March 4, 2008
A Donor Match Over Small Talk and Coffee
By WILLIAM YARDLEY
TACOMA, Wash. — Annamarie Ausnes is known for holding up the line at her favorite Starbucks here, carefully counting out her coins to pay for her “short drip, double-cupped” daily jolt. Over the years, Sandie Andersen, a friendly barista behind the counter, might have rolled her eyes once or twice but she has also taken these morning moments to make conversation, to make friends.

Grandchildren? A favorite topic. That tan Ms. Ausnes brought in one day? A vacation souvenir. And then there was the small talk that day last fall.

“She reached over the counter and said, ‘I’m a blood match,’ ” Ms. Ausnes said last week, recalling the conversation.

Ms. Andersen said, “We both stood there and bawled.”

Turns out, Ms. Andersen had made Ms. Ausnes a special offer, off menu. On March 11, the two women are scheduled to go into surgery at Virginia Mason Medical Center in Seattle. If all goes well, when they come out Ms. Ausnes, 55, who has polycystic kidney disease, will be the new owner of Ms. Andersen’s left kidney.

Ms. Andersen, 51, has worked at Starbucks for more than four years. She said she had taken the job for the good corporate health benefits, which her husband’s job does not provide. Her husband, Jeff, did not realize his wife would also be providing health benefits.

“My husband said, ‘Next time someone comes in and says they don’t feel good, don’t give away another body part,’ ” Ms. Andersen said.

Ms. Ausnes, an administrative assistant for student government at the University of Puget Sound, said she had been buying her morning coffee at this Starbucks, at North Proctor and 26th Streets, for three years. She has known for nearly two decades that she has a kidney disease, but her kidney function has declined significantly recently.

Last year, after tests showed that family members could not provide her with a transplant, it became clear that dialysis and a wait of some years for a donor were inevitable. Ms. Ausnes never mentioned this during her daily exchanges with Ms. Andersen.

“It looked like dialysis was coming close and I just said, ‘Annamarie, you never know where a donor’s going to come from,’ ” recalled Wanda Ryan, the transplant coordinator at Virginia Mason who is handling her case. “ ‘Keep telling people your story.’ ”

In November, not long after that conversation, Ms. Ausnes stopped into Starbucks as usual, but this time Ms. Andersen noticed that her customer was glum. Ms. Ausnes finally told her the news, and the response was instantaneous.

“I’m going to get tested,” Ms. Andersen said.

And she did. Blood type O? Yes, a match. Negative cross-match under the microscope? Yes, perfect. The six elusive DNA markers? One of six was alike, not ideal, but good enough.

So there they were that morning last fall, crying over the counter while the coffee line grew longer.

Both women expect to be in the hospital for about a week then to be out of work for up to six weeks. Howard D. Schultz, the chief executive of Starbucks, called both women and told Ms. Andersen “how proud I am to have someone like you working for our company.”

She joked about Mr. Schultz’s recent, well-publicized emphasis on having employees make a “human connection” with customers.

Ms. Andersen, who has done missionary work in Mexico and helped dig mud out of houses in New Orleans after Hurricane Katrina, said this latest gesture should not be viewed as unusually magnanimous. People should give freely of themselves, she said, and they do more often than is noticed.

Ms. Ausnes will undergo regular monitoring and testing and will need to take medication regularly for the rest of her life to prevent her body from rejecting Ms. Andersen’s kidney, according to Ms. Ryan, of the hospital. Ms. Andersen, who was interviewed extensively by the hospital to make sure she was physically and mentally stable, should be recovered in six months, charged only with keeping a slightly sharper eye on her basic health and diet.

Ms. Andersen said, “I asked my surgeon, ‘Will I be able to snowboard afterward?’ He said, ‘Do you snowboard now?’ I said, ‘No, but I’m hoping to.’ ”

I'm pretty liberal in who I'd give a kidney (any family, friends, coworkers, neighbors, members of my parents' church), but I can't see myself giving it to a total stranger.

do you think it was wrong of the ny times to publish this article before the procedure took place? what if the woman wanted to back out which happens often?

im scared of needles and blood and hospitals. if i wasn't id probably give it away to just about anyone though id like to know it was going to a *good* person. why would i want to help a shitty person live longer?

Meh. If she gave them permission to report it. Who cares?

No.

