Cash for kidneys might not necessarily be unethical

Meeting the demand for kidney transplants is a big problem worldwide. In the UK, for example, only 18% of patients waiting on the kidney transplant list and 28% on kidney/pancreas transplant list received a transplant during 2008-09.

Donations from living people only made up 37% of the total UK kidney transplant programme in the same period, and as such this approach represents a key method by which to increase the number of organs available.

But how do you convince someone to just give away a kidney?  One very controversial way is to pay donors. Given that kidneys from living donors work so much better than those from deceased donors, even giving donors pretty large payments (for example, $90,000/£58,600) is thought to be a cost-effective way to increase the supply of kidneys available for transplantation.

Unsurprisingly, this approach hasn’t really got off the ground because people are worried about donors blithely selling a kidney without adequately weighing up the risks just to get their hands on some “easy money” or payment disproportionally luring poorer donors. Also, there’s a chance that payments may dissuade altruistic donation or cause potential altruistic donors to request financial compensation.

A study of a hypothetical regulated US market for kidneys has addressed all three of these questions and concluded that “theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence.”

The authors surveyed 342 commuters on regional rail and urban trolley lines in Philadelphia County using 12 fictional scenarios in which the risk of subsequent kidney failure in the donor (0.1%, 1%, or 10%), the payment ($0, $10 000, or $100 000), and the recipient of the kidney (either a close family member or the next eligible patient on the waiting list) were varied. Participants responded to each scenario by stating their willingness to donate a kidney on a five-point scale ranging from “definitely would not donate” to “definitely would donate.”

As would be expected, people were more willing to donate to a family member than to a stranger. Lower risk and higher payment also encouraged donation, in particular when the scenario covered donating to a stranger.

More interestingly, incremental household income affected willingness to donate independent of payment – people with a household income of $20,000 a year or less were much more likely to donate than those who earned $100,000 or more. As such, “poorer persons may contribute disproportionately to the supply of organs with or without payment.”

The promise of hard cash didn’t affect people’s perception of the risk involved in living kidney donation: “the magnitude of reductions in willingness to donate associated with increased risk for renal failure was virtually identical across payment levels.” And the effect of a bigger paycheck on willingness to donate was the same across all income strata.

Finally, the introduction of payment for organs did not reduce the level of altruistic donation. “We found no evidence that any of the three main concerns with a regulated system of payments for living kidney donation would manifest if such a market were established,” the authors conclude.

Halpern SD et al. (2010) Regulated payments for living kidney donation: an empirical assessment of the ethical concerns. Annals of Internal Medicine 152 (6): 358-65. PMID: 20231566

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Gallbladder removed through the vagina

So, it’s Friday.  You’re tired and don’t want to plough through a post on some complicated issue.  Perfect time to revive my neglected Weird medical stories series then.


And here’s today’s bizarre case study: surgeons at Northwestern Memorial Hospital in Chicago have successfully removed a woman’s gallbladder through her vagina.

Heather Lamb, a junior high math teacher, was diagnosed with gallstones and had been experiencing severe abdominal pain for weeks. Surgeons at Northwestern decided to remove the offending gallbladder, but by using natural orifice translumenal endoscopic surgery (NOTES) rather than more-invasive laparoscopic or open surgery.

“I went home the day of surgery and felt nothing more than a little discomfort the following day,” said Ms Lamb, “I returned to work a few days later and I’m feeling great.”

The gallbladder concentrates bile produced by the liver, which is then released into the small intestine during the digestive process and helps to break down fatty  food.  In some people in balance of bile components gets out of whack, causing gallstones to form in the gallbladder.  Gallstones can make the organ inflamed and painful and can cause bile to become trapped in the gallbladder, leading to infection.  In such individuals this non-essential organ then needs to be removed.

NOTES can be used remove organs such as the gallbladder, kidney and appendix through the body’s natural orifices, such as the vagina or mouth, instead of via openings created in the skin by a surgeon’s scalpel.

Eric Hungness, a minimally invasive gastrointestinal surgeon at Northwestern Memorial Hospital who led the team that performed the surgery, says, “NOTES reduces the number of and may eliminate the need for abdominal incisions compared with traditional laparoscopic surgery, and may reduce pain and shorten recovery time for patients. This technique may also eliminate the risk of post-operative wound infections or hernias.”

In another recent example of NOTES, surgeons at Johns Hopkins University in Baltimore managed to successfully remove a healthy kidney through a donor’s vagina.  Even more remarkable, the kidney was then transplanted into the donor’s niece. Transvaginal kidney removals has been performed before in order to remove cancerous or nonfunctioning kidneys that endanger a patient’s health; however, this case is the first time that a healthy organ has been removed and then transplanted.

Speaking to the BBC, Dr Robert Montgomery, chief of the transplant division at Johns Hopkins University School of Medicine, Maryland, who led the team that performed the operation, said: “Surgeons have been troubled by the need to make a relatively large incision in the patient’s abdomen after completing the nephrectomy to extract the donor kidney.

“That incision is thought to significantly add to the patient’s pain, hospitalisation and convalescence. Removing the kidney through a natural opening should hasten the patient’s recovery and provide a better cosmetic result.”

It’s quite astounding that a relatively large organ like the kidney can be teased past connective tissue and other organs to be removed through a natural orifice such as the vagina.  Gross, but astounding.

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