Why you should care
Because we can all agree the financial incentives are out of whack.
The arrangement would be perfect. Sigrid Fry-Revere would give one of her kidneys to a dear friend, who was suffering from kidney failure. The friend would pay for someone to maintain her farm while she was indisposed. It wasn’t payment so much as a transaction between friends, she says, privately negotiated and set to benefit each.
Tune in at 11/10c for PBS’s new late-night series Point Taken — and watch OZY cofounder Carlos Watson host a debate on whether organs should be sold.
But Fry-Revere, a bioethicist (!), never could donate that kidney. She was denied approval to donate on the arguable grounds that she’d be paid for her organ. Her friend’s health rapidly declined, and he passed away before he found a suitable match. Incredulous and frustrated, Fry-Revere became a living-donor advocate. Today, she’s the president of the American Living Organ Donor Network and author of The Kidney Sellers: A Journey of Discovery in Iran. OZY caught up with Fry-Revere to see what the U.S. can learn from Iran’s organ-donation system — the only compensation-based organ-donation system in the world — as the debate rages on: Should organs be sold? As it turns out, it’s not so black and white. Our conversation has been edited for clarity.
OZY: Why Iran?
Sigrid Fry-Revere: Iran has the only legal, government-supported, compensation-based organ-donation system in the world, and it has a lot to offer. Thirty years ago, they gave up on the [full] market approach, but they are still the only place where they compensate donors.
OZY: How are donors paid?
SFR: It’s regulated by district. There’s a very regulated market in Tehran, which isn’t working well. The nonprofits in charge of making the matches between donors and recipients see themselves as recipient advocates. That means they want the lowest price possible, which is tough for people who are stuck in debtors’ prisons. I saw a lot of exploitation. We interviewed 200 people on one trip and one donor told me he needed six million toman, which is why he was donating. But the nonprofit took him to meet the recipient and his family, and they were crying. “How can I say no when they do that to me?” he told me. He felt trapped. Then, when he went to pick up his check after the operation, he was given no more than three million, where other people in line were receiving up to 10 million.
OZY: Who pays the donors?
SFR: The national government provides donors a year of health insurance, and the rest comes from a few places. Say, a million toman from the government and the rest would be negotiated — in part from charity and in part from the recipient. The part I think is kind of cool is that if you donate your kidney, you don’t have to do the required national military service.
OZY: What about other districts in Iran?
SFR: In Shiraz, for example, paid donation is totally outlawed. Other districts like Mashad and Isfahan treat it as a social service for the donors — it’s a way to address poverty. A donor might say he or she needs six million toman, so the matchmaker organization sees how they can make that happen. They might say, “OK, two from charity, two from the donor and two in interest-free loans.” Sometimes districts even give health insurance to the whole family.
OZY: It sounds like the Iranian system takes poverty into account. What about here in the United States?
SFR: We need to figure out how to make donations possible for the poor. If you’re rich, you are more likely to have a friend who can donate preemptively so you don’t go on dialysis in the first place. Right now, the government will pay donor expenses like travel and lodging if the recipient is 300 percent above the poverty line. So they’re getting their donor in the door, but tough shit if you get into trouble later. That’s the No. 1 complaint I hear: They feel used in America. A third of all donors are depressed. There’s a lot of demand for financial assistance for donors. We try to do that, but we can only help one-tenth of the applicants we get.
OZY: How did Iran end up trying out organ payments?
SFR: It’s fascinating. When the Shah was in power, Iran was part of the Euro-transplant network and gearing up to have a deceased-organ-transplant system in place. They would send their citizens to England for transplants, but when the Iranian revolution came, they got cut off from the learning exchange and the technology to do deceased-organ transplantation, which is expensive and requires technical know-how, chemicals and all sorts of things Iran didn’t have. So they went to a system that’s cheaper and easier: living donation.
OZY: Has it worked?
SFR: They solved their kidney shortage. Globally, around 90 percent of people who need organ transplants need kidneys. That number is around 82 percent in the U.S.
OZY: So should the U.S. allow people to sell their organs?
SFR: For 30 years, the debate has been: Pay donors or don’t pay donors? People are so entrenched they don’t realize maybe the first step is to pay donor expenses. But no one’s doing anything about it. The government shouldn’t be passing laws and resolutions about studying nonfinancial incentives like life insurance or offering free education, while not paying lost wages or medical expenses. There are a dozen things donors need before we start tempting people to donate with payment.