Over three thousand Americans develop renal failure every single month. They are left with two options, neither one appealing. For one, dialysis strips them of daily freedoms as they spend long hours statically sitting in a hospital room. On the other hand, a kidney transplant is their ultimate saving grace, but the national list is long and the wait arduous.
As of 2016, it takes an average of three and a half years for an individual on the waiting list to receive a transplant. These patients are the lucky ones, as over four hundred others perish every month waiting for their match. With the bulk of the “Baby Boomers” generation entering senescence in the coming years, the number of people developing end-stage kidney failure and thus requiring a transplant is projected to skyrocket, putting further strain on the already onerous waiting list.
For those with extensive means, there is another way to circumvent the queue: by tiptoeing around the law. Black markets for human organs exist in practically every nation and are especially prominent in countries with large demand, as is the case in the United States. Reports indicate that internationally trafficked kidneys can sell for more than $160,000 in the United States, easily topping the market value of a small house. Despite this absurd-sounding price, experts like Harvard Professor Francis Delmonco estimate that up to 10% of all kidney transplants performed globally every year are performed illegally.
According to teachings in many cultures and religions, the human body is considered sacred. As a result, even today, the very act of putting a price sticker on a human organ is repulsive to most. Thus, a vast majority of governments around the globe have a firm grasp on illegal organ trade; most governments do not hesitate to deal out the harshest penalties for these crimes, ranging from long prison sentences to capital punishment. However, with the exponentially growing strain on transplant lists over the past few decades, some governments have decided to take an innovative approach. Iran has spearheaded this new model.
In 1967, Iran was the first nation in the Middle East to perform a successful kidney transplantation. However, such procedures remained a rarity for over a decade, during which most Iranians requiring transplants could only find them abroad in more medically advanced nations, such as the United Kingdom. Following the Islamic Revolution in 1979, Iran experienced a steady rise in domestic demand for transplants. Initially, Iran set up a waiting list like most other nations capable of performing the procedure at the time. However, in the mid-1980s, it became obvious that the 25,000 and growing patients on the list dwarfed the 100 or so kidneys that became available each year. For Iran, this was not only a matter of medical importance; it was a quickly growing social ill. Urgent times called for creative solutions.
The Iranian Consultative Assembly, the equivalent of a parliament, legalized living non-related donations in 1988 and set up a new government-run transplant matching system. Within this novel framework, living donors could choose to have their organs typed and registered in advance. If they are needed, a third-party independent organization, the Dialysis and Transplant Patients Association (DTPA), would set up contact between the donors and recipients. The donors would be compensated by a payment from the government, free health insurance, and sometimes additional payment from the recipient. The payment from the government is said to be in the range of $2,000-$4,000.
Importantly, donors are forbidden from contacting potential recipients through channels other than the DTPA. The surgical staff was also strictly monitored to prevent any bribes sent from potential recipients. The system quickly produced promising results in its inaugural year, doubling the number of transplants from the previous year with 80% of all organs sourced from living non-related donations.
By the ten-year anniversary of the new system, Iran decided to officially scrap their traditional transplant waiting list, instead relying almost solely on the living non-related donations and DTPA for transplant oversight. This could be seen as a vote of confidence for the maturing algorithm. However, there are also several caveats that critics have brought up over the years, indicating that Iran might have painted an overly rosy picture of its transplant scene.
First, some experts have pointed out that Iran is only able to satisfy a great proportion of transplant demand due to under-diagnosed need. Many Iranians living with end-stage renal failure in rural areas have little-to-no access to healthcare, thus excluding them from entry into the transplant system. As a result, other opponents have pointed out socioeconomic and racial inequalities that exist within the framework. This is evident in certain minority refugee groups. For example, the Afghan people mostly donated to recipients within the ethnic group rather than to Iranians. Some say that this limits overall organ availability while others claim that this is good evidence that minority groups in Iran are not being exploited despite this unique, “commercialized” model.
Despite these criticisms, several other nations such as Turkey and Saudi Arabia have taken steps to similarly reform their transplant system. However, neither nation has introduced a government-compensated living non-related donation program even close to the scale of Iran’s. The more pressing question is how Western nations, such as the United States and the United Kingdom, will eventually deal with their strained transplant frameworks. The ethics around compensated organ donations will inevitably become a great controversy in both civic and political debates in these nations while growing pressures will eventually force governments to respond with innovation and sweeping changes.
If government-run, legal organ trade frameworks are set-up, it could help drive down profits of the black market, helping to greatly curb organ trafficking-related crimes and atrocities. However, this framework also has the potential for socioeconomic exploitation. Prices have to be strictly monitored to prevent the rich and powerful from offering absurd amounts that may “coerce” people from lower socioeconomic classes to sell their organs.
Ultimately, should kidneys become commodities? Whether the Western world will reform and follow in Iran’s footsteps will remain a curious question in the decade ahead.