Spain is one of the leading countries in kidney transplants. In 2016, near 3,000 transplants were carried out in Spanish hospitals, of which 11% came from living donors. Yet the number of chronic kidney disease (CKD) patients awaiting a kidney still amounts to 4,300 or around 140% of the number of transplanted patients last year.

Those CKD patients that have not received a transplant yet (80% of them never will due to medical reasons) have no choice but to undergo a time-consuming (4 hours) medical procedure called dialysis (more specifically hemodialysis, the most common type of dialysis) three times a week in order to have their blood filtered from waste and excess water. In addition, although dialysis is painless, patients often feel dizzy and extremely tired during few hours after the procedure.

A Supply Problem

The life of those dialysis patients that are still eligible for a transplant could be dramatically improved if the number of kidneys available for transplant increased. In economic terms, we would say that there is a shortage due to an insufficient supply of kidneys. Where does this shortage come from? From two sources. First, most transplants come from deceased people, whose organs are not always fit for a transplant (they might be damaged or incompatible with the recipient.)

Moreover, relatives are sometimes forced to make a decision about what to do with the transplantable organs (only in those cases in which the deceased does not have an organ donor ID or has not expressed his willingness to become a donor before passing away), which means that they can rightfully refuse to donate them. Public awareness about the importance of organ donations should undoubtedly play a role in tackling this issue. Yet it seems that it would not completely eliminate waiting lists.

The second reason that accounts for the shortage of kidneys is the de facto price ceiling imposed by the current legislation on transplants that explicitly forbids commercial transactions in human organs. Because CKD patients are not allowed by law to pay for a kidney to willing sellers, the supply of kidneys falls short of demand, which explains the existence of a waiting list for kidneys and other organs.

What can be done to address this shortage? From a free-market perspective, the obvious solution would be to get rid of harmful laws that prevent CKD patients from getting a kidney and create a market for organs where both potential sellers and recipients would benefit via voluntary and for-profit exchanges. Thereby, an equilibrium price would be reached, supply and demand would match and waiting lists would disappear.

The Benefits of a Market for Kidneys

The benefits of creating a market for kidneys would be enormous. First, it would dismantle the black market for organs. Even though this is not a problem in Spain, the World Health Organization estimates that around 7,500 illegal surgeries are performed every year on a global basis. Recipients pay around $150,000 for a healthy kidney whereas intermediaries pay as little as $2,500.

Second, and as pointed out above, the waiting list would be considerably shortened, if not eliminated. Gavin Carney, Senior Lecturer at the Australian National University Medical School, maintains that the waiting list in Australia would be halved in only five years if potential donors were allowed to be paid.

Iran, the only country in the world where organ trade is legal, has managed to eradicate waiting lists by making cash payments in exchange for kidneys. Despite the multiple limitations of its organ market, Iran is a good example that a market for kidneys could potentially work in a country like Spain, which possesses a far more advanced health care system.

Finally, a market for organs in Spain would significantly reduce the medical costs associated with dialysis (mostly hemodialysis), which in 2010 amounted to 1% of the total spending in health care.

A Sensible Objection

Not surprisingly, the idea of a market for organs has been opposed on different grounds. Although most objections are based on prejudices more than on rational arguments (e.g. the commodification argument debunked here by philosophers Jason Brennan and Peter Jaworski), there are some criticisms that should be taken into consideration.

For instance, some argue that a market for organs would result in only the well-off having access to kidneys. Poor people would thus be relegated to the role of organ providers out of necessity. Determining whether this would happen or not in a free market for organs or if this is necessarily immoral is out of the scope of this article. We will assume that this outcome is both inevitable and unethical. Does this mean that no step can be taken to eliminate the structural shortage of kidneys?

Let the Government Pay for Kidneys

The above objection could be easily bypassed while maintaining the status quo in organ donation. The idea is simple: the public health care system would pay for kidneys but prevent low-income people from donating. In other words, an income threshold would be imposed under which no one would be allowed to sell an organ.

The waiting list would still be controlled by the public health care system, prioritizing the most urgent cases as it does today. By paying a fair price (that is, the price that would emerge in a free market), we would make sure that most transplantable patients would receive a kidney. In addition, part of the costs would be self-financed by the decrease in dialysis costs.

This is basically what Sally Satel et al propose for the organ transplant system in the US: a reform within the legal framework of the National Organ Transplant Act that would introduce pecuniary incentives for potential donors in the form of tax credits or other compensation programs. This, the authors argue, would be a “middle ground between outright prohibition and unregulated markets”, which could save thousands of lives.

Introducing this reform would make the lives of thousands of patients easier while overcoming one of the most common objections against a market for organs. The aim is to achieve a wide consensus without altering substantially Spain’s regulatory system for organ donations. The longer we take to change the law, the more people will continue to suffer. What are we waiting for?

Picture: Creative Commons Global Panorama

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