Fair. But would it have killed them to wait till after the operation? Would have made for a better article too.

Do you think organs should be allowed to be sold in America? Why should someone stop me from making money off of my kidney if there is a willing buyer out there? Isn't it a win/win?

It is win/win, but our politicians are looking out for us.

As it stands, everybody between you and the beneficiary are allowed to profit from the transfer, but not you. Because selling organs is just morbid and gross and all around immoral. Who cares if it would save lives and the buyer would much rather have the organ than the money.

it just seems crazy to me to not allow it. sure, plenty of poor people would start selling their kidneys but so what? who are they hurting? plus the availability of kidneys would skyrocket. i wonder if this law changes in my lifetime. i can see ebay now...

Think how cool the world will be when only rich people can get transplants, and all the lame, poor people die off of organ failure!

its not really fair to argue this. if organs were allowed to be sold that would only ADD to the current available supply. that lady in the story above who gave her organ to the customer could still give away her organ to the customer without selling it.

what would happen is a rich person would basically be gauranteed an organ but you shouldnt assume that is coming at the expense of a poor person. there would simply be MORE organs available. now the only way it would negatively effect a poor person is if someone who before was willing to give away their organ for free now decides to sell it. i doubt that would happen very often.

also, poor people are denied all sorts of healthcare options vs. rich people in this country as it is.

That doesn't sit well with me AT ALL, and I would never accept that as justification for helping one group in need of kidneys to leapfrog another.

of course its not *right* but thats the way it is. if you want a pure socialist medical system then thats a whole different debate and really doesnt change this debate at all. and you are assuming they are leapfroging. that is NOT what would happen. currently you have 2 options: get someone to volunteer or be put on a list. all this would do is add a 3rd option. there would be MORE kidneys available. MORE people would have their lives saved. it would not be at the expense of the poor not getting kidneys. however, the poor would most likely be the ones donating their kidneys for money.

in fact you could argue this would HELP the poor who need kidneys. rich people who are on the same list as poor people would drop out of the list when they have a new source of kidneys to 'buy'. again, the core assumption here is that nobody who previously was going to donate their kindey for free would now decide they wanted money for it.

Kidney Shortage Inspires
A Radical Idea: Organ Sales
As Waiting List Grows,
Some Seek to Lift Ban;
Exploiting the Poor?
By LAURA MECKLER
November 13, 2007; Page A1

Amid a severe kidney-donor shortage, an idea long considered anathema in the medical community is gaining new currency: payments for people willing to give up a kidney.

One of the most outspoken voices on the topic isn't a free-market libertarian, but a prominent transplant surgeon named Arthur Matas.

Dr. Matas, 59 years old, is a Canadian-born physician best known for his research at the University of Minnesota. Lately, he's been traveling the country trying to make the case that barring kidney sales is tantamount to sentencing some patients to death.

"There's one clear argument for sales," Dr. Matas told a gathering of surgeons earlier this year. The practice, currently illegal in the U.S., "would increase the supply of kidneys, save lives and improve the quality of life for those with end-stage renal disease."

The doctor supports a regulated market only for kidneys, since live donors can give one up and survive without excessive health risks. (Transplants of other organs, such as livers and lungs, pose greater complications to a living donor.) And Dr. Matas doesn't rule out financial incentives for the families of deceased donors.

Among his opponents on the issue is a friend and colleague, Francis Delmonico. A Harvard University professor who has played a central role in shaping national transplant policy, the 62-year-old physician has several objections to organ sales. He fears such a system would attract the poor, vulnerable and unhealthy, and that altruistic donations might wither away.

"Payments eventually result in the exploitation of the individual," says Dr. Delmonico, who also worries about encouraging black-market sales both here and in developing countries. "It's the poor person who sells."

The two men, and their different perspectives, represent one of many intensifying battles in medicine -- a field where ethics and efficacy sometimes collide. At the core of the kidney-sale debate are complex issues surrounding transplantation. Given the imbalance of supply and demand, physicians and policy makers are forced to ration what's available while considering more radical ideas for obtaining organs.


The federal ban on organ sales dates back to 1983, when Virginia physician Dr. H. Barry Jacobs proposed buying kidneys -- mostly from the indigent -- and selling them to whomever could afford to buy. His plan was met with widespread outrage. In Congress, then-Rep. Al Gore (D., Tenn.) introduced legislation banning the sale of organs. The bill became law in 1984.

