seen as a high-level act of self-sacrifice. Assigning a price to the kidney would take out the altruistic part of the act. One may argue that the “altruistic” donor should be offered the option not to take any monetary incentive, but the legalized market would affect the stigma of kidney donors from an act of sacrifice into one of desperation. The shift of social stigma’s effect should be carefully considered and not to be underestimated.
The patient (demand side) would consist of…..anyone (the disease wouldn’t discriminate). Let’s assume the patient population consists of proportionally balanced individuals from lower and higher SES. But the ones who can actually afford the kidney? Most likely from the higher SES background. In economist-speak, we call this effective demand, or people who can actually afford the goods they are demanding.
Unless the government covers the cost via various social security schemes.
In Iran, kidneys are priced by the government at (equal to) USD 4,600 a pop. There of course, would be a queue or at least a lead-time of several months between offering of kidney, to getting matched, getting the operation, and getting paid. Considering the low SES donor, people wouldn’t donate their kidney unless they are pretty desperate for money. What if USD 4,600 won’t cut it? What if they have debts larger than 4,600? What if they can’t afford to wait the government to match and test them?
They go to the black-market. Unlike the legal market, the black-market most likely operates on a free market economy, with the price being regulated by the market. The black market may quote a higher price than the government price by offering the bypassing of government kidney queue. There, the donors may sell their kidneys at a higher price than what the government is offering.
It would be difficult to claim that a legalized market will eliminate the black-market. Due to the nature of black-market itself, it will be difficult to find any reliable information or concrete number on them.
Some also fear that legalizing, thus normalizing kidney trade, will create an expectation by those of higher SES to those of lower SES. An expectation that individuals with lower SES are to supply their kidney to those of higher SES, not unlike a cattle. Remember that a donor is more likely to come from lower SES background, while those buying is more likely to come from higher SES background. Creating a tangible rift between the rich and the poor is highly likely to lead to many more social problems down the road in the future far way beyond sales of kidney. Think a riot, or a coup, or politicians leveraging the rift to stage a political upheaval.
Is There Any Alternative?
So we found out the decision to legalize kidney trade is a very difficult subject (if it was easy, we won’t be talking about it since it would have been solved long time ago). Isn’t there any other ‘softer’ way to go around this?
One idea is instead of sales, or monetary incentive, we offer non-monetary incentive for donors. Non-monetary incentive can be access to lifetime free healthcare, or college scholarship. This may also still create a rift between those of lower and higher SES. Since it is essentially the same with the legalized market, those offering their kidney would still be those in need of “extra” facilities (scholarship). The patient won’t have to pay, but the cost of the non-monetary incentive is most likely going to be borne by the government. This may entail an increase in tax to fund such initiatives, as such, be met with resistance.
The government may also adopt an “opt-out” approach for kidney donation. “Opt-out” approach meaning that all individuals, upon death (or any specific condition of death), are immediately considered to be a voluntary cadaver donor. Although the match rate and longevity of kidneys from cadaver is lower than those from live donor, it is still better than nothing. This approach may meet resistance from countries where certain beliefs or religion plays a strong role on society, particularly those that insist that the “opt-out” approach is “desecrating the dead”. We argue that the dead have no further use of their organs, and would be much better use if given to a living person in need of a particular organ.
Other than increasing the supply, recall that we established another cause of kidney shortage other than the pool of kidney supply itself. Kidneys have to be compatible with the recipient in order for the transplant to be successful.
Enter the Kidney Paired Donation program.
Imagine the case where Willie and Indra are both in need of a kidney. Willie’s son, Albert, is willing to donate his kidney but is unfortunately not a match to Willie. Likewise, Indra’s son, Jordy, is willing to donate his kidney but is unfortunately also not a match to his father.
The Kidney Paired Donation (KDP) program uses certain algorithms to match potential donors such as Albert and Jordy, to Willie and Indra. The KDP algorithm would match Willie with Jordy’s (Indra’s son) kidney, and Indra with Albert’s (Willie’s son) kidney.
Think of it as them exchanging their son’s kidney with each other. That’s KDP in a nutshell.
With that, we have understood the current practice of kidney transplant, imagined what the world would be if kidney market is legalized, look at the potential downsides of a legalized kidney market, and consider potential alternatives to a legalized kidney market.
We are not a fan of the current state of kidney transplant affair. We agree that we need to increase the supply of kidneys, but that does not mean we are hell-bent on advocating a legalized kidney market. We have taken a look at the possibilities, and surmised that it may not be the best approach to take given all situation and condition of our country (and the world).
We may not be able to offer the world a sure-fire solution. What we can is to appeal to friends and those in power, to carefully consider this issue not just from the view of a humanitarian, nor economist, but a delicate mix of both.
Or you can just try a healthier lifestyle.
