The Global Organ Shortage: Economic Causes, Human Consequences, Policy Responses

201 Pages·2013·2.595 MB·English

by  T. Randolph Beard, David Kaserman, and Rigmar Osterkamp

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Library of Congress Cataloging-in-Publication Data
Beard, T. Randolph (Thomas Randolph), author.
The global organ shortage : economic causes, human consequences, policy responses / T. Randolph Beard, David Kaserman,
and Rigmar Osterkamp ; with a foreword by Friedrich Breyer.
pages cm
Includes bibliographical references and index.
ISBN 978-0-8047-8409-2 (cloth : alk. paper)
ISBN 978-0-8047-8464-1 (e-book)
1. Procurement of organs, tissues, etc.—Government policy. 2. Procurement of organs, tissues, etc.—Economic
aspects. 3. Donation of organs, tissues, etc.—Government policy. 4. Donation of organs, tissues, etc.—Economic aspects. I.
Kaserman, David L., author. II. Osterkamp, Rigmar, author. III. Title.
RD129.5.B43 2012
362.17′83—dc23
Typeset by Newgen in 10.5/14 Bembo
The Global Organ Shortage
Economic Causes, Human Consequences, Policy Responses
T. Randolph Beard, David L. Kaserman, and Rigmar Osterkamp
With a Foreword by Friedrich Breyer
STANFORD ECONOMICS AND FINANCE
An Imprint of Stanford University Press
Stanford, California
In memory of David L. Kaserman (1947–2008)
Contents
List of Illustrations
Foreword Friedrich Breyer
Preface
Acknowledgments
1. Introduction
2. The Evolution of Organ Transplantation and Procurement Policy
3. Consequences of the Current Policy
4. Social Costs and Benefits of Transplants
5. Economic and Political Causes of the Shortage of Organs
6. Reforms Short of Open Donor Compensation
7. An Assessment of the Moral Basis of Alternative Organ Donation Rules
8. Compensation for Organ Donation and a Proposal for a Public Monopsony for Organ
Acquisition
9. Conclusion
Notes
References
Index
Illustrations
Figures
Figure 3.1 Number of persons on organ waiting lists, United States, 1988–2009
Figure 3.2 Number of persons on kidney waiting lists, removals due to death and sickness,
United States, 1995–2009
Figure 3.3 Number of patients on dialysis, United States, 1995–2006
Figure 3.4 Eurotransplant waiting lists, by organ, 2001–2009
Figure 3.5 Number of organ donors, by organ and donor type, United States, 1996–2008
Figure 3.6 Number of organ transplants in Eurotransplant countries, 2001–2009
Figure 3.7 Deceased kidney donor characteristics, United States, 1999–2008
Figure 3.8 Shortages promote black market sales
Figure 5.1 The organ market and the shortage, a conventional view
Figure 8.1 The organ market and the shortage, including living donors (after Becker and
Elias)
Figure 8.2 Total organ supply—groups A and B exhibiting equal (absolute) supply elasticities
Figure 8.3 Total organ supply—group A’s supply elasticity is (absolutely) smaller than group
B’s
Figure 8.4 Total organ supply—group A’s supply elasticity is (absolutely) larger than group
B’s
Figure 8.5 Optimal organ procurement with positive prices for both sources (living and
cadaveric)
Tables
Table 3.1a Number of persons on organ waiting lists, Eurotransplant countries, by organ,
2009
Table 3.1b Time spent on Eurotransplant kidney waiting list, 2003–2009 (percent of patients)
Table 3.2a Number of persons on waiting lists, Scandiatransplant countries, by organ, 2004
and 2009
Table 3.2b Kidney transplants, cadaver and live grafts, Scandiatransplant countries, 2007 and
2009
Table 3.2c Persons on waiting list, death on waiting list, Scandiatransplant countries, 2007
and 2009, for kidney and liver
Table 3.3 Reliance on living kidney donation, 17 countries in 2004
Table 3.4 Living kidney graft rates, per 100,000 population, selected countries, 1995–2009
Table 3.5 Number of transplants in Eurotransplant region, by organ and donor type, 2001–
2009
Table 3.6 Number of kidneys transplanted per deceased donor, United States, 1996–2008
Table 3.7 Countries of origin of kidney sellers, buyers, and transplant locations
Table 3.8 Costs of illegal kidney transplants, seller’s remuneration
Table 3.9 Number of wealthy adults in the world, 2000
Table 3.10 Replies of Council of Europe member states to a questionnaire on organ
trafficking, 2004
Table 4.1 Estimated U.S. average first-year transplant costs
Table 4.2 Patients removed from waiting list in 2007, United States (in percent)
Table 5.1 Additional costs and cost savings after an increase of 1,000 postmortem organ
donors, over 10 years, for the United States (in thousands of dollars)
Table 6.1 Alternative measures of the organ shortage, 2001
Table 8.1 Comparative statics results for optimal quantities
Table 8.2 Comparative statics results for optimal prices
Foreword
Every day, 30 U.S. citizens die from the failure of a vital organ while still waiting for a
suitable transplant, and similar figures—relative to population size—are reported from all of
the other developed countries. It is one of the few problems of modern health care that cannot
be solved by pouring more money into the existing system. The reason is that the rate of organ
donations is simply not sufficient. Another tragic fact is that hundreds of thousands of people
with end-stage renal disease (ESRD) can be kept alive only by renal dialysis. They have to be
treated three times a week, at high costs and greatly reduced quality of life, while most of them
would be much better off after receiving a transplant. At the same time, hundreds of millions of
people have two healthy kidneys, and many of them would be willing to part with one of them
if only they were adequately compensated for the (small) risk attached to the surgery and any
possible pain and discomfort. That society in principle accepts this additional risk for living
donors is obvious because living kidney donation is a very common procedure among
relatives.
These facts describe a severe shortage of human transplants. Economics tells us that
