Finding the winning combination: how blending organ procurement systems used internationally can reduce the organ shortage.

• Author: Statz, Sarah Elizabeth

ABSTRACT

The shortage in transplantable organs worldwide not only leads to unnecessary death, but also to grave human rights abuses through illegal methods of procuring organs. The shortage leads some desperate to find an organ through any possible means, including purchasing an organ on the black market. The system for procuring organs in the United States is based on altruism, where potential donors have to opt in to the system in order for their organs to be donated. This creates issues at the time of death for medical professionals or the next of kin to decide whether their patient or loved one had decided to donate. This Note explores organ procurement systems used internationally and details the benefits and drawbacks of each. The Author proposes that a blend of some of the systems used internationally could reduce the illegal and immoral methods of organ procurement. The Author argues that the United States needs to implement a national registration system that tracks the willingness of all individuals to donate and is available to hospitals nation-wide through a database. In addition, the Author suggests that non-monetary incentives, including a paired organ exchange and giving priority to those who are themselves listed as donors, will also help decrease the shortage of organs.

TABLE OF CONTENTS I. INTRODUCTION II. ORGAN SUPPLY SHORTAGES CREATE AN INTERNATIONAL BLACK MARKET III. APPROACHES TO ORGAN PROCUREMENT A. The Altruistic Model 1. The Uniform Anatomical Gift Act 2. The National Organ Transplant Act 3. Problems with the Altruistic Model in the United States B. The Presumed Consent Model 1. The United States 2. France 3. Belgium 4. Austria 5. Spain 6. Singapore 7. Considerations for Implementing a Presumed Consent System C. Incentives for Organ Donation 1. Monetary Incentives a. Forward-Looking Incentives i. Futures Markets ii. Tax Breaks iii. Discounted Driver's License Fees b. On-the-Spot Incentives 2. Non-Monetary Incentives a. Transplant Priority for Donors b. Paired Organ Exchanges IV. BLENDING APPROACHES TO CREATE AN EFFECTIVE ORGAN PROCUREMENT SYSTEM A. Producing a More Efficient Organ Procurement System B. Creating Proper Incentives to Increase Donation Rates V. CONCLUSION I. INTRODUCTION

More than 93,000 people in the United States are currently in need of an organ transplant. (1) By contrast, only 14,699 transplants occurred in the year ending September 22, 2006. (2) Approximately nineteen people will die each day waiting for an organ donor. (3) The United States is not the only country facing this problem. In India, about 150,000 patients are diagnosed with kidney disease each year, but the number of kidney transplants fell from an estimated 3,600 per year in 2002 to 2,800 per year in 2003. (4)

A shortage in transplantable organs results not only in unnecessary death, it creates other problems worldwide. Internationally, the attempt to fulfill organ donation requests has led to grave human rights abuses through illegal methods of procuring organs. Some people travel to other countries to purchase organs on the black market. For example, in northeast Brazil, the Pernambuco (5) state legislature's investigative commission uncovered an international organ trafficking ring for transplants performed in South Africa. (6) The members of the trafficking ring recruited people in Brazil to sell their kidneys. (7) The sellers were taken to the South African city of Durban for the surgeries. (8) Most of the recipients of the organs were Israelis. (9) The Brazilian sellers were recruited from impoverished neighborhoods. (10) The first sellers were paid ten thousand dollars per kidney, but as the trafficking ring became more "successful" the payments fell to as low as three thousand dollars. (11)

A recent scandal at the University of California at Los Angeles (UCLA) medical school illustrates the demand for organs for medical research purposes in the United States. As part of the Willed Body Program at UCLA, donated bodies are available to the UCLA community for medical education and research. (12) Some body parts intended for the program were sold illegally to corporations involved in private medical research. (13) The individual selling the body parts received more than $700,000 from the sales. (14) The families of the donors were extremely disappointed when they heard of the sales of their loved ones' organs and brought class actions against UCLA. (15)

Few nations are able to meet the organ demand through their domestic organ transplant systems. (16) The existence of the international black market shows that the solution to the organ procurement problem must be dealt with on an international rather than a domestic level. (17) Unfortunately, national programs that cannot provide an adequate supply of organs essentially force citizens to look to alternative markets to get them. (18)

A cohesive organ procurement system that combines the beneficial aspects of current international systems would provide a framework for reducing the illegal and immoral methods of organ procurement. An efficient and effective system implemented in the United States would cut down on human rights violations while increasing the supply of available organs.

