That's because chronic kidney disease has become an epidemic. The waiting list for kidney transplants in the United States has reached 78,000, and about a third of the people on it will die before they get one. The average wait is now three to five years.
"In general, most people who are involved in this debate are talking about a regulated system of compensation [that comes from the government]. It's not rich buying from poor. You can have control, regulation and long-term follow-up," Matas says.
Mike Giglio
After Corey was fired, he stole his girlfriend's disability check and spent a week in a seedy motel. The day after this photo was taken, he was beaten and robbed in retribution.
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"I think you have to get rid of the rhetoric and simply say, what's worse?" he says. "Maintaining the status quo, where the patients are suffering and dying on dialysis, or taking a big step and at least trying?"
Part of the spike in demand results from improving transplant work. And better medicine in general means more people reach end-stage kidney disease. Mainly, though, Americans keep getting fatter. The causes of kidney disease and failure are more prevalent than ever, and expected to double in ten to 15 years. Even children now have high blood pressure and diabetes.
Dr. A. Osama Gaber chairs the Texas governor's task force on chronic kidney disease and says this state is in especially bad shape. He is leading an unprecedented push for state-level data collection and eventually prevention. But the best hope remains in finding more living donors, and this has inspired some bold initiatives in the transplant field.
As transplant director at Methodist, Gaber has been using "paired" donations, where people with willing but incompatible donors effectively swap them. He is also laying down the infrastructure for kidney chains, in which an unsolicited kidney from a purely altruistic donor can be used to leverage further donations. The massive database needed to fully implement these processes at a national level is just getting underway. Even when clicking on all cylinders, Gaber says, this will only make a dent in the demand (see "You Want A Piece of Me? Let's Make A Deal").
"Would they solve the problem? I don't think anything would solve the problem."
But Gaber maintains this doesn't mean all options should be on the table. He says the compensation debate is one he tries to avoid, because his view — that it should be forbidden at all costs — is no longer popular.
Gaber believes that operating on a donor motivated by anything other than altruism would violate his Hippocratic Oath. And he says compensation would bring about one of two uncomfortable realities. The government would be forced to regulate an organ market — "a pretty grim thing to do." Or, he says, "You would do what the transplant society says shouldn't be done, which is take the bodies of the poor and put them in the rich."
Dr. Benjamin Hippen, a nephrologist at the Carolinas Medical Center in Charlotte, North Carolina, believes this is already happening — that the vast unmet demand for kidneys in rich countries creates black markets for them in poor ones. He became involved in the compensation discussion specifically to address the specter of transplant tourism. It is currently not illegal in the U.S. to travel abroad and buy an organ.
As for whether illegal purchases happen here, Hippen, like most nephrologists, says it's possible but probably rare.
The basis for most opposition to compensation, Hippen says, is what he calls the "yuck factor." People conflate selling one's kidney with selling oneself, and they worry about exploitation of the poor.
"It's surely the case that marketing organs could be degrading and alienating," Hippen says. "But it need not be."
To start, Hippen believes people living in poverty should not be allowed to donate at all — simply because chronic kidney disease disproportionately affects the poor, and the usually small health risks that accompany donation become much greater for them.
But beyond that, Hippen suggests nontransferable, nonmonetary forms of government compensation that, as he puts it, "demonstrate the type of respect for a person selling their kidney that tossing a couple of bucks on the ground doesn't."
These could be anything from pension plans to lifelong health care. He says pilot projects are the best way to determine what, if anything, works best.
Late last year, Republican Senator Arlen Specter of Pennsylvania sponsored a bill that would amend the 1984 law against compensation to allow for exactly that. It's up for consideration this session.
Compensation's fiercest and most powerful opponent says the bill will never pass. As president of the United Network for Organ Sharing (UNOS), which collects and manages all transplant data and oversees the waiting list, Dr. Francis Delmonico holds considerable sway over transplant policy. While he challenges the idea of black markets, and even the size of the waiting list, his primary contention is that any organ market would be impossible to regulate. A situation like Corey's, he says, "becomes a reality in markets."
"Once you have markets, there are markets. Get over it," he says. "Why should I have to go through [the government's] system?"
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There is an almost imperceptible mark on Corey's wrist that testifies to one of his many abortive suicide attempts. He was about ten years old and locked alone in a room in the basement of a foster home. He tried to peel back his skin with a plastic knife and sever the artery.
