Kidney transplantation in the United States isburdened by a terrible policy failure. The cost ofthis failure will be paid in the currency of years ofhuman lives unnecessarily lost, as well as a massiveincrease in federal expenditures over the nextdecade and beyond. The number of patients withend-stage renal disease (ESRD) in the UnitedStates has grown, but the supply of kidneys—forthe preferred treatment for ESRD, kidney trans-plantation—has not kept pace with the demand.Unfortunately, the issue is not simply one of sup-ply and demand: in the United States the supplyof kidneys for transplantation is kept artificiallylow by a prohibition on the sale of human organs.

If a decade’s worth of reports in the trans-plant literature are to be believed, only one coun-try in the world does not suffer from an organshortage: Iran. Although Iran clearly does notserve as a model for solving most of the world’sproblems, its method for solving its organ short-

age is well worth examining. Organ donation isubiquitous throughout the world, but Iran is theonly country that legally permits kidney vending,the sale of one individual’s kidney to another suf-fering from kidney failure.

After a critical examination of what can belearned from the Iranian experience that will helpthe United States solve its organ shortage, certainconclusions seem inevitable: The portion of theNational Organ Transplant Act of 1984 whichprohibits the sale of organs should be repealed.The savings that will likely accrue should be spenton long-term study and maintenance of the ven-dor system and on the creation of mechanisms toensure fair trading. Finally, because so much isstill unknown regarding how organ sales wouldwork in the United States, individual transplantcenters and organ procurement organizationsshould be permitted to experiment with how toimplement a system of organ vending.

Organ Sales and Moral TravailsLessons from the Living Kidney Vendor Program in Iran

by Benjamin E. Hippen

_____________________________________________________________________________________________________

Benjamin E. Hippen, MD, is a transplant nephrologist in private practice with Metrolina Nephrology Associatesand the Carolinas Medical Center in Charlotte, North Carolina. He is an at-large member of the United Networkfor Organ Sharing/Organ Procurement and Transplant Network Ethics Committee and serves as an associate edi-tor of the American Journal of Transplantation.

Executive Summary

No. 614 March 20, 2008�������

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Introduction

Entrenched health care policies can costlives. Nowhere is that more evident than in acomparison of the government policies onrenal replacement therapies for end-stagerenal disease (ESRD) in the United States andIran. While many Iranians in the past suf-fered greatly for their country’s lack of ESRDpolicies, thousands of patients in the UnitedStates continue to suffer today.

Political and financial realities in theUnited States and Iran directly influenced theavailability of scientific developments whichchanged ESRD from a fatal diagnosis to achronic disease. Dialysis was developed in theUnited States in the 1960s, but this life-savingtherapy was expensive and scarce.1 The firstsuccessful kidney transplant in the UnitedStates was performed in 1951.2 In Iran, thefirst successful renal transplant took place in1967.3 Still, without reliable, effective immu-nosuppressant drugs, dialysis remained theonly reasonable alternative for many patientswith ESRD until the early 1980s.4 Both theU.S. and Iranian governments paid for dialysiswhile continuing to develop transplant op-tions. In the United States, dialysis became thefirst fully funded Medicare health benefit; adiagnosis of ESRD and a modest contributionto social security tax revenues is all that isrequired to qualify for the entitlement, regard-less of age or financial status.5 But the expenseof dialysis, the economic collapse in Iran fol-lowing the 1979 revolution, and the expense ofthe subsequent protracted conflict with Iraqencouraged the Iranian government to pay fortransplantation as soon as immunosuppres-sant drugs made it a viable alternative to dial-ysis.6

The Iranian government paid for its citizensto have transplants abroad,7 while the UnitedStates entrenched itself in its existing dialysisreimbursement policies. In 1972 a hearingbefore the House Ways and Means Committeewas enlivened by the performance of a dialysistreatment before an audience of duly impressedlegislators.8 This event was compelling enough

that within weeks the Social Security Act wasamended to provide a full Medicare-fundedentitlement for dialysis therapy.9 Then, in 1984,an overzealous entrepreneur testified beforeCongress that he was planning to import im-poverished denizens from developing nations,remove their organs, transplant them intoAmerican patients, and then return the “don-ors” to their homelands with a pittance to showfor their efforts. A horrified Congress passed theNational Organ Transplant Act, including aprohibition against “knowingly acquir[ing],receiv[ing], or otherwise transfer[ring] anyhuman organ for valuable consideration for usein human transplantation if the transfer affectsinterstate commerce.”10 Two decades later theUnited States and most of the world is stilllaboring under the ill-conceived notion that thesale of organs should be prohibited under all cir-cumstances, and the number of people dying ondialysis while waiting for an organ that nevercomes continues to steadily increase. Mean-while, in 1988 Iran began providing remunera-tion for unrelated donors, and its list of patientsawaiting transplants steadily decreased.11

The contrast in the policies of the twocountries is reflected in the stark differences inthe number of patients on dialysis, waiting fora kidney, and subsequently dying. In theUnited States alone, 341,000 patients suffer-ing from ESRD were dialysis-dependent in2005—triple the number in 1988.12 Currentestimates vary, but that number is expected togrow to between 400,00013 and 520,00014 by2010 and to approach 525,00015 to 700,00016

by 2020. Today, in the United States, morethan 73,000 people are waiting for a kidneytransplant from a deceased donor, and by2010, the waiting list is expected to grow tonearly 100,000.17 In Iran, the waiting list forkidneys was eliminated in 1999, 11 years afterthe legalization of organ vending, and for thepast 8 years, Iran has had no waiting list forkidneys.18 By contrast, since 1999 more than30,000 U.S. patients with kidney failure havedied waiting for an organ that never arrived.19

In addition to thousands of lives unneces-sarily lost, another dimension of the U.S.ESRD policy is the staggering cost to taxpay-

2

Most of the worldis still laboring

under the ill-conceived notion

that the sale oforgans should beprohibited underall circumstances.

ers. The cost of the ESRD entitlement grew tomore than $21 billion in 2005, nearly 6.5 per-cent of the Medicare budget, and was spent onbehalf of 0.6 percent of eligible Medicare ben-eficiaries in 2005.20 Of that $21 billion, only$586 million was spent on kidney acquisitionand transplantation.21 The perversity of thisvast disparity in relative funding for dialysisand transplantation is compounded by thefact that kidney transplantation confers a sig-nificantly improved quality and quantity oflife for nearly every category of patient withESRD: The median survival rate for a new dial-ysis-dependent patient is 35 percent after fiveyears, compared to a 75 percent survival rateafter kidney transplantation.22 In short, kid-ney transplantation represents the best formof renal replacement therapy for the vastmajority of patients with ESRD and at a frac-tion of the cost of dialysis. The extent of theU.S. policy failure with respect to ESRD is onlybeginning to be fully realized, but someadverse consequences are already apparent:23

Demand for renal replacement therapy esca-lated following the passage of an open-endedand ballooning federal entitlement. A perversefinancial incentive favors dialysis over trans-plantation despite the manifest medical supe-riority and relative cost-savings of the latter.The disparity between the demand for andsupply of kidneys continues to grow.24 Andthe death rate for individuals waiting fordeceased-donor kidneys is increasing.25

This Policy Analysis provides a criticaloverview of the 20-year-old Iranian systemthat has legalized the purchase of kidneysfrom living vendors. Common criticisms ofthe Iranian system are scrutinized with an eyetoward understanding what the UnitedStates can learn from the Iranian experience,incorporating what works, and improvingwhat either does not work or might notwork, with special attention paid to the prob-lems that Iranian transplant professionalshave identified as avenues for improve-ment.26 The Iranian system is far from per-fect, as Iranian transplant professionals arethe first to admit. But a comprehensiveexamination of the Iranian system suggests

the United States can learn a great deal fromthe Iranian experience. Many common objec-tions to a market for organs in the UnitedStates are not sustainable, and existing prob-lems with the Iranian system can suggestalternative solutions to the current deceased-donor and dialysis system in this country.