Since then, the gap between demand and supply has widened. In 1988, the first year for which data are available, there were fewer than 14,000 patients waiting for a kidney transplant and about 7,000 deceased-donor kidneys. Today, the waiting list has grown more than fivefold -- an increase fueled partly by higher rates of diabetes -- but the number of deceased-donor kidneys has only inched up. Some of the gap is made up by living donors, but demand still far outstrips supply. Last year, about 4,400 people died on the waiting list.

The issues for and against sales have been debated in many medical forums across the country, as surgeons and others in transplantation consider whether the U.S. should experiment with some sort of regulated organ market.

Appearing at a January meeting of the American Society of Transplant Surgeons, Drs. Matas and Delmonico each presented their thoughts on the issue. Afterwards, the audience was asked to take sides with a show of hands. The surprising result: A majority indicated they would support a trial to determine the viability of a U.S. organ market.

At an August conference in New York, Marian A. O'Rourke, a nurse and former president of the North American Transplant Coordinators Organization, listened to Dr. Matas. She, too, found herself persuaded.

"Every time I hear this talk, it makes me think a little bit more about it and question why I had such a gut-wrenching reaction against it," she told him after his presentation.

"You need to hear the talk a few more times," Dr. Matas quipped back.

Kidney sales are common in some developing countries, including Pakistan and the Philippines, though they are technically against the law. Iran is the only country with a government-sanctioned market. Outside medical observers say that sellers in these places are often exploited. Much of the fees go to unscrupulous brokers, for instance, and there is little screening to ensure donors are healthy enough to withstand surgery.


Under the current system, patients who need a kidney transplant are put on a waiting list for kidneys from deceased donors, which are handed out based on geography, waiting time and various medical factors. Waits vary across the country, and easily top five or six years in many areas. Those who have a willing, living donor can bypass the list altogether and get transplants right away. But the donors must give their kidneys freely and attest that no one is paying them to do so.

Dr. Matas envisions a plan where donors would be able to sell their kidneys, regardless of motivation. A set price, he says, could be established by the government and paid by the recipient's insurance, typically Medicare. The kidney would go to whoever is at the top of the waiting list, rich or poor. Potential sellers would be medically and psychologically screened to make sure they are suitable donors. Afterwards, they would be tracked by the government to see what impact the kidney sale had on their life and overall health.

"It's a concept that takes a little while to sink in," Dr. Matas acknowledges. "When you first hear about it, it doesn't sound right."

While ethical questions loom -- especially those about exploiting the poor -- Dr. Matas maintains that sales shouldn't be written off as taboo.

His logic: The poor might be the most likely to sell a kidney. But if it is safe enough for friends or family to donate out of a sense of compassion or obligation, why should giving up a kidney be banned for someone motivated by money?

Some medical ethicists are coming around. These include Arthur Caplan, a noted bioethicist at the University of Pennsylvania who once debated this issue with Dr. Matas. He had been concerned that poor people would sell "under desperate and trying circumstances," and that wealthy types would find a way to get around a regulated market to get a kidney faster.

Now, he says, "I've started to think [a trial is] at least worth a look."

The idea still faces plenty of opposition. Last year, for instance, the Institute of Medicine, a branch of the National Academies of Science, explicitly rejected payments of any kind. They cited objections similar to Dr. Delmonico's.


The National Kidney Foundation was so strongly against kidney sales that its director objected when a Washington think tank sought to host a panel discussion on the issue last summer. "NKF is unwavering in its long-established opposition to any initiative that makes organs a commodity and its aversion to any scheme of buying and selling organs," the group's chief executive, John Davis, wrote.

Dr. Delmonico, meanwhile, has worked to maintain the status quo -- and his credentials carry substantial weight. Until last June, he was president of the United Network for Organ Sharing. Under direction of the federal government, the network runs the nation's organ-distribution system. Dr. Delmonico now serves as medical director of the Transplantation Society, an affiliate of the World Health Organization.

Despite their differences over organ sales, Drs. Matas and Delmonico have much in common. Both have been kidney-transplant surgeons since the late-1970s, when the field was young and all the leading surgeons knew one another. Dr. Matas's wife sent gifts when Dr. Delmonico's grandchildren were born. Dr. Delmonico was quick with recommendations for the best Italian food in Boston's North End when Dr. Matas came to town to visit.

