Face to Face
The Contrarian
By Kim Kiser
Arthur Matas has riled ethicists and transplant surgeons by proposing that the United States allow a regulated market for kidneys.
At first glance, Arthur Matas, M.D., appears to be an unlikely lightning rod. A slight man with wispy, graying hair and a chin full of stubble, he looks more like a folk singer than a prominent transplant surgeon with a radical idea.
He speaks softly, and when asked about becoming the public face for creating a regulated market in this country for kidneys, he downplays the notion that he’s a front man for kidney sales. “I have a real world to deal with,” Matas, director of the University of Minnesota’s kidney transplant program, says, explaining that he’s tired of watching the number of people waiting for kidneys grow faster than the supply of available organs. “It’s not something I’m promoting,” he insists, pausing before speaking again. “But if people ask me to talk about it, I go.”
Arthur Matas, M.D.
At A Glance
Director, University of Minnesota kidney transplant program
Education: University of Manitoba College of Medicine, 1972
Postdoctoral Training:
Surgery internship and residency, University of Minnesota, 1972-1979; fellowship in transplantation, University of Minnesota Hospitals, 1979-1980
Why transplant surgery?
“I did a rotation as a second-year resident. It was just fascinating. It mixed elements of patient care, infectious disease, critical care medicine, general medicine, long-term care, and working with families. It wasn’t a pure surgical specialty. And there was a lot of excitement about transplantation at this institution at the time.”
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Recently, more and more groups have been asking Matas to discuss the controversial idea, in which the government would control the price and distribution of kidneys. A trial would require Congress to revisit the National Organ Transplant Act, which outlaws organ sales. The law was passed in 1984 in response to a proposal by Virginia physician Barry Jacobs to create a brokerage that would buy kidneys from people in poor countries, sell them to those needing a transplant, and profit from the deal. (“Exactly the kind of thing we don’t want to see,” Matas says.)
Among the organizations to which Matas has spoken are the American Society of Transplant Surgeons, the American Transplant Congress, the World Summit on Organ Donation, and the President’s Council on Bioethics. Earlier this year, his speaking schedule took him to the annual scientific meeting of the Canadian Society of Transplantation in Mont-Tremblant, Quebec, the National Kidney Foundation’s scientific meeting in Dallas, and the Cato Institute in Washington, D.C.
During those talks, Matas ignites outrage. When speaking before the Cato Institute, members of the panel compared his idea with black-market organ sales in the Philippines, Pakistan, and India, and even with child pornography. On a podcast of the talk, Matas’ voice climbs an octave as he tries to set them straight: “We can’t throw these horror stories out and say this has anything to do with what’s being proposed! I’ve been listening to Manila, to India, to Pakistan, this has got nothing to do with what we’re proposing! Child pornography has nothing to do with what we’re proposing today! We’re proposing a solution to solve a terrible problem for patients—patients who are dying on the transplant list!”
Matas believes that the ethical issues need to be balanced—that concern about exploiting the individuals providing kidneys should not override concern for patients in need. He believes that a regulated system that doesn’t take advantage of people could be established, and he emphasizes that until there is a trial, there is no way of knowing whether his idea would work.
Untangling Arguments
The fact that people were mixing arguments was what drew Matas into the debate in the first place. As he listened to discussions about how to solve the kidney shortage, he noticed people confusing the issues of paying for organs from deceased individuals, reimbursing living donors for their expenses, taking organs from prisoners against their will, and compensating destitute people for kidneys that may not be healthy. “They were putting their arguments into one big basket, and it didn’t make sense,” he says.
At the same time, he and other surgeons were seeing more and more successful outcomes in both patients who received kidneys from living donors and the people who gave them organs. “That sort of gave us the moral authority to think about this and talk about it, rather than somebody who isn’t paying attention to the donors and worrying about them,” he says.
But even with the establishment of programs such as the University of Minnesota’s nondirected organ donation program, in which a person may donate a kidney to a nonrelative, and an increase in the number of deceased organ donations, he saw the gap continue to widen between the number of people waiting for kidneys and the number of available organs (see “Supply and Demand”). By 2005, the average time a patient spent waiting for a kidney had increased to more than five years. Eight percent of those patients on the transplant waiting list die each year.
After looking at outcomes, the imbalance between supply and demand, and the reasons against paying for organs, Matas concluded that “the arguments against a regulated system were far outweighed by the arguments in favor of trying to do something for our patients.”