shortages can be alleviated by acting either on the demand or on the supply side. In the
particular case of human organs, the demand is more or less fixed by medical need (e.g.,
reducing the rate of kidney failure by persuading people to eat less and exercise more is an
extremely slow process). The supply, however, can be and is in fact influenced by policy
measures and regulations. The most important feature in this respect is the universally
established rule that all organ donations must be altruistic and no compensation may be paid to
the donor. And it is this very rule that the authors of this book—three economists who have
studied the problem for decades—hold accountable for the lack of adequate supply and thus
for the enormous pain and suffering caused by the shortage of organ transplants.
This book is “provocative” in the best sense of the word: its purpose is to provoke a new
discussion not only on how to increase the procurement of organ transplants, but on the very
nature of health care policy in the United States, in Europe, and in many other developed
countries. Is it better to prevent unnecessary pain, suffering, and early death, or is it more
important to comply with certain widely held normative convictions such as “no
commodification of the human body”?
The authors must be congratulated for providing a comprehensive overview of the severity
of the problem, the reasons for the failure of existing institutions, and the potential of
alternative proposals to solve the problem. Of course, at the heart of this book is their own
proposal to create a system of donor compensation that meets ethical criteria. The authors
argue their case very carefully and forcefully, but they may not be able to convince all those
readers who are skeptical of using monetary incentives in matters of life and death. (On the
other hand, why does no one object to paying doctors and nurses for their services?) At the
very least, however, the book should spur a discussion of what we all can do to solve one of
the most pressing health care problems of our time.
Friedrich Breyer
Preface
The extent of the global organ shortage is horrifying. Tens of thousands of patients die every
year around the world due to the shortage of organs. Even the “lucky ones” may languish on
waiting lists for years until an organ is made available to them. Moreover, due to the shortage,
a global black market for organs—mainly kidneys—has developed, and it has been rightly
criticized for unfairness and even exploitation. In the course of our work, we have arrived at
the conviction that the dire situation that patients in need of an organ are facing is—not
exclusively but overwhelmingly—the consequence of the primary element of organ
procurement systems implemented practically all over the world: exclusive reliance on
uncompensated donation. Our main motivation in writing this book is to contribute to a change
in the current organ procurement policy.
We have, however, a private motive, and, to us, it is ultimately the most compelling. David
Kaserman, one of the authors, responded to the profound challenge that his congenital kidney
disease presented in a manner that many would be unable to imitate: he applied his training as
an economist to his predicament as an organ transplant patient, and he concluded that the
medical misery in which he found himself had an economic cause. David Kaserman made
several significant contributions to economics, especially in the areas of vertical integration,
competitive market analysis, and regulation, but he felt more engaged by his work on the organ
shortage than on any other topic. As his health deteriorated (partially as a consequence of the
long-term use of drugs designed to block rejection of his transplant), his focus on the organ
shortage became stronger, and he was actively engaged in work on this book at the time of his
death. Our decision to complete this project is our way of honoring his memory.
T. Randolph Beard
Rigmar Osterkamp
Acknowledgments
This book is the outcome of a four-year intense collaboration among three economists, two
Americans and a German. It was one of the American authors, David Kaserman of Auburn
University, who encouraged the other to take the global organ shortage problem more seriously.
He was the guiding light for this book. We say “was” because David died in January 2008 in
the renal intensive care unit of the University of Alabama at Birmingham Hospital. He
designed the outline of the whole book and wrote drafts or outlines for most of the chapters.
David deserves the most credit for the success of this book.
We were fortunate to be able to present seminars in Munich and elsewhere, where we
received many valuable criticisms. We are very much indebted to the contributions made by
Professor Friedrich Breyer, University of Konstanz; Dr. Detlef Bösebeck, regional chair of the
German organ procurement network DSO; Michael Horvath of the Technical University of
Munich; Professor Clifton Perry Esq., Auburn University Department of Political Science;
Professor Thomas Gutmann of the University of Münster Faculty of Law; Dr. Charles Diskin;
John Covell of MIT; theologian Andreas Peltzer of Windhoek, Namibia; and Auburn
economists Bob Ekelund, Mike Stern, Richard Saba, Hyeongwoo Kim, Mark Thornton, and
John Jackson. All of these individuals provided suggestions, criticisms, and support, although
none of them should be blamed, in any way, for any errors, nor for our conclusions. If nothing
else, in this process of writing this book, we learned that compensation for organ donors is a
topic that generates very strong opinions on all sides.
Finally, we would like to express our gratitude for the patience and support we received and
the stimulating discussions we had with our and David’s loved ones: Lois Kaserman, Leslie
Beard, Erna Sutter, and Judith Osterkamp.
T. Randolph Beard, Auburn
David L. Kaserman (1947–2008)
Rigmar Osterkamp, Munich
January 2012