Dr. Delmonico has used his influence to help kill efforts on the kidney-selling front. In 2003, several medical groups, including the American Medical Association and the United Network for Organ Sharing, endorsed legislation to allow pilot studies of payments to families that donate a loved one's organs after death.

Dissent was strong, including from Dr. Delmonico, who testified before Congress on behalf of the National Kidney Foundation. "The sale of bodies or body parts would undermine the fundamental values of our society," he told the House Energy and Commerce Committee. The bill went nowhere.

The federal government has since established a program to reimburse living donors for expenses including travel, lodging and meals. Today, more than a dozen states offer a tax deduction of up to $10,000 to help defray expenses. Until recently, outright sales have remained a largely unpopular subject.


In some ways, Dr. Matas is an unlikely change agent. He is best known for his early research on the use of cyclosporine, an important post-transplant medication used to prevent organ rejection.

Completing his residency at the University of Minnesota in 1979, he gravitated toward transplant, attracted to the excitement that coursed through the developing field. Researchers and clinicians were working to improve shaky success rates, which saw only about half of transplanted organs survive a year.

"The opportunity to do clinical research to try and improve that was phenomenal," he says. "I really didn't set out to become a crusader."

He didn't think much about organ sales, going along with the orthodoxy in opposition. But then the rising demand for transplants -- and a shortage of kidneys -- began to take its toll on Dr. Matas. Describing the wait-list process to patients was particularly rough. "I used to tell them a year, then two or three years, then four or five years. Right now in Minnesota, I'm telling them six years."

This was on his mind in 2002, when he traveled to Miami and heard a talk by philosopher Janet Radcliffe Richards of University College London. She posited that none of the arguments against organ sales made sense. Her lecture got him to further examine his own beliefs.

His first step was to ask whether kidney sales would be financially viable. If not, he felt, the ethics were irrelevant.

In February 2004, he and a colleague published a paper calculating that the government could spend $95,000 to evaluate and compensate a donor and still break even. The reason: Medicare pays for dialysis for all Americans who need it. Transplant recipients no longer need the costly procedure, which translates to huge savings.

His paper suggested that compensation to donors include health and life insurance as well as cash, given the risks of the surgery. Initially, he called the people who would sell their kidneys "vendors."

"A significant payment could be made to the vendors without increasing the overall costs to the health-care system," the paper, published in the American Journal of Transplantation, concluded.

In the same issue, Dr. Delmonico and another colleague sought to choke off the debate. Their opinion piece cited research that found some kidney sellers in India suffered postoperation health problems. And despite the cash fusion, their finances didn't necessarily improve after the operation. They said sales could alter the doctor-patient relationship, with doctors pressured to approve donors because money was on the line.

The debate in the medical literature was on. A few months later, Dr. Matas submitted a letter to the journal's editor, rebutting Dr. Delmonico's main points. The poor are more likely to be sellers, he wrote, but society has no problem letting them take on other dangerous jobs. And if the body is so sacred, why does the U.S. allow egg and sperm sales?

In late 2004, Dr. Matas, writing in the same publication, offered a full-fledged argument in favor of sales. He said that a regulated U.S. market could counter unregulated ones in other countries.

Dr. Matas was elected president of the American Society of Transplant Surgeons in May of 2006. He continued his debate with Dr. Delmonico. At the New York transplant conference this summer, Dr. Delmonico argued that problems found abroad would be inevitable here, too: young people forced by their poverty-stricken families to sell a kidney, out-of-control bidding for the best organs.

"The person is not left better off, but they're left with one less kidney."

Dr. Delmonico, who opened the conference as keynote speaker, had left by the time Dr. Matas addressed the group later that day. Despite several years of sparring at conferences and in journals, the pair had never discussed kidney sales one-on-one -- until this fall.

Two months ago, they found themselves at the same conference in Minneapolis, and slipped off to an empty meeting room at the Hyatt Regency. For more than an hour, they talked about their differences and found some common ground. They agreed that the U.S. should eliminate disincentives to kidney donation (such as barriers to health insurance for donors) and that all donors should be properly monitored after surgery.

