Can paying for a new kidney save organ donation?

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The Internet advertisement reads like a used-car classified: "33 yr old American male. Non smoker or drinker with a clean bill of health. $75,000 U.S. Will travel anywhere. Facility and Physician must meet the highest standard."

Meet those conditions, and his kidney can be yours.

"This is a rough economy," says the California man who placed the ad, speaking on the condition his name won't be used: What he's doing is illegal. But a good price for a spare organ (plus paid travel and medical expenses) would knock a chunk off the $100,000 he owes on his student loans. A day after placing his latest ad online, he says he has already received 16 e-mails. Eventually, he figures, someone will pay his price for a sturdy, American-bred kidney. Most other sellers on the website say they're from places such as India or Indonesia - organ-trafficking hot spots.

The right contact in those countries will find a citizen willing to sell a kidney dirt cheap, by Canadian prices. So if you're rich enough, why wait in line? A quick trip, and you can fly home with your new body part installed (properly, you hope). Good for you, not so good for your donor, who has just received a relative pittance from a broker and now faces questionable follow-up care. And certainly pointless to your fellow Canadians - now numbering about 3,800 - who linger on an ever-growing wait list because too few people are willing to give up what they don't need for those who will die without it.

Organ donation is a tragic case of supply not meeting demand, even though transplants have become much safer for recipients and donors. Living Canadians are relatively generous on international rankings, on par with Britain, but our posthumous donations lag far behind leading Spain. Either way, there aren't nearly enough to go around, especially as the population ages. In British Columbia, those who can't afford the international black market can expect to wait an average of nearly six years for a kidney - longer than many patients survive on dialysis.

The best way to bring supply in line, as any economist knows, is to sweeten the deal for the suppliers. So why don't we?

In June, when Canadian Blood Services is due to deliver recommendations on the situation to the provinces, what won't be on the list will be allowing people to profit from the sale of what they clearly own - the parts of their own bodies. It won't even be up for discussion.

However many lives and however much money a market for organs may save, the thought of trading coin for kidney makes too many of us squeamish - that is, until we're watching the slow death of someone we love.

"When something is repugnant to you," Arthur Matas says, "you just keep finding reasons to justify your gut reaction rather than thinking about it."

Dr. Matas is the Canadian-born director of the renal-transplant program at the University of Minnesota and a former president of the American Society of Transplant Surgeons. He has long been a vocal advocate for a broader incentive system for donors that would go beyond covering travel and missed-work expenses, as some provinces do now. (Saskatchewan announced this week that it would provide up to $5,000 to reimburse donors.)

Profiting from organ donations is illegal in most countries, including Canada and the U.S., despite the occasional ad on Craigslist. Iran allows people to sell their organs - receiving cash from both the government and the recipient - and claims to have eliminated its waiting list. And despite prohibitions, an underground market thrives in nations such as China, Egypt and Brazil.

Many countries are already testing the idea of some form of incentive, even if it's not monetary. Israel has created a law where people who commit to being donors after they die may jump the line if they or a family member need a new organ themselves. In Britain, consultations are being held to decide where the public stands, for instance, on the idea of covering some funeral expenses for donors. A University of Montreal researcher recently proposed a tax credit for consenting donors that after their death would go to their next of kin.

Would poor people become an organ pool?

The case against allowing people to profit off their organs is usually moral: Critics say it would stop people from giving altruistically, make poor people an organ pool for the wealthy and even encourage the more nefarious among us to hasten the death of unwanted, but organ-rich, relatives. Could someone deep in gambling debts be pressured to give up a kidney?

While donors are rigorously screened, even Dr. Matas concedes that concerns about abuses are legitimate - though safeguards, such as keeping the benefit small, should be part of any debate. "Why do I have to design a perfect system before this concept can be acceptable?" he asks.

Some economists, such as University of Chicago Nobel laureate Gary Becker, argue that something closer to a freely competitive market would stabilize prices and mitigate organ trafficking while recognizing individual freedom. But Dr. Matas envisions a regulated organ market in which governments would determine the compensation for living donors and still control who receives the organs based on need. (At this point he is not including deceased donors, as it's difficult to decide who receives the benefit.)

The cost to taxpayers would be offset by the health-care savings: In Canada, statistically, giving someone on dialysis a transplant saves about $50,000 a year.

Under Dr. Matas's system, people would be properly educated about the risks of donation and would receive a financial perk - perhaps in the form of discounted college tuition, or $1,000 each time they go to the doctor for an annual checkup after the operation, as an incentive to take care of their own health as well.

He scoffs at the notion that this would sully the purity of the donor's act of giving. "This concept that donors today are gaining nothing is ridiculous. If your husband is sick and you donate a kidney to him, you benefit from having a healthy husband," he argues. "There are huge other things going on in conventional donation beyond pure altruism. In what other situation do we say that you can do something for free, but you can't do it for an incentive? There is no parallel."

Even the pairing approach to kidney transplants - which allows families to exchange kidneys when they don't match for their own relatives - is a form of transaction. What makes a bonus compensation so different?

Risk and reward - a time-honoured combination

A large part of the resistance is that compensation such as cash or discounted college tuition is mainly an incentive for lower-income people. "Why is that bad? Poor people do all sorts of things that rich people aren't doing," Dr. Matas says. "Well-informed people are capable of making decisions in their best interest. I won't argue with that the fact that billionaires aren't likely do this. So what?"

Altruism doesn't preclude compensation: Society already rewards people such as firefighters and soldiers for taking on dangerous roles that serve the public good. An organ donor is no different, suggests Phil Halloran, a transplant surgeon at the department of medicine at the University of Alberta and the editor-in-chief of the American Journal of Transplantation.

"You are getting paid for what you do," he says. "Surgeons get paid for what they do. Health care works on the basis of people providing good services to other people - and they get paid."

As for the risk of exploitation, he argues that people are already receiving unequal care because organs are in shorter supply in certain locations and because the wealthy can seek out other options.

Other experts, such as University of Toronto bioethicist Linda Wright, say Canada should consider some other options first - ones that might be sold more easily to the public, including doing a better job of promoting the idea of organ donation.

Canadian Blood Services hopes to get a national waiting list for organ donations up and running this year - the current one, astonishingly, is still maintained manually by the London Health Sciences Centre in London, Ont., and then faxed out to hospitals.

A key recommendation of the agency's report in June will be to improve front-line resources and personnel in emergency rooms and intensive-care units so that donors can be identified more quickly and families counselled to reach an informed decision - a top priority for Dr. Halloran, and the main factor credited with Spain's high donation rate. (One option that is being tried in New York won't be considered here: having transplant teams in "organ preservation units" trail ambulances responding to 911 calls.)

Some European countries have adopted an opt-out system - in which, with some caveats, people have to alert the government that they will not be donors. However, Canadians are divided on this approach, so it's also not being considered.

"It's really a trust factor," says Peter Nickerson, executive medical director of organ transplantation at Canadian Blood Services. For the system to work, he says, people need to believe that the final choice is theirs.

Prof. Wright, the bioethicist, says people still want organ donation to be "an altruistic act and not for payment." But altruism isn't getting the job done. And Dr. Matas argues that it's wrong that such idealism has kept the idea of compensation for organs from being tested with a government pilot project - or even seriously debated.

Shouldn't we find the status quo equally distressing? "If we don't do something," he says fiercely, "the waiting lists are going to get longer and more of our patients are going die every day."

Erin Anderssen is an Ottawa-based feature writer for The Globe and Mail.

[Click here to see a related story about how the field of regenerative medicine is addressing the need for organs to transplant.]