How the Iranian SystemWorks

Insofar as the kidney procurement systemin Iran can be characterized as a “market,” it isa highly standardized and regulated marketwith only modest room for negotiation. Oncepotential kidney recipients are identified, theyare evaluated by kidney transplant teams,including transplant nephrologists and trans-plant surgeons. Recipients are counseled that itis in their best interest to identify a biologicallyrelated living donor. If no biologically relatedliving donor is available or willing to donate,the recipient is referred to the Dialysis andTransplant Patients Association. From there,disposition of the recipient depends onwhether the transplant center has an activedeceased-donor program. For example, at amajor university hospital in Zhiraz, which hasan active deceased-donor program, recipientsreferred to DATPA must generally wait sixmonths for a deceased-donor kidney (thoughsome recipients elect to circumvent thisrequirement by traveling to Tehran for trans-plantation).27 If the recipient does not receive atransplant from a deceased donor after sixmonths, DATPA identifies an immunological-ly compatible kidney vendor for the recipient.28

DATPA is staffed by volunteers with ESRDand receives no remuneration for matchingkidney vendors with recipients. Neither thetransplant center nor transplant physiciansare involved in identifying potential vendors.Instead, vendors express their own interest inparticipating by contacting DATPA. Onceidentified, vendors are referred to the trans-plant center and evaluated according to thesame medical standards applied to livingdonors who are not financially compensated,

3

Today, in theUnited States,more than 73,000people are waiting for a kidney transplantfrom a deceaseddonor.

including the evaluating physician’s right touse his medical discretion to veto a vendor’scandidacy.

Vendors are paid in two ways. First, theIranian government provides a fixed compen-sation to the vendor of approximately $1,200plus limited health insurance coverage, whichcurrently extends to one year after theexchange and covers only conditions deemedrelated to the surgery.29 Second, the vendorreceives separate remuneration either from therecipient or, if the recipient is impoverished,from one of a series of designated charitableorganizations; this amount is usually between$2,300 and $4,500.30 The amount and sourceof the second remuneration is arrangedbeforehand by DATPA.31 It is important tonote that noncitizens are not eligible to partic-ipate in the Iranian organ procurement sys-tem as either vendors or recipients. As withdialysis, the Iranian government assumes thecost of treatment, including the kidney pro-curement, transplant surgery, immunosup-pression medications, and postoperative careof the vendor and recipient. Thus, while theIranian market in organs is heavily regulated,it does allow people to receive several forms ofcompensation for their organs, includingfinancial compensation.

Unlike the rest of the world, and theUnited States in particular, the Iranians havefound a way to solve their organ shortage;and although their market system is notwithout problems, it clearly has advantagesover other organ procurement systems, pri-marily that thousands in need do not diewhile waiting for a compatible donor.

Merits of the IranianSystem

Permitting legal organ vending has broughtthe greatest benefit: By 1999 the waiting list forkidney transplants in Iran had been eliminated,a success no other country can claim.32 In addi-tion, the Iranians have found a way to minimizethe potential negative impact of financial incen-tives. DATPA serves as an alternative to the for-

profit organ brokers who are such a perniciousfeature of illegal organ trafficking in othercountries. Exchanges by freelance brokers (par-ticularly where legal protections against coer-cion or fraud are inconsistently enforced) cancreate incentives for both the broker and thevendor to be untruthful if disclosures mightthwart the exchange. For example, if a vendorhas a communicable infectious disease, or haskidney disease, there are clear disincentives toidentify, discover, or disclose such facts in a sys-tem that does not enforce organ brokerage con-tracts. The Iranian system addresses this prob-lem by making the intermediary a nonprofit,patient-run service organization that trades onthe moral commitment of patients to help oth-ers in a position similar to their own. That, inturn, provides as powerful a motivation toavoid harmful practices as a system that consis-tently and strictly enforces laws against coer-cion and fraud, which redounds to the benefitof vendors.

The Iranian not-for-profit, charity-basedsystem also provides a convenient intermedi-ary between the organ vendor and the patientor transplant center, thus mitigating a host ofpotentially difficult, moral conflicts of inter-est. Separating the role of identifying vendorsfrom the role of evaluating their medical, sur-gical, and psychological suitability permitstransplant professionals to avoid confusingjudgment on a vendor’s candidacy with vari-ous financial and professional incentives toperform more transplants. Without dwellingon which potential conflicts of interest mightevolve into actual conflicts of interest, it isclear that systemwide separation betweenidentifying and screening potential vendorshas the advantage of reducing potential con-cerns.

The Iranians have eliminated their waitinglist for kidneys by allowing a limited market inlive-donor kidney vending, and in so doingthey have discovered a way to minimize someof the perceived dangers of such a system.With DATPA acting as intermediary, the Irani-ans have reduced the possibility that organvendors will be taken advantage of by eitheroverzealous middlemen, procurement institu-

4

In Iran, the waiting list for

kidneys was eliminated

in 1999, 11 years after

the legalization of organ vending.

tions, or physicians desperate to help theirpatients. Despite those successes, however, theIranian system is not without problems.

Concerns with the Iranian System

Both proponents and opponents of kid-ney vending from the living have reason to beskeptical about the veracity of outcomesreported by Iranian transplant professionals.Precautions must be taken to carefully parseout sound conclusions from those that lacksufficient evidence. Both proponents andopponents share valid concerns regardingsafety and the lack of information on long-term outcomes for vendors. Furthermore,the vast political, cultural, and religious dif-ferences between Iran and the United Statesmight make in-depth comparative analysesof little value.33 But, given that thousands ofAmericans die each year waiting for a kidney,rejecting the Iranian system out of hand, andwithout careful analysis, is ill-advised. Whilethe Iranian system may not be as successfulas that country’s transplant professionalsclaim, concerns voiced by opponents of kid-ney vending are typically predicated on oppo-sition to organ vending in general ratherthan any specific concerns about the Iraniansystem in particular.

Vendor Organs, Donor Organs: A CloserLook at Recipient Outcomes

The outcomes for recipients of organs fromvendors do not appear to be as good as out-comes for recipients of living donor organs,with at least one report of a 10-year organ sur-vival of 44 percent for recipients of organs fromliving vendors, compared to a 10-year organsurvival of 53 percent for recipients of organsfrom living donors.34 When compared withoutcomes from living related donors in Iran,however, this difference did not reach statisti-cal significance. Why might outcomes not beas good for recipients of organs from vendors?One explanation can be found by examiningthe socioeconomic demographics of kidney

vendors in Iran. In the available literature onthe subject, there is widespread agreement thatthe majority of vendors are “poor.” Althoughthis term is often used imprecisely (sometimesit is undefined, but sometimes it denotes livingat or below the poverty level in Iran, whichmeans an income of less than $5 per month35),there is little reason to doubt the general truthof the assessment.36 In the United States, someevidence suggests that low socioeconomic sta-tus alone is a predictor for the development ofkidney disease.37 That is not to say that beingpoor somehow causes kidney disease, but lowsocioeconomic status may predict exposure toa host of environmental factors (particularlyinfections) which can increase the risk of devel-oping kidney disease. If kidney vendors in Iranare disproportionately poor, then as a groupthey are quite possibly more likely to have sub-clinical kidney disease at the time of their kid-ney vending. In addition, they may be mal-nourished or suffer from other conditionswhich make them a less than ideal source ofkidneys. That might also account for theslightly lower organ survival rate in recipientsfrom impoverished donors.

What Happens to Organ Vendors?The most contentious disagreements in

the literature regarding kidney vending inIran have to do with the personal, physical,and financial consequences for vendorsthemselves. This issue is complicated by anabsence of routine follow-up.38 Still, thehypothesis that the long-term health of ven-dors is adversely impacted is plausible, sincesuch a conclusion would logically coincidewith the slight trend toward worse long-termoutcomes for recipients of transplants fromkidney vendors.

Since there is no central repository of out-come data for recipients, donors, or vendors inIran, the information available to outsidersconsists of what is published in the medical lit-erature and anecdotal evidence provided bythose who live in or visit Iran. Conceivably,both the reassuring and the worrisome reportson vendor outcomes are true, with each reportaccurately reporting facts in different geo-

5

Since 1999 morethan 30,000 U.S.patients with kidney failurehave died waitingfor an organ thatnever arrived.

graphic areas. Absent a system of routine ven-dor follow-up, just how to integrate reportsand popular accounts remains an open ques-tion.39 While the lack of accurate data justifiesconcern, it does not justify abandoning theidea of organ vending. The solution is to care-fully monitor outcomes and adjust the vend-ing system or, if need be, abandon it shouldresults prove unacceptable.

Does a System of Organ VendingUndermine Deceased Donation? Not inIran

William Harmon and Francis Delmonicohave charged that the number of kidneys pro-cured “per million population” in Iran is low-er than in countries without remunerationpolicies.40 Since deceased donation was notreally feasible in Iran until 2000, such claimsare misleading. In 2000, the Iranian parlia-ment made organ retrieval from deceaseddonors possible by legislating the acceptanceof a cessation of brain function as deathinstead of accepting only heart-lung criteria.41

Once this legislative commitment was madeto respond to cultural and religious concernsregarding donation after death,42 the numberof kidneys from deceased donors increasedsignificantly.43 Neither the donor’s estate northe families of deceased donors receive pay-ment for these kidneys. At least in Iran, theconcern that a system of compensating livingvendors inevitably renders a system of unpaiddeceased donation moribund is unsupportedby the evidence.44 Lastly, whether Iran obtainsas many kidneys per million population asother countries is simply irrelevant. Quiteapart from whether Iran has not procured thesame number of kidneys per million popula-tion, the evidence shows that Iran has pro-cured enough kidneys to eliminate its waitinglist, a claim that no other country, and partic-ularly no “donor-only” country, can evenbegin to approach.

