Thursday, January 23, 2014

Kidney for sale? Why it’s now okay

Surgeons conduct an organ transplant. PHOTO |

Surgeons conduct an organ transplant. PHOTO | FILE 

By The Citizen Reporter and Agencies

Dar es Salaam. The world has long debated whether or not to legalise the sale of human organs like kidneys for medical purposes. But Tanzanians do not have to think too hard about it.

They are free to sell their kidneys since there is no policy guiding transplants in the country and no one would interfere where the donor was willing, says Minister for Health and Social Welfare Seif Rashid.

“It is none of our business in the ministry whether a healthy kidney is sold or taken from one person and surgically placed in someone with kidney failure,” said Dr Rashid. “Not even whether it is from a live or deceased donor.’’

The newly appointed minister added, though, that there were plans to invest in transplant treatment in Tanzania so patients do not have to go overseas.

The Citizen wanted to establish whether there is any law that regulates the sale or donation of organs for medical use in Tanzania following a report published by the Wall Street Journal that called for the legalisation of kidney-for-cash deals in order to save millions of patients who have been waiting for a transplant for years.

When 56-year-old Jumanne Dologwe was diagnosed with kidney disease in 2012, he was told he would need artificial kidneys for the rest of his life. The treatment would cost him Sh1.5million every week treatment unless a Good Samaritan volunteered to give him a kidney donation.

Mr Dologwe is one of the lucky few. He got a kidney donation from a relative last year and, with government sponsorship, he had one of his kidneys replaced at India’s Apollo Hospital.

Thirty five-year-old Joyce is not so lucky. The resident of Mbezi beach in Dar es Salaam has been on the waiting list for a transplant for 18 months after she suffered kidney failure. No one has volunteered yet.

According to statistics provided by the National Kidney Foundation when Tanzania was marking last year’s World Kidney Day in Arusha, 5.85 million people are estimated to have kidney disease. Of these, about 65.3 per cent were in the late stages of the disease.

Prime Minister Mizengo Pinda revealed that three out of every 1,000 patients admitted to local hospitals suffer kidney failure and announced that Tanzania would start performing transplants by 2020. Only 100 patients with kidney disease can afford dialysis. There are nearly half a million sick people in the country who need the service but cannot get it.

Cash for kidneys: Is it immoral?

With the acute shortage of kidneys for transplant in United States and around the globe, the Wall Street Journal this week published a report pointing out that finding a way to boost the supply of organs would reduce waiting times and death—and also greatly ease the suffering that many ill individuals endure as they hope for a transplant.

“The most effective change, we believe, would be to provide compensation to people who give their organs—that is, we recommend establishing a market for organs,” the US-based newspaper says in its report titled, “Cash for Kidneys: The Case for a Market for Organs”

Organ transplants are one of the extraordinary developments of modern science. They began in 1954 with a kidney transplant performed at Brigham & Women’s hospital in Boston. But the practice only took off in the 1970s with the development of immunosuppressive drugs that could prevent the rejection of transplanted organs.

Since then, the number of kidney and other organ transplants has grown rapidly—but not nearly as rapidly as the growth in the number of people with defective organs who need transplants. The result has been longer and longer delays to receive organs.

According to the Wall Street Journal, 95,000 American men, women and children were on the 2012 waiting list for new kidneys, the most commonly transplanted organ. Yet only about 16,500 kidney transplant operations were performed that year. Taking into account the number of people who die while waiting for a transplant, this implies an average wait of 4.5 years for a kidney transplant in the US

“The situation in US is far worse than it was just a decade ago, when nearly 54,000 people were on the waiting list, with an average wait of 2.9 years…For all the recent attention devoted to the health-care overhaul, the long and growing waiting times for tens of thousands of individuals who badly need organ transplants hasn’t been addressed,” The Wall Street Journal says.

Many of those waiting for kidneys are on dialysis, and life expectancy while on dialysis is not long. People aged 45 to 49 live, on average, eight additional years if they remain on dialysis, but they live an additional 23 years if they get a kidney transplant. That is why almost 4,500 persons died in America in 2012 while waiting for kidney transplants. Although some of those waiting would have died anyway, the great majority died because they were unable to replace their defective kidneys quickly enough.

The toll on those waiting for kidneys and on their families is enormous, from both greatly reduced life expectancy and the many hardships of being on dialysis. In the US, most of those on dialysis cannot work and the annual cost of dialysis averages about $80,000 (Sh128 million), according to the Wall Street Journal.

