The seamy underside of the organ transplant business made the news recently when Levy-Izhak Rosenbaum, a Brooklyn businessman, was arrested on accusations of trying to broker the purchase of a kidney for $160,000.

That the organ shortage is so great in this country that people are resorting to buying and selling kidneys is not a surprise; it probably happens more than we know. That’s because some 102,640 patients are waiting for an organ donation in the United States, according to the United Network for Organ Sharing. More than 7,000 people died last year while they awaited kidneys, hearts, livers, lungs, and intestines.

The situation is particularly dire when it comes to kidneys. A sharp increase in diabetes rates in this country has fueled demand;  there are now more than 80,000 people on the official waiting list for a kidney transplant. Reports are that thousands of other patients–those that aren’t in bad enough condition to warrant a spot on the official list—could benefit from a kidney.

Last year only 16,517 of  those in need of kidneys received transplants; 10,550 were cadaver organs and close to 6,000 came from living donors who most often were relatives or friends of the recipients. With an average wait time of 5 years on the official list for a cadaver organ, about 11 patients die each day awaiting a kidney.

Because kidneys can be donated by healthy, live donors with little long-term impact on their physical health, there has been a new emphasis on increasing the supply of organs donated by the living.

One idea, called kidney paired donation, is being explored in a pilot program that will be launched in September by the United Network for Organ Sharing. Currently, most live donors are relatives or friends of those needing kidneys. Some of those willing to donate to a loved are not good matches because of immune system or blood type incompatibilities. In kidney paired donation, an incompatible donor and recipient (a husband and wife, for example) are brought together with other incompatible pairs and matched up to each other.  The process is rather like drawing diagonal lines between celebrities and their matching baby pictures in a magazine quiz. The transplants are performed simultaneously; in part to keep a live donor from backing out once his/her friend or relative has received a kidney.

A further twist on this scheme is the “donor chain;” a group of donors and recipients that includes one or more “altruistic” donors who have chosen to give up a kidney out of the goodness of their hearts. Described in a report in the March issue of the New England Journal of Medicine, these chains can be very elaborate and the transplants sometimes are performed weeks or months apart at multiple sites around the country. In the NEJM case there were 10 people involved and surgery took place at six transplant centers in five states.

The most recent donor chain transplant occurred in July, involving 14 people—seven live donors and seven recipients—at three hospitals in Washington D.C. The donors included relatives and friends of some of the recipients as well as two “altruistic” individuals who had registered independently with a kidney donation site.

The problem is that live donors, especially altruistic ones, are hard to come by. And even if they can be found, the vetting process for potential donors (psychological testing as well as blood work and health history) eliminates many. Larissa MacFarquar writes about these seemingly selfless individuals in her piece for the New Yorker, “The Kindest Cut.” She reports that about 600 altruistic donors have gone through the surgery so far and that almost every day another willing Samaritan signs up at MatchingDonors.com —a website where “people who need a kidney transplant can post a message on the site, describing themselves and their situation in the hope that a stranger will see the posting and be moved to donate.”

Despite this steady increase in live kidney donation, experts agree that there will never be anywhere near enough kidneys to meet demand. The truth is that most of us would be unwilling to give up a kidney to a stranger; at least not without some compensation in return. With this in mind, some transplant advocates are now calling for the government to set up a legitimate market for organs—complete with a uniform compensation rate, possibly paid for by Medicare.

Virginia Postrel, writes a great piece in the Atlantic on the state of the kidney transplant field and various strategies for increasing the supply of organs. Postrel donated a kidney to a friend in 2006 so she has first-hand experience with the subject.. After laying out the short-comings of schemes to increase cadaveric donations, donor chains and kidney paired donation, she makes the case for an above-board market for buying and selling kidneys:

“Just as the National Kidney Registry initially screens non-directed altruistic donors, a central organization could do the same for prospective kidney vendors. Those who qualified would be referred to local transplant centers for full medical and psychological testing, after which they could be matched with the recipients—and possibly chains—for whom they were best suited. Unlike volunteers, vendors would not get to choose their recipients, giving everyone in need of a kidney a fair shot. Payment would come not from individual recipients but, as for the rest of the transplant process, through normal insurance (including Medicare) at standard rates.”