Living Organ Donation and LivingOrgan Vending: Not Mutually Exclusive

Admittedly, the kidney vendor program inIran has resulted in fewer kidneys procured

from biologically related donors, than fromliving vendors;45 however, that does not neces-sarily mean that altruistic donations havedropped. Despite a flourishing kidney vendorprogram, biologically related donation hasconsistently constituted 12–13 percent of alldonated kidneys, and that fraction has persist-ed in tandem with the rapid rate of growth inkidneys procured (without compensation tothe donor’s estate or family) from deceaseddonors.46 While a great many recipientschoose to purchase a kidney from a living ven-dor through DATPA, in 2006 some 28 percentof recipients did not do so. That raises a trou-bling problem for critics of the Iranian system,and of a market for kidneys more generally.The Iranian system, as any market-based sys-tem for organ procurement would do, per-mits, but does not require, altruistic donation.A market permits recipients and potentialdonors/vendors to choose whether they preferremuneration or more altruistic rewards. Thedata from Iran suggests that allowing remu-neration does not discourage those whobelieve altruistic donation is the only accept-able option from continuing to donate orreceive donated organs exclusively.

It is not at all clear that “donor-only” poli-cies encourage altruism. In donor-only coun-tries, like the United States, identified donorsare free to refuse to donate, but they do so withthe clear understanding that their designatedrecipient may be significantly disadvantagedand perhaps die waiting for a kidney as a con-sequence of their decision. Under such condi-tions, at least some donors surely choose toprevent that consequence by donating. Evenso, that shouldn’t be interpreted as fosteringaltruism. Donations motivated by familial orsocial pressures, or profound feelings of guilt,are hardly the hallmarks of altruistic action. InIran, however, biologically related potentialdonors who choose not to donate can makethat choice without jeopardizing the health oftheir relative, because in Iran it is easier toobtain a kidney from other sources than it isin countries where organ vending is not per-mitted. In this sense, a market for kidneysserves to clarify altruistic choices.47 As Tibor

6

The Iranian system permits,

but does notrequire, altruistic

donation.

Machan has argued, when acts of altruism arepermitted but not required, choosing to actaltruistically is correctly understood as actingabove and beyond the call of duty, and thusaccrues additional moral credit in ways thatmerely meeting moral obligations does not.48

Are Organ Vendors Coerced into SellingTheir Kidney?

Paying for kidneys is not “coercive,” asopponents of the Iranian system often claim.A preponderance of evidence confirms thatkidney vendors in Iran are disproportionately(more than 70 percent in every available sur-vey) impoverished—by nearly any definition ofthe term.49 But whether remuneration of kid-ney vendors in Iran is therefore coercive is notas self-evident as the critics suppose50—thoughobviously much turns on what is understoodin labeling an offer coercive.51 The broader theconcept of what constitutes a coercive offer,the narrower the range of noncoercive choicesavailable. Stipulating that the range of optionsopen to poor people is generally more limitedthan the range of options open to the well-off,the question is this: Are all offers made toimpoverished persons coercive, or only some?If all offers made to the impoverished are coer-cive, this leads to the counterintuitive conclu-sion that no choices made by impoverishedpersons are uncoerced, and thus there is noth-ing morally unique about offering themremuneration for their organs. A charitableoffer, or the offer of employment, to an impov-erished person would be coercive in exactly thesame way, in that circumstances coerce theperson into accepting a gift or a paying job.However, if some offers are coercive and someare not—and the coercive nature of an offer ismorally relevant—then some defensible dis-tinctions must be drawn between coercive andnoncoercive offers.

It is useful to compare the offer of remu-neration for an organ with other options avail-able to impoverished vendors, and to considerwhether organ vending is somehow uniquelycoercive in a way that (for example) the offer ofcharity or the offer of a paying job is not coer-cive. Voluntariness is antithetical to the con-

cept of coercion, and an offer cannot be coer-cive if the relationship is initiated by the per-son in danger of being coerced. In Iran, ven-dors present themselves voluntarily to DATPAfor consideration based on general knowledgeabout the option of organ vending.52 TheIranian system specifically prevents physiciansin need of an organ for a particular patientfrom initiating organ vending. More expan-sive interpretations of coercion53 would apply,equally and unfavorably, to offers such as acharitable gift or a menial job, which are nottypically thought to be coercive. If those exam-ples are judged coercive, then perhaps thesame can be said of the psychological pres-sures inherent in currently acceptable meth-ods of soliciting organs for donation.54 Inshort, any claim that offers to impoverishedorgan vendors in Iran are inherently coercivebears the burden of explaining what makes anoffer to vend uniquely coercive and otheroffers relevantly less so.

The Best of Both Worlds:Learning from the Iranian

Experience and Moving toward Solving the Organ Shortage in

the United States

Taking into consideration the concernsdescribed above, the United States can learnimportant lessons from Iran. Seven suchlessons make clear that organ vending is aremarkably effective means of eliminating acountry’s organ shortage. The only plausibleexplanation for Iran’s accomplishment ofeliminating its waiting list for kidneys is itssystem of organ procurement from livingvendors. Twenty years of experience withorgan vending in Iran has demonstrated thata vendor system can exist in harmony withboth a living-related-donor program and aflourishing deceased-donor program. Farfrom restricting access to transplantation tothe well-off, access to organs in Iran is possi-ble regardless of the recipient’s ability to pay.

7

Far from restricting access to transplantationto the well-off,access to organsin Iran is possibleregardless of therecipient’s abilityto pay.

In addition, the Iranian system has sparedthat country the atrocities that accompanygray-market organ trafficking, a practicemade possible only because desperate recipi-ents from countries such as the United Stateshave no recourse to a legal market in organs.

More Organs from All SourcesPresumably, altruism could persist and

even flourish alongside a kidney market in theUnited States as it does in Iran. Contrary tocritics’ assertions, the Iranian model of kidneyvending does not preclude either living ordeceased donation, as demonstrated by stablerates of biologically related living donation, aswell as escalating rates of deceased donation.Deceased donation would and should contin-ue in the United States as it does in Iran. Somehave raised the concern that the introductionof market mechanisms would result in lowerrates of procurement from living and deceaseddonors,55 a claim unsupported by the evi-dence.56 The donor system, whether relying onliving or deceased donors, permits individualswho are morally committed to donating (notselling) their organs to do so. Recipients withmoral objections to receiving an organ pur-chased from a vendor need not pay for thatdecision with their lives. Instead, those recipi-ents can request that they only receive anorgan from a donor; and donors who plan ondonating at death can stipulate that theirorgans may be procured only if they are notsubsequently sold.57 If a vendor market in theUnited States can be as successful in reducingdemand as it has in Iran, the recipient pool fordeceased donors would be far smaller than it istoday, making the actualization of the moralcommitment not to receive an organ from aliving vendor less likely to be a fatal decision.

Minimizing Risks to VendorsIn the United States, a market approach to

kidney procurement could function far betterthan the Iranian system by working to ensureoptimal outcomes and minimize risk for ven-dors and recipients alike. If the long-term out-comes of organ vendors are formally includedas a moral and financial responsibility of the

vending system, then market forces will mini-mize costs by selecting a vendor populationwith the lowest risk of developing social orphysical complications after the exchange.58

There is a growing consensus throughout thetransplant community regarding standardsfor evaluation and care of the live organdonor.59 That is the obvious starting point forgenerating analogous standards for the liveorgan vendor. The government’s financialinterest in identifying a vendor population atlowest risk of short- and long-term complica-tions after organ procurement overlaps withthe obligations of transplant professionals tominimize the risk of harm to vendors. In turn,the obligation not to harm vendors suggeststhat standards for choosing vendors should bemore stringent than current standards for liv-ing donors. Furthermore, in a vendor system,an increased potential pool of organs from thehealthiest vendors should reduce pressure ontransplant professionals to consider living-donor candidates of questionable medicalacceptability. The hazardous temptation tobalance the ongoing suffering of a recipientwith the sheer determination of a living donorto donate regardless of the risks to themselveswould be sharply reduced in a vendor system.For all the well-founded concerns about safety,a properly constructed vendor system wouldquite probably be safer for all parties com-pared with the current system.

