Sellers and losers

A newly published study underlines the fact that selling a kidney hardly benefits the seller.

POOR people in southern India who sell a kidney do not get a long-term economic benefit from the sale and have a worsening of their health. These are the main findings of a study we recently reported in the Journal of the American Medical Association ("Economic and Health Consequences of Selling a Kidney in India,'' by Madhav Goyal, Ravindra L. Mehta, Lawrence J. Schneiderman and Ashwini R. Sehgal in JAMA, October 2, 2002, Vol. 288, No. 13). The investigation involved 305 individuals in southern India who had sold a kidney an average of six years earlier for an average of Rs.50,000 apiece (about twice their annual family income). The study compared the sellers' current economic and health status with their economic and health status before they sold a kidney. The income of the sellers declined by one-third after selling a kidney, and nearly all had a worsening of their health.

As reported in previous issues of Frontline, the sale of kidneys by living donors is common in India and many other developing countries. This practice is justified as a way both to increase the supply of kidneys for transplantation and benefit the seller economically with little or no health risk. However, critics argue that purchasing kidneys amounts to exploitation of the poor and that the poor do not overcome poverty as a result of the sale.

Our study, led by Madhav Goyal, MD, from Geisinger Health System in State College, Pennsylvania, sought to determine whether individuals who sell a kidney actually benefit from the sale. We used newspaper articles and information provided by transplant professionals to identify neighbourhoods of Chennai where sellers lived. A team of Tamil-speaking research assistants then identified sellers by going door to door. They also asked each seller for names and locations of other people who had sold a kidney. The answers ranged from next-door neighbours to persons from neighbourhoods more than 15 km away. This process was continued until all identified neighbourhoods were visited and no more sellers were identified.

The key findings of the study were:

* The average seller was 35 years old, 71 per cent of the sellers were female, and 70 per cent worked as labourers or street vendors.

* Sellers had sold their kidneys an average of six years prior to our interview.

* Seventy per cent of the sellers sold their kidneys through a middlemen and 30 per cent sold directly to a transplant clinic.

* Almost all sellers sold their kidneys to pay off debts. Food and household expenses, rent, marriage expenses, and medical expenses were the most common sources of these debts.

* Ninety-five per cent of the sellers said that a desire to help a sick person with kidney disease was not a major factor in their decision to sell.

* Fifteen per cent said their spouse had also sold a kidney.

* The average amount promised for selling a kidney was Rs.65,000 while the amount actually received was Rs.50,000. Both middlemen and clinics promised on average about one-third more than they actually paid.

* Most of the money received was spent on debts (60 per cent), food and clothing (22 per cent), or marriage (5 per cent). Only 11 per cent was retained as cash equivalents (cash, jewellery, bank deposit, or other investment).

* Average annual family income declined from Rs.30,000 at the time of the sale to Rs.20,000 at the time of our interview. Fifty-four per cent of the sellers were below the poverty line at the time of the sale. At the time of our interview, 71 per cent were below the poverty line.

* Of the 292 sellers who sold a kidney to pay off debts, 74 per cent were still in debt at the time of our interview.

* Eighty-six per cent of the sellers reported a worsening of their overall health. Fifty per cent complained of persistent pain at the site of the surgical scar. Thirty-three per cent complained of long-term back pain.

* Seventy-nine per cent would not recommend that others sell a kidney.

These findings undercut the arguments made by supporters of the sale of kidneys. Selling a kidney did not help poor donors overcome poverty. In fact, family income declined by one-third, and most sellers were still in debt and living below the poverty line at the time of the interview. Selling a kidney was also associated with a decline in health.

Regardless of these poor economic and health outcomes, it could be argued that sellers have a right to make informed decisions about their own bodies. However, most sellers would not recommend that others sell a kidney. This suggests that potential donors would be unlikely to sell a kidney if they were better informed of the likely outcomes.

SUPPORTERS of this practice will undoubtedly respond to our study by calling for continued selling of kidneys, but with additional regulations and safeguards. For example, better medical care after surgery may prevent persistent pain and worsening of health. Similarly, assistance with managing the money received may improve economic outcomes. While these are theoretically worthwhile, an examination of two previous safeguards does not provide scope for optimism. First, because middlemen are criticised for misleading potential donors about the surgery involved and for keeping a large share of the payment, some transplant clinics purchased organs directly from donors. However, we found similar economic and health outcomes regardless of whether a middleman was involved or not. Secondly, the Transplantation of Human Organs Act, 1994, required all transplant centres to have an Authorisation Committee review donations by non-relatives to ensure that donations were made out of altruism and not for payment. However, we found widespread sale of organs despite this Act. Moreover, the price paid for kidneys has declined somewhat over the last decade. If the 1994 law were effective, we would expect a decrease in the supply of kidneys and therefore an increase in price.

THERE are several alternatives to selling kidneys. A national cadaveric programme would allow transplantation of organs from brain dead individuals (for example, victims of motor vehicle accidents). Eliminating purchase of kidneys as an option may encourage relatives of kidney failure patients to donate organs. An increased emphasis on preventing diseases that lead to kidney failure would lessen the need for transplants. Since paying off debts was the most common reason for selling a kidney, social and economic efforts to reduce or prevent indebtedness are also essential.

The use of financial incentives to increase the supply of organs is also being actively debated in the United States. A majority of kidneys for transplantation in the U.S. come from brain dead individuals whose families have consented to donate. Because families refuse to donate in nearly half the cases, offering to pay for funeral expenses is proposed as a way to nudge reluctant families to agree to donate. So far, legal issues as well as concerns about weakening altruism and exploiting poor families have prevented this proposal from being implemented.

In conclusion, the sale of kidneys by poor people in India does not lead to a tangible benefit for the seller. Although patients with kidney failure deserve access to optimal treatment, we believe such treatment should not be based on the exploitation of poor people.

Ashwini R. Sehgal is Associate Professor of Medicine, Case Western Reserve University, Cleveland, Ohio, United States.