The total cost over the average 4.5-year waiting period before receiving a kidney transplant is $350,000(Sh560 million), which is much larger than the $150,000(Sh240 million) cost of the transplant itself. In Tanzania, the cost of dialysis in a year is roughly Sh72 million ($45,000).

According to the Wall Street Journal’s report, individuals can live a normal life with only one kidney, so about 34 per cent of all kidneys used in transplants come from live donors in USA. The majority of transplant kidneys come from parents, children, siblings and other relatives of those who need transplants. The rest come from individuals who want to help those in need of transplants.

In recent years, kidney exchanges—in which pairs of living would-be donors and recipients who prove incompatible look for another pair or pairs of donors and recipients who would be compatible for transplants, cutting their wait time—have become more widespread.

Although these exchanges have grown rapidly in the US since 2005, they still account for only nine percent of live donations and just three percent of all kidney donations, including after-death donations.

Exhortations and other efforts to encourage more organ donations have failed to significantly close the large gap between supply and demand. For example, some countries use an implied consent approach, in which organs from cadavers are assumed to be available for transplant unless, before death, individuals indicate that they don’t want their organs to be used.

It is not clear whether such arrangements are possible in Tanzania.

(The US continues to use informed consent, requiring people to make an active declaration of their wish to donate.) In a preliminary study of a few countries—Argentina, Austria, Brazil, Chile and Denmark—that have made the shift to implied consent from informed consent or vice versa, the switch did not lead to consistent changes in the number of transplant surgeries.

According to the Wall Street Journal, paying donors for their organs would finally eliminate the supply-demand gap. In particular, sufficient payment to kidney donors would increase the supply of kidneys by a large percentage, without greatly increasing the total cost of a kidney transplant.

The Wall Street Journal report has estimated how much individuals would need to be paid for kidneys to be willing to sell them for transplants. These estimates take account of the slight risk to donors from transplant surgery, the number of weeks of work lost during the surgery and recovery periods, and the small risk of reduction in the quality of life.

The report adds: “Our conclusion is that a very large number of both live and cadaveric kidney donations would be available by paying about $15,000(Sh24 million) for each kidney. That estimate isn’t exact, and the true cost could be as high as $25,000(Sh40 million) or as low as $5,000(Sh8 million)—but even the high estimate wouldn’t increase the total cost of kidney transplants by a large percentage.

“Few countries have ever allowed the open purchase and sale of organs, but Iran permits the sale of kidneys by living donors. Scattered and incomplete evidence from Iran indicates that the price of kidneys there is about $4,000 and that waiting times to get kidneys have been largely eliminated. Since Iran’s per capita income is one-quarter of that of the US, this evidence supports our $15,000 estimate.”

Other countries are also starting to think along these lines: Singapore and Australia have recently introduced limited payments to live donors that compensate mainly for time lost from work.

According to the Wall Street Journal, since the number of kidneys available at a reasonable price would be far more than needed to close the gap between the demand and supply of kidneys, there would no longer be any significant waiting time to get a transplant. The number of people on dialysis would decline dramatically and death due to long waits for a transplant would essentially disappear.

Today, finding a compatible kidney isn’t easy. There are four basic blood types, and tissue matching is complex and involves the combination of six proteins. Blood and tissue type determine the chance that a kidney will help a recipient in the long run.

But the sale of organs, says the Wall Street Journal, would result in a large supply of most kidney types and, with large numbers of kidneys available, transplant surgeries could be arranged to suit the health of recipients (and donors) because surgeons would be confident that compatible kidneys would be available.

The idea of paying organ donors has met with strong opposition from some (but not all) transplant surgeons and other doctors, as well as various academics, political leaders and others.

“Critics have claimed that paying for organs would be ineffective, that payment would be immoral because it involves the sale of body parts and that the main donors would be the desperate poor, who could come to regret their decision. In short, critics believe that monetary payments for organs would be repugnant.” the report further says.

“Though the poor would be more likely to sell their kidneys and other organs, they also suffer more than others from the current scarcity…

Today, the rich often don’t wait as long as others for organs since some of them go to countries such as India, where they can arrange for transplants in the underground medical sector, and others (such as the late Steve Jobs ) manage to jump the queue by having residence in several states or other means.

The sale of organs would make them more available to the poor, and Medicaid could help pay for the added cost of transplant surgery, according to the report.

But, according to the Minister for health and social welfare in Tanzania, the sale of organs is allowed as long as both parties agree to the transaction.