Good Outcomes for Vendors Have MoralValue and Market Value

The moral value of safe practices can betraced to the general obligation of a physicianto avoid doing harm to patients. For bothdonors and vendors alike, providing a clear, evi-dence-based understanding of the long-termrisks of exchanging a kidney are paramount forachieving authentically informed consent. Themarket value of safe practice has many facets.First, a system where the safety of vendors isgiven priority offers the stability and repro-ducibility necessary for fostering trust. Second,a safe system minimizes adverse outcomes bydefinition, which results in lower expenditureson the consequences of adverse outcomes.

8

The Iranian system has spared

that country theatrocities that

accompany gray-market

organ trafficking.

Consider that, in the United States, the vastmajority of people with moderate kidney dis-ease do not live long enough to develop kidneyfailure because any degree of kidney disease sig-nificantly accelerates the progression of heartattacks and strokes. Kidney vendors withundetected, preexisting kidney disease or riskfactors for kidney disease are likely to developthe attendant cardiovascular complications ofreduced kidney function and, by extension,incur considerably higher health care expens-es.60 Thus, a system that selects as organ ven-dors those individuals least likely to developshort- and long-term complications is mostlikely to reduce overall health care expendi-tures. In this way, moral obligations and mar-ket pressures to maximize cost-efficienciesintersect when the safety of organ vendors andorgan recipients is a priority.

The United States Has the Infrastructureto Adopt the Best Aspects of the IranianSystem

In the United States, no institution precise-ly compares to the Iranian DATPA. But organprocurement organizations (OPOs) haveserved basically the same function for procur-ing and distributing organs from deceaseddonors, so the responsibility for identifyingand screening living organ vendors can reason-ably be assigned to OPOs. OPOs in the UnitedStates have cooperative relationships with indi-vidual transplant centers, limited to the identi-fication and procurement of organs fromdeceased donors. Living donors are typicallyidentified and evaluated by individual trans-plant centers. Individual centers provide thecounseling and disclosures necessary forinformed consent without the involvement ofthe OPO. In Iran, a clear division of labor existsbetween the DATPA and transplant centers,with the former identifying potential organvendors and referring them to transplant cen-ters for medical and surgical evaluation.

A similar division of labor would makesense in the United States for several reasons.First, making OPOs, not transplant centers,solely responsible for identifying and screen-ing potential organ vendors would mirror

OPOs’ current role in deceased donation. Thatwould limit the burden on OPOs to assimilatenew responsibilities beyond their traditionalareas of technical expertise. Second, theresponsibility for the medical and surgicalevaluation of organ vendors would lie withtransplant nephrologists and transplant sur-geons, where it belongs. Third, this division ofresponsibilities would mitigate potential con-flicts of interest between the competing goalsof increasing rates of organ procurement andensuring safe practices in the screening andapproval of potential organ vendors. OPOscan be offered incentives for correctly identify-ing appropriate candidates for organ vending;and conflicts of interest which might encour-age the approval of inappropriate candidatescan be mitigated by offering very differentincentives to transplant nephrologists andsurgeons. The incentives for OPOs should begeared to maximizing the supply of organs,but the incentives for physicians should bedirected toward maximally ensuring the safetyof organ donors and organ vendors alike.

Parallel Charitable Structures CouldDevelop

In the United States, multiple institutionscould develop to support a system of organvending. In Iran, compensation for vendorscomes from a variety of sources includingcharities and the DATPA, which is run by vol-unteers who match vendors with recipients.As indicated in the previous section, theUnited States could more feasibly rely onexisting infrastructure to distribute organs,rather than try to emulate the Iranian DAT-PA. Nevertheless, the creation of alternativemechanisms for identifying potential ven-dors and paying their fees should not be dis-couraged.

One of the great strengths of the Americansocial and economic structure in general is thatit permits economic, government, and charita-ble institutions with overlapping goals to coex-ist. As H. Tristram Engelhardt has argued, onevirtue of markets is that they permit personswith diverse and conflicting moral views tocooperate in limited ways with others who

9

One of the greatstrengths of theAmerican socialand economicstructure is that it permitseconomic, government, and charitable institutions withoverlapping goalsto coexist.

agree with them.61 The same can be said ofcharities. Since charitable organizations existprimarily to advance a particular moral vision,different charitable organizations could helpfind vendors for and from within their specificmoral community.

Organ vendors motivated by more thanmere self-interest might actualize multiplemoral goals with assistance from such charities.Different charities might be devoted to advanc-ing a plurality of moral visions: one might bededicated to improving access to transplanta-tion in a geographic area; another to membersof groups disproportionately affected by kidneydisease such as African Americans; anothertoward encouraging organ allocation to indi-viduals in need, independent of other consider-ations. Charities could even spring up to pro-mote organ donation, dedicating funds todefray financial disincentives to organ dona-tion such as lost wages from time away fromwork and travel expenses, or to broadly publi-cizing appeals to particular moral communitieson behalf of a member in need. Far from ap-pealing to an abstract concept of organ vendorsas interested only in financial gain, parallelcharity structures would permit vendors, recip-ients, and entire moral communities to cooper-ate in finding ways to end the organ shortage.

Caveat venditor? Avoiding Bad Outcomesfor Vendors

If a regulated system of kidney vending wereobserved to routinely reduce vendor well-being,that would be cause for moral concern. Theconcern would arise not because the impover-ished are unable to make choices which mightentail bad outcomes, but because the impover-ished, like the rest of us, are ostensibly less like-ly to make bad choices if the consequences areknown in advance. If an offer is attractive onlybecause its manifestly unattractive features havebeen deliberately concealed, then the offer ispredicated on deceit, and the vendor is a victimnot of coercion, but of fraud.

The evidence reviewed here does not sup-port the contention that kidney vendors arecoerced, nor that an offer of compensation forkidneys in any way constrains a vendor’s

autonomy. However, it may be the case thatkidney vendors in Iran suffer reduced well-being often enough to warrant closer scrutinyof how vendors are selected. Several studiesreporting outcomes from kidney vendors inIran support that concern.62 As previously dis-cussed, reports on the social and economicconsequences of kidney vending in Iran varyfrom the reassuring63 to the dire,64 with no dis-positive means to discern which reports arecloser to the truth, or indeed whether bothaccounts are accurate.65 Given the lack of dis-positive evidence, the United States shouldtrack long-term vendor outcomes in caseunanticipated negative side effects arise frompermitting the sale of organs.

Registries, Lifelong Health CareCoverage, and Medical Judgment

Reforms advocated by Iranian proponentsof their own system of organ vending overlapwith safeguards included in organ marketproposals for the United States. Both advo-cate a registry for vendors and donors, as wellas lifelong health care coverage, to moreclearly define the short- and long-term con-sequences of exchanging a kidney;66 and bothreserve the right of transplant professionalsto veto a vendor’s candidacy based on med-ical judgment alone.67

To ground generalizations about long-termoutcomes of donors and vendors in verifiablefact, any organ vending system should track themedical, surgical, psychological, and socioeco-nomic consequences of both organ donationand organ vending. The most obvious way todo this would be to provide lifelong, compre-hensive health insurance to living donors andvendors, perhaps making it a mandatory bene-fit of any privately arranged organ vendingagreement. As Arthur Matas and MarkSchnitzler have shown, the cost savings to thegovernment of paying for transplantationinstead of dialysis are vast.68 Thus, it might beboth cost-effective and morally salutary to com-pensate vendors with regular tax-free depositsinto personal health savings accounts, whichvendors could use to purchase comprehensiveinsurance coverage from private insurers.

10

A repeal ofSection 301 of the

National OrganTransplant Act

would be themost effective

first step towardestablishing a

comprehensivesystem of organ

vending in theUnited States.

Private insurers, in turn, should have an interestin providing health insurance to rigorouslyscreened vendors. If vendor screening is suchthat organ vendors, as a group, can part with akidney and suffer even fewer short- and long-term complications than donors, vendors as agroup would be attractive to insurers from anactuarial standpoint.

The lessons learned from the Iranian systemof organ vending suggest several potential haz-ards that need to be taken into account. First,physicians have an obligation to avoid coopera-tion with vendors if the vending system regu-larly and predictably results in the reduced well-being of kidney vendors.69 Whether this will bethe case in the United States is unclear, but thepossibility certainly exists. Iran has avoided theproblem by having the DATPA arrange recipi-ent/vendor matches. Second, the governmenthas a fiduciary obligation not to permit a pro-gram of kidney vending if a significant numberof vendors suffer from serious complications,including but not limited to an increase in kid-ney disease. It is unclear whether the Iraniangovernment is meeting that obligation. TheU.S. government should monitor outcomesright from the beginning to make sure seriouscomplications are identified and avoided. Andthird, kidney vending must routinely providemutually beneficial exchanges;70 otherwise, fos-tering such exchanges constitutes moral com-plicity with unfair arrangements. The degree towhich these hazards apply to the current sys-tem of kidney vending in Iran is not known.Regardless, a system where these concerns,when identified, are systematically managed,minimized, or eliminated is clearly preferable.