Dr. Arthur Matas, a surgeon and director of the Renal Transplant Program at the University of Minnesota is one of the strongest advocates for an official payment program for organs—which could include health insurance for life, a tax deduction or one-time payment. Mattas and others have calculated that if Medicare paid $25,000 or $50,000 to each living kidney donor, many more people would line up to contribute. And ultimately, paying for kidneys would save billions of dollars for taxpayers. Patients awaiting kidneys must undergo dialysis; at a cost of $100,000 per patient. “Eliminating the waiting list would thus save taxpayers $8 billion, or $4 billion if each living donor received a lump-sum payment of $50,000,” says Postrel.

This argument makes a lot of economic sense. It also seems like a humane choice that would help all those people languishing on waiting lists for kidneys. But there are some serious legal and ethical problems involved. For one, in 1984 Congress passed the National Organ Transplant Act that specifically outlaws the buying and selling of organs.

That said, there are precedents in this country for compensating live donors for body components. People are compensated for donating blood and plasma—sometimes with theatre tickets, gift certificates or even cash. Surrogate mothers are paid an average fee of $15,000 for bearing children for others (not including medical expenses, travel costs and legal fees). And of course, women sell their eggs for between $5,000 and $10,000 a pop.

Although fertility centers like to make it sound like these women are doing it out of the kindness of their hearts to help infertile couples, CNN reports that there has been a recent spike in “donations” that is linked to hard economic times. The egg harvesting process requires weeks of hormone injections, ultrasound scans, blood work and a painful egg recovery procedure.

The reality of the situation is that the black market buying and selling of organs has been going on for years in Iran, India, China, Hong Kong and Pakistan, among other places. The local “vendors” are often coerced into donating their organs—either because they are desperately poor and see donating a kidney as the only way to get money or because they are prisoners and given no choice. In China, many organs are obtained from executed prisoners, for example.

The buyers, by contrast, are most often wealthy individuals (often foreigners) who can afford to pay a premium for an organ. The World Health Organization studied the growing problem of “transplant tourism”
in their 2007 report, and noted that buyers are most likely to come from Australia, Canada, Israel, Japan, Oman, Saudi Arabia or t
he USA.. The WHO estimates that some 10% of all organ transplants performed worldwide qualify as “transplant tourism.”

Would a legitimate and equitable system for compensating donors work ethically in this country? Opponents have real questions about preying on the poor, desperate and frankly; mentally unstable. There are also concerns that once we start compensating donors, the altruists will be turned off and cease to donate.

Arthur Caplan, professor of bioethics at the University of Pennsylvania, believes that creating a market for live kidney donation violates the underpinnings of medicine. He writes in the Hastings Center Report:

For me, the answer is less clear. I think we need to do some more research before starting a pilot program to test the idea of compensating live donors for their kidneys.

No one in this country has undertaken a comprehensive study of live kidney donors and how they feel after they’ve gone through surgery. In fact, there is little follow-up of these individuals at all. That might be a good place to start—with the healthy, live donors currently involved in the chains and pairings that have recently been arranged.

In Pakistan, which until recently was a leading center of unregulated organ sales, Farhat Moazam, a surgeon and bioethicist at Sarhad University of Science and Information Technology in Karachi, interviewed some 34 villagers who had sold a kidney for financial gain—to pay off debts, provide a dowry or afford medical expenses for relatives. Her findings, which were published in the May/June 2009 issue of the Hastings Center Report and are discussed here are troubling:

As we confront the overwhelming need for kidneys, it would make sense to proceed with caution. Just because we allow egg donation, surrogate pregnancy and other medical procedures (uterine transplants, for example) that seem ethically fraught, doesn’t mean we should go even further and allow healthy people to sell their organs.