The call by two US renal specialists for active consideration of “the controlled initiation and study of potential regimens that may increase donor kidney supply in the future in a scientifically and ethically responsible manner” through cash payments is an uncomfortable challenge (Kidney International 2006;69: 960-2). However, it is not one that necessarily requires us to venture far into new territory. We already have well regulated tariffs for the valuing of various body parts, including kidneys. And the valuation that the two specialists suggest—$40 000 (£22 000; €32 000), which prize winning economist—is compatible with these tariffs.
We already permit the sale of body parts and fluids on the market model
Several “incentive models” (American Journal of Transplantation 2005;5: 15-2015636607) already operate for the involvement of people in medical activities that do not benefit themselves directly. In the United Kingdom and the United States living donors currently have their expenses related to the operation and recovery reimbursed by the NHS, Medicare, or insurance companies (or in the state of Wisconsin by tax rebates to the value of $10 000). Private sector employers and the US federal government provide several weeks of leave for organ donation. This reimbursement model is closer to a “service” model of compensation for income lost than a “market” model of sale of a commodity.
We have gone a long way towards commodifying body parts, tissues, and fluids
The service model is well established in the payment of research subjects for their time and loss of earnings (on a wage payment model that references the national minimum wage) and the risk factor and unpleasantness of the procedures they are subjecting themselves to. A US study found that payments to participants in medical research ranged from $5 to $2000 (Contemporary Clinical Trials 2005:26; 365-75), and UK drug testing companies commonly offer £2000 to £3000 for unpleasant regimes requiring residence in a testing unit. Another US study found that although monetary payment had positive effects on respondents' willingness to participate in research, regardless of the level of risk, higher payments did not seem to blind respondents to the risks of a study (Journal of Medical Ethics 2004;30: 293-8). Many research organisations pay completion bonuses.
We already permit the sale of body parts and fluids on the market model. Blood and gametes are distributed and redistributed for a monetary value. The UK is one of the minority of countries that still rely on predominantly voluntary donations of blood. Although sperm and ova have the awesome power of creating new human life, we do not seem to worry too much about their “fungibility”—the fact that in these transactions they are being traded and provided as exchangeable things. Which is to say that we have gone a long way towards commodifying body parts, tissues, and fluids and accepting their fungibility in the process of enhancing their use in both curative and preventive medicine—and indeed in elective procedures such as abortion, fetal reduction, and selection.
We have also already determined “tariffs” for the value of certain body parts in compensation models for workers' accidents, criminal injury, or injury incurred during military service. The UK Criminal Injuries Compensation Authority pays £2500 for a fractured coccyx, £3800 for a hernia, and £22 000 for loss of one kidney. The UK Veterans Agency has just issued a 15 level list of tariffs that is compatible with the Judicial Studies Board's guidelines for the assessment of general damages in personal injury cases. More than a billion dollars has been paid out under the US radiation exposure compensation systems and the Marshall Islands nuclear claims tribunal (which pays $75 000 for cancer of the kidney).
If we are not shy about reaching these values why do we shrink from constructing a regulated exchange system for body parts that would undercut the existing illegal trade, which is so hazardous for the vendors? The average wage in the UK in 2004 was £26 151, which is close to the national average wage index of $35 000 in the US. Both values are close to the $40 000 recommended by the Nobel prize winner Becker and his colleague. If such a sum were part of a package that involved the highest level of clinical care and follow-up, would it be any more reprehensible than the “vending” that is currently permitted for other body materials?
Competing interests: SRR is a lay member of the Unrelated Live Transplant Regulatory Authority (soon to be decommissioned). She is also a lay member of the Postgraduate Medical Education and Training Board, the fitness to practise panel of the General Medical Council, and a deputy non-clinical scientist member of Tayside Local Research Ethics Committee.