First Steps toward a Systemof Organ Vending in the

United StatesA system of organ vending in the United

States, informed by the Iranian experience,will entail several reforms. To be successful,such reforms must allow room for experi-mentation with various types of vendorarrangements while simultaneously ensuring

the fairness of those arrangements. No singlesuccess or failure should define the accept-ability of a market approach to organ vend-ing. Many options may need to be tried and,with time and careful study, a fair and equi-table market approach to solving the organshortage should be possible.

Legalize Organ VendingA straightforward repeal of Section 301 of

the National Organ Transplant Act,71 whichproscribes the exchange of “valuable considera-tion” for organs, would be the most effectivefirst step toward establishing a comprehensivesystem of organ vending in the United States. Amore feasible but politically difficult first stepwould be for Congress to allow exemptionsfrom Section 301 of NOTA to permit pilot pro-grams in organ vending. However, whether ornot such programs proved successful coulddepend on many variables. For example, a pilotprogram might increase the number of organswithout fulfilling other obligations to organvendors, inviting unflattering comparisons tounderground organ trafficking. Or a programmight be successful in one community but inef-fective (or inappropriate) in other communi-ties. An incentive program that works inChicago might not be nearly as effective inPoughkeepsie. By extension, a single programwhich fails to increase the number of organsshould not lead to the conclusion that all incen-tive proposals are certain to fail. For these rea-sons, a straightforward repeal of Section 301would be preferable.

Use the Savings WiselyBy making use of existing institutional

structures such as transplant centers andOPOs, the maintenance costs of a vendor mar-ket would be much lower than for dialysis, andefforts should be made to use the surpluswisely. The vast expense of dialysis means thatthe amount of money potentially available topay vendors and still break even is quite high(by some estimates, more than $100,000 pervendor).72 Thus, a successful vendor marketwill probably reduce government expendi-tures significantly compared to the current

11

The vast expenseof dialysis meansthat the amountof money potentially available to payvendors and stillbreak even isquite high.

system. At a minimum, the financial liabilitiesto a vendor market would include maintain-ing a registry, paying for health coverage fordonors and vendors, making up the addition-al operational costs to OPOs for identifyingand screening vendors, and funding oversightof various incentive programs to ensure thatmechanisms for safe practices and long-termfollow-up are in place. At least some of the sur-plus (if any) from a vendor program should beset aside to maintain the solvency of fundsdedicated to paying for the long-term medicalobligations to vendors.

Create Mechanisms to Ensure FairTrading

The legalization of organ vending cannotbe an invitation to anarchy. Legal organ vend-ing requires adapting existing infrastructureto ensure “mutual gains through trade,” byprioritizing the safety of all parties, and to suc-cessfully increase the number of availableorgans.73 These goals can best be achieved bylegislative and court action affirming an indi-vidual’s property right in their own body andensuring that fairly executed contracts fororgan vending are upheld. To help ensure fair-ness, laws might require lifelong health cover-age for donors or at least some direct pay-ments into an individual health savingsaccount delineated for purchasing compre-hensive health insurance only for the desig-nated vendor. To encourage vendors to followup with a physician over the long-term,deposits to the health savings account couldbe amortized, contingent upon the vendormaking follow-up visits at specified intervals.Such restrictions are justified by the fact thatthe government has a direct financial interestin ensuring that vendors are at minimal risk ofdeveloping short- or long-term complicationsafter the exchange. Similarly, tying incentivesfor organ procurement organizations andtransplant physicians to the correct identifica-tion and assessment of low-risk vendors,rather than to the absolute number of vendorsapproved, merges the moral obligations oftransplant professionals to minimize harmwith the economic interests of the govern-

ment to avoid the costs of paying for the con-sequences of injury.

Let a Thousand Flowers BloomSince the constraints on a proposed vendor

system in the United States are modest, and theeffectiveness of various incentives must beempirically validated (in the form of bothincreasing the number of transplantable organsand documenting long-term outcomes of ven-dors and recipients), individual transplant facil-ities and OPOs should be permitted to fashiontheir own vendor systems, subject to modestoversight. There is little reason to suppose thata given package of incentives offered to resi-dents of New York City will appeal equally toindividuals in Charlotte, Chicago, or Houston.Permitting diversity in structure encouragesinnovative approaches, which in turn offercommunities and vendors a panoply of incen-tive options, though each set of options shouldinclude safeguards for all parties. So long asincentives are successful, and the proper safe-guards are in place, the specifics become lessimportant.

Conclusion: Solutions Instead of

SermonsDespite vast cultural and political differ-

ences between Iran and the United States,much can be learned from the Iranian system.A review of 20 years of experience with a livingorgan vendor system in Iran reveals successes,deficiencies, and ambiguities. Each of thoseaspects is instructive for demonstrating whatan organ market can be, as well as what itought to be. If there is a salient irony in thedebate over the moral defensibility of theIranian system, it is that American critics seemdisappointed that the Iranians did not followour lead. But carrying this reasoning to itsconclusion would entail admitting that in sodoing, Iran would have also incurred our cur-rent shortage of organs, our waiting list mor-tality, and our consequent moral complicity insustaining an international market in illegal

12

A review of 20 years of

experience with aliving organ

vendor system inIran reveals

successes, deficiencies, and

ambiguities.

organ trafficking.74 If the discussion of kidneymarkets in this country can progress beyondpreconceptions as to what can and cannotwork, in Iran or elsewhere, to an examinationof the example of Iran based on the evidence,that will be a significant step in the rightdirection.

NotesThanks are due to Sigrid Fry-Revere, James StaceyTaylor, and Lisa Rasmussen for their insightfulcomments and criticisms. Responsibility for allerrors of fact or of reasoning is mine alone.

1. Shana Alexander, “Medical Miracle and a MoralBurden of a Small Committee: They Decide WhoLives, Who Dies,” Life Magazine, November 7, 1962,pp. 102–25

2. Nicholas Tilney, Transplant: From Myth to Reality(New Haven: Yale University Press, 2003), pp. 60–64.

3. Ali Nobakht Haghighi and N. Ghahramani,“Living Unrelated Kidney Donor Transplantationin Iran,” Nature Clinical Practice Nephrology 2(2006): e1.

4. The introduction of Cyclosporin A in 1983, animmunosuppressant medication targeting T-lym-phocytes, ushered in an era of substantially im-proved graft outcomes after transplantation: 80percent versus 64 percent one-year graft survival.See “A Randomized Clinical Trial of Cyclosporinein Cadaveric Renal Transplantation,” New EnglandJournal of Medicine 309 (1983): 809–15

5. Richard A. Rettig, “Historical Perspective,” inEthics and the Kidney, ed. Norman G. Levinsky (Ox-ford, UK: Oxford University Press, 2001).

6. Haghighi and Ghahramani, “Living UnrelatedKidney Donor Transplantation in Iran.” Manytransplant programs in Iran were discontinued afterthe 1979 revolution, and nearly all Iranian trans-plant surgeons emigrated to either the United Statesor Europe. Prior to 1985, some 4,000 patients weremaintained on dialysis in Iran, but only 100–110kidney transplants took place from 1967 to 1985.See Ahad J.Ghods, “Renal Transplantation in Iran,”Nephrology Dialysis Transplantation 17 (2002): 222–28;and author’s correspondence with Ahad Ghods,M.D. F.A.C.P., October 10, 2007. Used with permis-sion; copy in author’s files.

7. From 1980 to 1985, prior to the legalization oforgan vending in Iran, the Iranian Ministry ofHealth provided reimbursement for recipients

with living-related donors to travel abroad fortransplant surgery. Ghods, “Renal Transplantationin Iran.”

8. See Richard A. Rettig, “Origins of the MedicareKidney Disease Entitlement,” in Biomedical Politics,ed. Kathi Hanna (Washington: National AcademyPress, 1991), pp. 188–89.

9. Social Security Amendments of 1972, Public Law92-603, Section 299I, U.S. Statutes at Large 86(1972): 1329, 1463–64, codified at U.S. Code 42(1972), Section 1395. The legislative history of theMedicare entitlement for ESRD is recounted in alively fashion in Rettig, “Origins of the MedicareKidney Disease Entitlement.”

10. The National Organ Transplant Act of 1984, PublicLaw 98-507, U.S. Statutes at Large 98 (1984): 2344,codified at U.S. Code 42 (2002), Sections 273–74,contains a specific criminal prohibition (NOTASection 301) against any person receiving “valuableconsideration” in exchange for a human organ,U.S. Code 42 (2002), Section 274e.