Part II of this Note discusses how the shortage of organ supplies across nations has created a black market and has led to human rights violations. Part III explores systems currently in place internationally and discusses the benefits and drawbacks of each of these systems. Part IV concludes with a description of a framework that blends the various systems used worldwide to create an efficient and effective organ procurement system for the United States.

2. ORGAN SUPPLY SHORTAGES CREATE AN INTERNATIONAL BLACK MARKET

   Patients waiting to receive organ transplants often live in countries where there is an insufficient supply of organs available for transplant. Moreover, nations with the fewest restrictions on organ procurement often generate a surplus of available organs. (19) This situation has led to the development of an international black market for organ sales. Unfortunately, this international market produces human rights violations, including the sale of organs harvested from the poor. (20) It is often the poorer citizens of developing countries who are supplying organs to members of the upper class, either directly or indirectly. (21) To solve the black market abuses taking place in many nations, it is crucial that other nations increase the supply of available organs. (22)

   It is illegal to sell or buy a human organ in all developed nations, but it is legal in Iran and Pakistan. (23) However, despite the alleged ban on selling human organs, many countries do not stringently enforce these laws. (24) Countries with relaxed laws on sales of human organs include: Israel, India, South Africa, Turkey, China, Russia, Iraq, Argentina, and Brazil. (25)

   The demand for organs compels people on waiting lists to travel to other countries to procure an organ for transplant. In Israel, removal of cadaver organs is allowed only with specific permission of the family, and donation of organs from living patients (living donors) requires written permission from the ministry after assessment by a hospital committee including a psychologist and a social worker. (26) A national committee must also interview non-relative living donors, but organ donation by living non-relatives is rarely approved. (27) With these stringent restrictions on organ donation, Israel's organ supply cannot meet the demand. (28) Many Israeli patients travel to India and Iraq to receive organs from unrelated living donors. (29) Most of the patients traveling to Iraq for a kidney meet their donors in the street outside the hospital among a group of competing donors. (30) The young, able-bodied men, aged twenty-five to thirty-five years, receive around $500 for a kidney. (31) Reports have shown that some of the patients receiving kidneys in India acquired hepatitis or HIV infections as a result of their organ transplants. (32)

   Even U.S. citizens may feel that an organ transplant is hopeless, and some U.S. citizens travel to foreign countries to purchase organs on the black market. Sami, age twenty-three, waited more than eighteen months for a cadaver kidney in the United States. (33) He finally gave up on receiving a transplant in the United States and traveled to Iraq to receive a kidney transplant from a paid, non-related living donor. (34)

   Reports have accused China of harvesting the organs of thousands of executed prisoners each year and selling them for transplants. (35) China denies that organs have been procured from non-consenting prisoners but admits that organs from prisoners have been used with the prisoners' prior permission. (36) The British Transplantation Society (BTS) has mounting evidence that suggests "the organs of thousands of executed prisoners in China are being removed for transplants without consent." (37) In fact, the BTS notes that the speed of matching donors and patients, sometimes in as little as a week, suggests that the prisoners are being selected before execution. (38) The BTS commented that "transplant tourism" often lures British patients in need of a transplant to China. (39)

   Black markets in organs will continue to produce human rights abuses if the organ shortage continues. These abuses--usually of poor citizens in developing countries--could be diminished by establishing a cohesive, successful organ procurement system.

3. APPROACHES TO ORGAN PROCUREMENT

   This Part looks at a variety of organ procurement approaches currently used around the globe. The first is the altruistic model, which is used in the United States, where potential donors have to opt in to the system in order to donate organs. The second model is presumed consent, used in many European countries, where it is assumed that the organs will be donated unless the patient has opted out of the system...