In 2003, he published his first paper on the topic in the American Journal of Transplantation. He presented a cost analysis that compared transplantation with dialysis. Matas suggested transplanting a kidney from an unrelated living donor into a patient on the waiting list would save approximately $95,000 (what Medicare paid for a year of dialysis) and give the recipient an additional 3.5 years of quality-adjusted life. The following year, he published another paper in the same journal making the case for living kidney sales.
In it, Matas proposed a system in which the government or a government agency would set a price and pay the person willing to sell a kidney using money saved by public and private insurers. Potential sellers would be evaluated and, if accepted, receive long-term follow-up care. They would also receive compensation of around $95,000 that might include a cash distribution and health and life insurance. The kidneys would be allocated in the same way kidneys from deceased donors are, and everyone on the transplant waiting list would have a chance to receive a purchased kidney.
Supply and Demand
More than 74,000 people in the United States were waiting for a kidney at the end of 2007, according to the United Network for Organ Sharing (UNOS), which maintains the Organ Procurement and Transplant Network, a national list of patients waiting for kidneys. That same year, more than 13,000 kidneys became available from deceased or living donors, yet nearly 34,000 people were added to the waiting list.
In some parts of the country, those people will wait at least five years for an organ; in others, the wait could be as long as 10 years. “In Minnesota, I tell new patients they’re going to wait five or six years. They have a 50/50 chance of dying before they get a kidney,” says Arthur Matas, M.D., director of the University of Minnesota’s kidney transplant program. In the late 1980s, the time patients spent waiting on dialysis was less than one year.
Why the longer waits? According to Matas, more patients with end-stage renal disease are candidates for transplantation than in the past (UNOS data show fewer than 18,000 people were on the transplant list in 1995; that same year, more than 8,000 kidneys became available). Because immunosuppression has improved, transplantation is now an option for people older than 50 years who, because of their age, may not have been candidates 25 years ago. “Now we routinely transplant people in their 60s and early 70s,” he says. In addition, transplantation holds the promise of a longer and better-quality life than dialysis.
Matas says the combination of more eligible patients and more patients opting for transplantation over dialysis explains the reason why demand for kidneys is outstripping supply. “In the old days, a lot of people chose dialysis because transplantation wasn’t much better for them,” he says. “Now, the majority of people choose transplantation.”—K.K.
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The articles brought letters from some who believed his proposal had merit and others who thought it was an abomination. It would “precipitate complete disintegration of altruistic donation,” wrote one physician. “Existing experience with markets has been dismal,” wrote Arthur Caplan, Ph.D., director of the Center for Bioethics at the University of Pennsylvania and former director of the University of Minnesota’s Center for Bioethics. “The devastating moral cost to medicine of engaging in organ brokering is far too great a price to pay for the meager benefits that might be had by those in need of transplants.”
Matas suddenly found himself drawing fire from big names in both the transplant and ethics communities.
War of Words
Listening to Matas speak, he challenges his audience to set aside their discomfort with the concept of compensation for organ donation for a moment. “It doesn’t sound right,” he admits. “But the idea of patients dying on the waiting list doesn’t sound right, either.” Matas acknowledges the positions of his opponents—the primary one being Francis Delmonico, M.D., a fellow transplant surgeon and professor of surgery at Harvard University, whom he met while working on a cooperative clinical trial of an immunosuppressant agent in the 1980s and whom he considers a personal friend. Then he takes each argument, attempts to expose its weakness, and counters it in an effort to turn the discussion back to his advantage.
When Delmonico, a former president of the United Organ Sharing Network who also sat on the Cato Institute panel, says creating such a market would exploit the poor, Matas responds that it’s a fundamental tenant of Western society that people be allowed to control their own destiny. “I do not think we are willing to say that being poor removes the ability to make rational decisions.” Besides, he says, a ban on sales removes a potential option for lifting people out of poverty.
When Delmonico disputes the number of people waiting for a kidney, saying that 30 percent of those on the list are ineligible for various reasons—and that that number has increased substantially over the last five years—Matas deflects the argument, saying they were good candidates at the time they were put on the list.
When another critic brings up the idea of organ sales leading to commodification of the body, he argues that it’s already taking place. “We have lawsuits that put a value on the body … we put a value on surrogate mothers, sperm, and eggs. That doesn’t in any way diminish the humanity or dignity of the person.”
When one says sales would compromise the health of the seller, Matas counters that if they were screened in the same way as living donors, that the short- and long-term risks would be identical for the two groups.