11. Ghods, “Renal Transplantation in Iran.”

12. United States Renal Data System, Annual DataReport 2007 (Minneapolis: USRDS, 2007), http://www.usrds.org.

13. Ibid.

14. J. L. Xue, et al., “Forecast of the Number ofPatients with End-Stage Renal Disease in theUnited States to the Year 2010,” Journal of theAmerican Society of Nephrology 12 (2001): 2753–58.

15. United States Renal Data System.

16. David T. Gilbertson, et al., “Projecting theNumber of Patients with End-Stage Renal Diseasein the United States to the Year 2015,” Journal of theAmerican Society of Nephrology 16 (2005): 3736–41.

17. Xue, et al.

18. Ghods, “Renal Transplantation in Iran.”

19. “Removal Reasons, by Year, 1999–2006,” OrganProcurement and Transplantation Network, http://www.optn.org/latestData/viewDataReports.asp.

20. United States Renal Data System. See Figure11.1, http://www.usrds.org/.

21. Ibid.

22. Ibid. See Figure 6.16, http://www.usrds.org/.

23. Benjamin E. Hippen, “The Case for KidneyMarkets,” New Atlantis 14 (2006): 47–61, http://

13

www.thenewatlantis.com/archive/14/hippen.htm.

24. Benjamin E. Hippen, “In Defense of a Regulat-ed Market in Kidneys from Living Vendors,” Jour-nal of Medicine and Philosophy 30 (2005): 593–626.

25. Data available at the Organ Procurement andTransplantation Network, http://www.optn.org.

26. Ahad J. Ghods, “Review of the Unique IranianModel for Living Kidney Donation, Two Decadesafter Its Initiation,” September 2, 2007. Unpub-lished manuscript, used with permission of theauthor; copy in author’s files.

27. Author’s correspondence with Ghods, October10, 2007.

28. Ahad J. Ghods and S. Shekoufeh, “IranianModel of Paid and Regulated Living-UnrelatedKidney Donation,” Clinical Journal of the AmericanSociety of Nephrology 1 (2006): 1136–45.

29. Whether and to what degree vendors makeuse of this health benefit is not clear, as there is noformal longitudinal follow-up for vendors afterthe exchange.

30. S. Ossareh, et al., “Attitude of Iranian Nephrol-ogists toward Living Unrelated Kidney Donation,”Transplantation Proceedings 39 (2007): 819–21.

31. Ghods and Shekoufeh, “Iranian Model of Paidand Regulated Living-Unrelated Kidney Donation”;and Haghighi and Ghahramani, “Living UnrelatedKidney Donor Transplantation in Iran.”

32. Ghods and Shekoufeh.

33. Benjamin E. Hippen, “A Modest Approach toa New Frontier: Commentary on Danovitch,”Transplantation 84 (2007): 464–66.

34. Malek-Hosseini and colleagues reviewed theresults of 1,200 consecutive kidney transplants atNemazee Hospital in Shiraz, Iran, from 1998 to2003 and reported a 92 percent four-year patientsurvival for recipients of living-related-donor kid-neys, 91 percent for recipients of vendor kidneys,and 90.5 percent for recipients of deceased-donorkidneys. No statistically significant difference inorgan survival was observed between biologicallyrelated donors, living kidney vendors, and recipientsof deceased-donor kidneys after four years. See S.Malek-Hosseini, et al., “Long-Term Results of RenalTransplantation: A Single-Center Analysis of 1,200Transplants,” Transplantation Proceedings 38 (2006):454–56. Reviewing results in a different institution,Ahad Ghods reported significantly different rates oforgan survival between immunologically well-

matched, biologically related donors, and less-well-matched related donors from living kidney vendors.Organ outcomes were slightly worse for recipients ofkidney vendors 10 years after transplantation (10-year organ survival of 44 percent), but the differ-ences were modest when compared to outcomesfrom less-well-matched, biologically related livingdonors (53 percent at 10 years) and did not reach sta-tistical significance. Ghods, “Renal Transplantationin Iran.” For comparison, consider that the mostrecent reports of 10-year organ survival in theUnited States are at 54.9 percent. “Adjusted GraftSurvival by Year of Transplant at 3 Months, 1 Year, 3Years, 5 Years and 10 Years—Living Donor KidneyTransplants,” Table 5.9c in Scientific Registry of Trans-plant Recipients, 2006 Annual Report (Washington: U.S.Department of Health and Human Services, 2006),http://www.ustransplant.org/.

35. Tahereh Malakoutian, et al., “SocioeconomicStatus of Iranian Living Unrelated Kidney Donors:A Multicenter Study,” Transplantation Proceedings 39(2007): 824–25.

36. In a survey of 500 kidney vendors selected at ran-dom, Ghods and colleagues found that the vastmajority of vendors was male (90.2 percent) and“poor” (84 percent so classified, 16 percent “middleclass”), with a low level of educational achievement(6 percent “illiterate,” 24 percent possessing an ele-mentary education). Among the recipients, some 50percent were classified as “poor,” 36 percent “mid-dle-class,” and 13 percent “wealthy.” See Ahad J.Ghods, S. Ossareh, and P. Khosravani, “Comparisonof Some Socioeconomic Characteristics of Donorsand Recipients in a Controlled Living UnrelatedDonor Renal Transplantation Program,” Transplan-tation Proceedings 33 (2001): 2626–27. However,another survey of 301 kidney vendors who had solda kidney between 1989 and 2000 in Kermanshah,Iran, reported somewhat different trends: 71 percentmale, 27 percent unemployed with 18 percent con-fined to “home duties,” and 35 percent illiterate withan additional 25 percent having an elementary edu-cation. J. Zargooshi, “Quality of Life of IranianKidney ‘Donors’,” Journal of Urology 166 (2001):1790–99.

37. T. V. Perneger, P. K. Whelton, and M. J. Klag,“Race and End-Stage Renal Disease: Socioeconom-ic Status and Access to Health Care as MediatingFactors,” Archives of Internal Medicine 155 (1995):1201–208; N. Drey, et al., “A Population-BasedStudy of the Incidence and Outcomes of Diag-nosed Chronic Kidney Disease,” American Journal ofKidney Disease 42 (2003): 677–84; E. W. Young, et al.,“Socioeconomic Status and End-Stage RenalDisease in the United States,” Kidney International45 (1994): 907–11; and C. M. Fored, et al., “Socio-Economic Status and Chronic Renal Failure: APopulation-Based Case-Control Study in Sweden,”

14

Nephrology Dialysis Transplantation 18 (2003): 82–88.

38. Malakoutian and colleagues, for example,reported that 91 percent of the vendors they sur-veyed reported they were “satisfied” with theexchange and that 53 percent recommended organvending to others. See Malakoutian, et al., “Socio-economic Status of Iranian Living UnrelatedKidney Donors.” However, J. Zargooshi reported alitany of adverse outcomes for vendors: 38 percentlost their jobs due to postoperative complications,39 percent were subjected to severe socialostracism, 84 percent reported difficulty securingemployment because of social ostracism, and 60percent fully expected to be dialysis-dependentthemselves or die in the near future as a conse-quence of selling a kidney. See Zargooshi, “Qualityof Life of Iranian Kidney ‘Donors’.” Since thesestudies were undertaken at different institutions, itis possible that both are correct. The lesson for theUnited States in considering a system of organvending is that the risk to vendors must be mini-mized by careful screening modeled on the screen-ing of living donors, transparency regarding theknown and unknown risks of organ vending, andlong-term prospective follow up of organ vendors.See Hippen, “In Defense of a Regulated Market inKidneys from Living Vendors.”

39. N. Savrestani, “Iran’s Desperate Kidney Trad-ers,” BBC News, October 31, 2006, http://news.bbc.co.uk/2/hi/programmes/thisworld/6090468.stm.

40. William Harmon and Francis Delmonico, “Pay-ment for Kidneys: A Government-Regulated Sys-tem Is Not Ethically Achievable,” Clinical Journal ofthe American Society of Nephrology 1 (2006): 1146–47.

41. The history of the progression from religious tolegislative acceptance of brain death is described inB. Larijani, F. Zahedi, and E. Taheri, “Ethical andLegal Aspects of Organ Transplantation in Iran,”Transplantation Proceedings 36 (2004): 1241–44; andM. Raza and K. M. Hedayat, “Some SocioculturalAspects of Cadaver Organ Donation: Recent Rul-ings from Iran,” Transplantation Proceedings 36 (2004):2888–90.

42. A series of fatwa (Islamic religious decrees) wereissued, beginning in the 1980s with AyatollahKhomeini, that paved the way for legislative approvalof the concept of brain death. See M. M. Golmakani,M. H. Niknam, and K. M. Hedayat, “TransplantationEthics from the Islamic Point of View,” Medical ScienceMonitor 11 (2005): 105–09.