But they couldn't bridge the divide on sales. Dr. Delmonico is convinced that the U.S. would be stuck with a free-for-all if the door to sales is allowed to open at all. "[Dr. Matas says] 'You regulate it'; I say, 'It's impossible to regulate it.'"

"We're just friends," says Dr. Matas, "who have agreed to disagree."

Right. The "if the poor people can't have it, nobody can have it" ideology really irks me. This would NOT mean that fewer poor people get organs, it only means that wealthier people have a better chance than they would otherwise. The only reason anybody would be opposed to that is out of pure spite towards the wealthy.

If anything, poor people would be better off, because they could sell a healthy organ for some extra cash.

it's interesting that this topic appeared today, as i wanted to start a discussion on the issues surrounding the creation of a functionally legal market for organs. as it stands, somewhere between 7,000 and 8,000 people die each year while on the waiting list for organs (more than have died in the war). since the national organ transplant act was codified in 1984, over 70,000 people have died while waiting for an organ. the act makes payments to any potential donors illegal. it effectively restricts the supply of available organs and ensures that demand exceeds supply. the ban on payments also makes the nominal cost of such an organ $0, a price for which there is no good supplied that will ever meet demand.

there are two types of donors - living and cadaveric. between 2 and 3% of all organs harvested from cadavers are suitable for transplantation. each cadaveric donor yields between three and four organs suitable for transplant. only 6% of all liver transplants last year came via living donor; the rest were transplanted from a cadaver. nearly all heart and liver transplants are of the cadaveric variety (for obvious reasons). the percentage of kidney transplants that comes from cadavers varies from locale to locale, but the majority are, in fact, cadaveric. there are approximately 90 organ procurement agencies in the united states, each with its own assigned exclusive collection territory. each of the agencies operates as a non-profit organization. in short, you could not concoct a setup more conducive to bring about a shortage: nonprofit monopsonists (monopolists on the buying side) collecting organs under the constraint that they pay a price of $0.

all that is required (and all that i would propose) to clear the market, and begin chipping away at the more than 90,000 people on the waiting list for organs, is to allow a death benefit of X dollars (estimates usually fall somewhere between $1000 and $3500 per donor, not per organ) be offered to the families of the deceased. that is, help facilitate the market for cadaveric organs, a market both less objectionable and more efficient than one for organs from living donors. the payment for cadaveric organs, relative to the payment necessary to fetch organs from live donors, is small enough to eventually drive out the market for living organs.

here are some of the things that i am NOT proposing:
1.) create (or allow) a market for living donors.
2.) putting the organs up for bid to patients.

right now, the costs of organ acquisition is paid for under the end-stage renal disease program as part of medicare. they pay for all dialysis costs, the costs of renal, heart, lung, and liver transplants, and the costs of post-op immunosuppressive drugs for three years before cutting off the patients. what happens? the poor and uninsured cannot afford to continue taking the medicines and their body eventually rejects the new organ. they're then placed back onto the waiting list and the cycle begins anew. dialysis costs upwards of $50,000 - $75,000 per year and the immunosuppressive drugs run between $12,000 and $15,000 per year. a transplant is a one-time expenditure of around $75,000, a much more cost-effective option.

the only way to significantly relax the industry's barriers to entry, and and to allow competing, for-profit firms to replace the non-profit monopsonists, is to create financial incentives for the donation of cadaveric organs. again, please notice that this is a buying-side market, not a selling-side market. it's a market that would save needless hardship, taxpayer dollars, and thousands of lives a year.

Paying for organs? Hahaha. Good joke.

so is it that you're uninterested in engaging in a reasonable, mature, and informed debate? or just unable?

I'd give a kidney if the money or the situation was right.

Oh, c'mon. Talk about ridiculous spin. You've turned equal access advocacy into bitter hate for the wealthy. Wanting people to have equal access to good quality of life is not spite for people with money. I'm suddenly a dick because I don't applaud a system that gives Bill Gates a kidney in a day while my neighbors wait for months?

It's not like suddenly everyone will have a kidney. They'll still be long lists and people will die waiting for a viable, willing candidate near them. It's just the people who will die or watch their health dither away while their medical debt goes up will be middle class and poor, while someone with a bank roll is back on their feet as fast as their diagnosed.

I don't hate money, but I don't think you should have it to get quality healthcare, safe food, clean water, or a decent education. A kidney's not an extravagance. It's life.