43. Hippen, “A Modest Approach to a New Frontier.”

44. Gabriel M. Danovitch, “Cultural Barriers toKidney Transplantation: A New Frontier,” Trans-

plantation 84 (2007): 462–63; and Gabriel M.Danovitch and Alan B. Leichtman, “Kidney Vend-ing: The ‘Trojan Horse’ of Organ Transplantation,”Clinical Journal of the American Society Nephrology 1(2006): 1133–35. The increase in kidneys procuredfrom deceased donors since the statutory recogni-tion of brain death by the Iranian parliament in2000 appears to be a consequence of several factors.The legislative imprimatur made possible the estab-lishment of a kidney procurement organization(given the acronym IRANTOP—the Iranian Net-work for Transplant Organ Procurement—byIranian scholars who write in English) capable ofprospectively identifying potential candidates forkidney donation after the declaration of death bywhole-brain criteria. See B. Larijani, F. Zahedi, andE. Taheri, “Deceased and Living Organ Donation inIran,” American Journal of Transplantation 6 (2006):1493. In addition, success was contingent uponestablishing essential infrastructural componentssuch as trained organ procurement professionalsand standards for diagnosing brain death, as well assecuring and promulgating religious imprimatursfor living and deceased donation. See Larijani,Zahedi, and Taheri, “Ethical and Legal Aspects ofOrgan Transplantation in Iran”; and Raza andHedayat, “Some Sociocultural Aspects of CadaverOrgan Donation.”

45. Ghods and colleagues reported that, in a survey ofrecipients of vendor kidneys, some 81 percent had apotential biologically related donor who declinedeither for “cultural reasons” or because of the avail-ability of a kidney vendor program. See Ahad J.Ghods, S. Savaj, and P. Khosravani, “Adverse Effectsof a Controlled Living-Unrelated Donor RenalTransplant Program on Living-Related and Cadav-eric Kidney Donation,” Transplantation Proceedings 32(2000): 541.

46. The use of public education campaigns in Iranto combat indigenous concerns about deceaseddonation (e.g., perceived religious proscriptionsor the potential for a reduced intensity of care atthe end of life), has helped to increase the numberof organs procured from deceased donors from1.8 percent (n=26) of all kidney transplants in2000 to 15 percent (n=243) in 2006. See Ghods,“Review of the Unique Iranian Model for LivingKidney Donation.”

47. Hippen, “In Defense of a Regulated Market.”

48. Tibor R. Machan, “Blocked Exchanges Revisit-ed,” Journal of Applied Philosophy 14 (1997): 249–262.

49. Malakoutian, et al., “Socioeconomic Status ofIranian Living Unrelated Kidney Donors”; Ghods,Ossareh, and Khosravani, “Comparison of SomeSocioeconomic Characteristics of Donors andRecipients”; and Zargooshi, “Quality of Life of

15

Iranian Kidney ‘Donors’.”

50. See Harmon and Delmonico, “Payment forKidneys.”

51. Alan Wertheimer identifies no fewer than 11 dis-tinct uses of “coercion” in legal and moral contexts,which range from the straightforward definition of“cases in which the agent’s actions or movementsare non-volitional,” to “claims to emphasize theefficacy or usefulness of informal pressures that donot involve specific penalties.” Alan Wertheimer,Coercion (Princeton, NJ: Princeton University Press,1987), pp. 185, 187.

52. Ghods and Shekoufeh, “Iranian Model of Paidand Regulated Living-Unrelated Kidney Donation.”

53. Examples of more expansive interpretations ofthe concept of coercion include instances when onlyone prudent offer among many exists; when theoffer in question is not one the individual is mosthappy with; when the offer exist only along a spec-trum of very limited options; or when the choiceoccurs in the context of a host of filial, social, andcultural pressures that threaten disapproval or dis-grace if the offer is not accepted. These examples aretaken from Wertheimer, Coercion, pp.185–89.

54. Describing a phenomenon famously dubbedthe “tyranny of the gift,” Renee Fox and JudithSwazey observed, “This psychological and moralburden is especially onerous because the gift therecipient has received from the donor is so extraor-dinary that it is inherently unreciprocal. It has nophysical or symbolic equivalent. As a consequence,the giver, the receiver, and their families may findthemselves locked in a creditor-debtor vise thatbinds them one to another in a mutually fetteringway.” Renee C. Fox and Judith P. Swazey, SpareParts: Organ Replacement in American Society (Oxford,UK: Oxford University Press, 1992), p. 40.

55. Ajay K. Israni, et al., “Incentive Models to IncreaseLiving Kidney Donation: Encouraging WithoutCoercing,” American Journal of Transplantation 5(2005): 15–20.

56. A recent survey of likely donors, found thatthe prospect of financial incentives for organ pro-curement from deceased donors would increasethe likelihood of donation in 19 percent of cases,decrease the likelihood in 10 percent of cases, andmake no difference in 70 percent of cases. See C.L. Bryce, et al., “Do Incentives Matter? ProvidingBenefits to Families of Organ Donors,” AmericanJournal of Transplantation 5 (2005): 2999–3008.

57. Hippen, “In Defense of a Regulated Market.”

58. Ibid.

59. Francis L. Delmonico, “A Report of theAmsterdam Forum on the Care of the Live KidneyDonor: Data and Medical Guidelines,” Transplanta-tion 79 (2005): S53–66; and Connie L. Davis,“Evaluation of the Living Kidney Donor: CurrentPerspectives,” American Journal of Kidney Diseases 43(2004): 508–30.

60. For the same reason, aggressive measures toprevent the progression of kidney disease typicallyprevent more people from dying from heartattacks and strokes, thereby permitting more peo-ple to live long enough to develop kidney failureand require either dialysis or transplantation. SeeBenjamin E. Hippen, “Preventive Measures MayNot Reduce the Demand for Kidney Transplan-tation. There Is Reason to Suppose This Is Not theCase,” letter to the editor, Kidney International 70(2006): 606–07.

61. H. Tristram Engelhardt, Jr., The Foundation ofBioethics, 2nd ed. (New York: Oxford UniversityPress, 1996).

62. In a recent study of living donors and vendorsfrom a single institution in Iran, 80 out of 86 (93 per-cent) of those studied were vendors. High blood pres-sure was the most frequently reported complication,occurring in 32 of 86 cases. Surgical complicationsoccurred in 5.8 percent of cases, including postopera-tive infections, excessive blood loss, and one case of acollapsed lung. Patients were left with residual kidneydysfunction in 6.9 percent of cases, developed pro-teinuria in 10.4 percent of cases, and developed hema-turia in another 13.9 percent of cases. Any of theseconditions suggest preexisting kidney disease, thoughthey may not have been identified (or identifiable) inpreoperative screening. Persistent neurological com-plaints were reported in 17.5 percent of cases, and per-sistent postoperative pain in an additional 12.7 per-cent of cases. Of special concern, 9.3 percent ofpatients had been prescribed medication for severedepression. No vendor was reported to have died orprogressed to kidney failure, but the length of follow-up was limited to three years. See N. Ghahramani, etal., “Occurrence of Hypertension and Proteinuriaamong Kidney Donors in Shiraz Nemazee Hospital,”Transplantation Proceedings 31 (1999): 3139; H. Salahi,et al., “Effect of Donor Nephrectomy on Renal Func-tion and Blood Pressure,” Transplantation Proceedings33 (2001): 2654; and S. A. Azar, et al., “Is Living KidneyDonation Really Safe?” Transplantation Proceedings 39(2007): 822–23. These findings stand in sharp con-trast with reported rates of surgical and long-termmedical complications of kidney donation in theUnited States and Europe. See Arthur J. Matas, et al.,“Morbidity and Mortality after Living KidneyDonation, 1999–2001: Survey of United StatesTransplant Centers,” American Journal of Transplan-tation 3 (2003): 830–34; Amy L. Friedman, et al., “Fataland Nonfatal Hemorrhagic Complications of Living

16

Kidney Donation,” Annals of Surgery 243 (2006):126–30; J. Gossmann, et al., “Long-Term Conse-quences of Live Kidney Donation Follow-Up in 93percent of Living Kidney Donors in a Single Trans-plant Center,” American Journal of Transplantation 5(2005): 2417–24; and T. Ramcharan and A. J. Matas,“Long-Term (20–37 Years) Follow-Up of Living Kid-ney Donors,” American Journal of Transplantation 2(2002): 959–64.

63. Malakoutian, et al., “Socioeconomic Status ofIranian Living Unrelated Kidney Donors.”

64. Zargooshi, “Quality of Life of Iranian Kidney‘Donors’.”

65. A clue may be found in the general attitude ofnephrologists in Iran. In the only survey ofnephrologists available in English, 60 percent sup-ported the existing system of kidney vending inprinciple, 42 percent assumed that kidney failurewas a potential long-term complication of kidneydonation or kidney vending, and 92 percentreported informing donors/vendors of the risks ofcomplications verbally (none in writing)—though48 percent thought that most donors/vendors pre-ferred not to hear about the risks. See S. Ossareh, etal., “Attitude of Iranian Nephrologists toward Liv-ing Unrelated Kidney Donation,” TransplantationProceedings 39 (2007): 819–21.

66. Ghods, “Review of the Unique Iranian Model forLiving Kidney Donation;” and Robert S. Gaston, et al.,“Limiting Financial Disincentives in Live Organ Don-ation: A Rational Solution to the Kidney Shortage,”American Journal of Transplantation 6 (2006): 2548–55.

67. Hippen, “In Defense of a Regulated Market inKidneys from Living Vendors”; and Ghods, “RenalTransplantation in Iran.”

68. Recent cost estimates have suggested that thebreak-even point between the cost of dialysis andthe cost of transplantation is less than 1.5 years($101,259 for 1.5 years of dialysis versus $85,507after two years of transplantation and full reim-bursement for immunosuppression medications).In other words, cost savings occur if a recipient livesfree of dialysis for more than 1.5 years, which is the

case for more than 95 percent of recipients. SeeArthur J. Matas and Mark Schnitzler, “Payment forLiving Donor (Vendor) Kidneys: A Cost-Effective-ness Analysis,” American Journal of Transplantation 4(2004): 216–21.

69. Hippen, “In Defense of a Regulated Market inKidneys from Living Vendors.”

70. Richard A. Epstein, Simple Rules for a ComplexWorld (Cambridge, MA: Harvard University Press,1995), p. 80.

71. The National Organ Transplant Act of 1984, PublicLaw 98-507, U.S. Statutes at Large 98 (1984): 2344,codified at U.S. Code 42 (2002), Sections 273–274,contains a specific criminal prohibition (NOTASection 301) against any person receiving “valuableconsideration” in exchange for a human organ,U.S. Code 42 (2002), Section 274e.

72. Matas and Schnitzler, “Payment for LivingDonor (Vendor) Kidneys.”

73. “The case in favor of freedom rests on the pos-tulate of mutual gains through trade. The ratio-nale for the institution provides the essential cluefor its limitation. When bargaining takes place insettings where mutual gain is not the probableoutcome, there is sufficient warrant for the law tostep in and set that transaction aside.” Epstein,Simple Rules for a Complex World, p. 80.

74. A statement by the United Network for OrganSharing board of directors condemns the practice ofpatients traveling abroad to purchase organs notavailable in their own countries (i.e., “transplanttourism”). However, it explicitly acknowledges thiscomplicity: “ . . . the Committee would be remiss infailing to observe that the practice of transplanttourism might not exist but for the growing dispari-ty between the demand for and supply of organs. It isthe solemn obligation of the transplant community,not only to publicly condemn the exploitative prac-tices of transplant tourism, but to endorse ethicallydefensible policies, which will ultimately render suchpractices unnecessary.” From “UNOS Board FurtherAddresses Transplant Tourism,” June 26, 2007, http://unos.org/news/newsDetail.asp?id=891.

17

STUDIES IN THE POLICY ANALYSIS SERIES

613. The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World by Michael Tanner (March 18, 2008)

612. Electronic Employment Eligibility Verification: Franz Kafka’s Solution to Illegal Immigration by Jim Harper (March 5, 2008)

611. Parting with Illusions: Developing a Realistic Approach to Relations with Russia by Nikolas Gvosdev (February 29, 2008)

610. Learning the Right Lessons from Iraq by Benjamin H. Friedman, Harvey M. Sapolsky, and Christopher Preble (February 13, 2008)

609. What to Do about Climate Change by Indur M. Goklany (February 5, 2008)

608. Cracks in the Foundation: NATO’s New Troubles by Stanley Kober (January 15, 2008)

607. The Connection between Wage Growth and Social Security’s FinancialCondition by Jagadeesh Gokhale (December 10, 2007)

606. The Planning Tax: The Case against Regional Growth-Management Planning by Randal O’Toole (December 6, 2007)

605. The Public Education Tax Credit by Adam B. Schaeffer (December 5, 2007)

604. A Gift of Life Deserves Compensation: How to Increase Living KidneyDonation with Realistic Incentives by Arthur J. Matas (November 7, 2007)

603. What Can the United States Learn from the Nordic Model? by Daniel J. Mitchell (November 5, 2007)

602. Do You Know the Way to L.A.? San Jose Shows How to Turn an UrbanArea into Los Angeles in Three Stressful Decades by Randal O’Toole (October 17, 2007)

601. The Freedom to Spend Your Own Money on Medical Care: A Common Casualty of Universal Coverage by Kent Masterson Brown (October 15, 2007)

600. Taiwan’s Defense Budget: How Taipei’s Free Riding Risks War by Justin Logan and Ted Galen Carpenter (September 13, 2007)

599. End It, Don’t Mend It: What to Do with No Child Left Behind by Neal McCluskey and Andrew J. Coulson (September 5, 2007)

598. Don’t Increase Federal Gasoline Taxes—Abolish Them by Jerry Taylor and Peter Van Doren (August 7, 2007)

597. Medicaid’s Soaring Cost: Time to Step on the Brakes by Jagadeesh Gokhale (July 19, 2007)

596. Debunking Portland: The City That Doesn’t Work by Randal O’Toole (July 9, 2007)

595. The Massachusetts Health Plan: The Good, the Bad, and the Ugly by David A. Hyman (June 28, 2007)

594. The Myth of the Rational Voter: Why Democracies Choose Bad Policiesby Bryan Caplan (May 29, 2007)

593. Federal Aid to the States: Historical Cause of Government Growth and Bureaucracy by Chris Edwards (May 22, 2007)

592. The Corporate Welfare State: How the Federal Government Subsidizes U.S. Businesses by Stephen Slivinski (May 14, 2007)

591. The Perfect Firestorm: Bringing Forest Service Wildfire Costs under Control by Randal O’Toole (April 30, 2007)

590. In Pursuit of Happiness Research: Is It Reliable? What Does It Imply for Policy? by Will Wilkinson (April 11, 2007)

589. Energy Alarmism: The Myths That Make Americans Worry about Oil by Eugene Gholz and Daryl G. Press (April 5, 2007)

588. Escaping the Trap: Why the United States Must Leave Iraq by Ted Galen Carpenter (February 14, 2007)

587. Why We Fight: How Public Schools Cause Social Conflict by Neal McCluskey (January 23, 2007)

586. Has U.S. Income Inequality Really Increased? by Alan Reynolds (January 8, 2007)

585. The Cato Education Market Index by Andrew J. Coulson with advisers James Gwartney, Neal McCluskey, John Merrifield, David Salisbury, and Richard Vedder (December 14, 2006)

584. Effective Counterterrorism and the Limited Role of Predictive Data Mining by Jeff Jonas and Jim Harper (December 11, 2006)

583. The Bottom Line on Iran: The Costs and Benefits of Preventive War versus Deterrence by Justin Logan (December 4, 2006)

582. Suicide Terrorism and Democracy: What We’ve Learned Since 9/11 by Robert A. Pape (November 1, 2006)

581. Fiscal Policy Report Card on America’s Governors: 2006 by Stephen Slivinski (October 24, 2006)

580. The Libertarian Vote by David Boaz and David Kirby (October 18, 2006)

579. Giving Kids the Chaff: How to Find and Keep the Teachers We Needby Marie Gryphon (September 25, 2006)

578. Iran’s Nuclear Program: America’s Policy Options by Ted Galen Carpenter(September 20, 2006)

577. The American Way of War: Cultural Barriers to Successful Counterinsurgency by Jeffrey Record (September 1, 2006)

576. Is the Sky Really Falling? A Review of Recent Global Warming Scare Stories by Patrick J. Michaels (August 23, 2006)

575. Toward Property Rights in Spectrum: The Difficult Policy Choices Ahead by Dale Hatfield and Phil Weiser (August 17, 2006)

574. Budgeting in Neverland: Irrational Policymaking in the U.S. Congress and What Can Be Done about It by James L. Payne (July 26, 2006)

573. Flirting with Disaster: The Inherent Problems with FEMA by Russell S. Sobel and Peter T. Leeson (July 19, 2006)

572. Vertical Integration and the Restructuring of the U.S. Electricity Industryby Robert J. Michaels (July 13, 2006)

571. Reappraising Nuclear Security Strategy by Rensselaer Lee (June 14, 2006)

570. The Federal Marriage Amendment: Unnecessary, Anti-Federalist, and Anti-Democratic by Dale Carpenter (June 1, 2006)

569. Health Savings Accounts: Do the Critics Have a Point? by Michael F. Cannon (May 30, 2006)

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