When another talks about sales decreasing donations, he counters by asking, If the total number of available organs increased, what would it matter?
When critics claim such a system would undermine the public’s trust in medicine, he insists we won’t know until we test it.
And when they tell him a regulated market might bring people from the Philippines and other countries who can get more money here for a kidney than at home, Matas says the point of government regulation is to prevent such things from happening.
Acknowledging that his opponents make some valid points, Matas admits that he finds the sparring fun at times. He explains that when he started talking about this, he had a list of 13 arguments against a regulated system and why he thought they were wrong. That number is now up to 24. “As you defuse one argument, the people who are opposed to this just come up with another one,” he says.
Idealistic Idea?
Although finding ways to increase the number of available organs has been on the agenda of transplant organizations for years, the current kidney shortage has brought out a number of ideas that have ethical implications: Donation after cardiac death as opposed to brain death, expanded-criteria donation (involving donors who were once considered unsuitable because of their age and medical condition), paired donation (pairing a living incompatible donor and recipient with another living incompatible donor and recipient in order to achieve a match), and compensation.
“It’s a timing issue,” says Jeff Kahn, Ph.D., M.P.H., director of the University of Minnesota’s Center for Bioethics, of the attention Matas has garnered. “He happens to have articulated this position at a time when there has never been a greater demand for organs in this country or around the world. I think there may be a greater willingness to listen to the arguments in a serious way than in the past.” Kahn, who has debated Matas and believes his proposed system would exploit people who were desperate for money, says Matas’ credibility as a transplant surgeon and former president of the American Society of Transplant Surgeons has earned him respect in the debate. “He’s someone who not only talks the talk but walks the walk. He’s involved in the transplanting of organs and knows the problem first-hand.… People listen when he speaks.”
Matas has noticed that the reception his idea gets, especially at transplant meetings, has changed. “I think the audience response over the last four to five years has become more and more favorable of doing at least a trial of something like this,” he says. Matas recalls bringing up the idea at a national meeting five years ago and counting about 15 percent of the audience siding with him. At the American Society of Transplant Surgeons’ winter symposium in January 2007, 10 percent said they opposed the idea, about 20 percent favored it, and the rest said they would like to see a trial take place to find out if it really would bring more kidneys to those in need.
The University of Pennsylvania’s Caplan, who instead would like to see everyone become a donor upon death unless they specify otherwise in advance, admits that even though he still has plenty of concerns about the idea, he wouldn’t oppose a trial. “I don’t mind trying to test it,” he says. “But the chance of going to a market politically is nothing.” Caplan argues that recent stories such as the one about the doctor in California who is accused of hastening a patient’s death in order to harvest his organs hurt the chances of that happening. “If you say money is starting to mix in here, people are going to get even more nervous,” he says.
Testing a regulated market would mean convincing Congress of its merits. And the Canadian-born Matas, who came to the University of Minnesota in 1972 as an intern in the department of surgery, admits he’s no activist. “I’m not much for mobilizing people,” he says, quietly. When asked if he saw himself testifying on behalf of the issue, he dismisses the idea and explains that he’s too busy conducting research (he’s known for his work on immunosuppression) and caring for patients.
Matas believes kidney patients and their families are the ones who would have the best chance of persuading lawmakers to test his idea. However, unlike breast cancer survivors, those in need of kidney transplants haven’t organized around this or any other issue. “You spend four hours on dialysis three times a week … and you don’t have a lot of time to take up a cause,” Matas explains. And there are other reasons patients may not be willing to take up the cause. After an article about the debate over kidney sales appeared in the Wall Street Journal last year, Matas says he got emails from patients who claimed to be better off staying on dialysis because the government would pay 100 percent of the cost indefinitely. Coverage for the drugs they would need to prevent rejection following a transplant would eventually run out. “It’s an interesting sideline,” he admits—one that raises another set of ethical questions about the motivations of insurers.
Will the question of whether there should be a regulated market in this country for kidneys be confined to the lecture halls of think tanks and academic and professional organizations? At this point, Matas doesn’t know. “I’d love to see a trial. I think a lot of the objections could be answered in a trial,” he says. “Maybe the trial would show that my thinking is totally wrong, but that’s OK, too. That’s why you do trials.” But he admits that even if the idea never gets beyond grist for ethical debates, it has achieved one goal: “It got people thinking about the organ shortage, if nothing else.” MM
Kim Kiser is associate editor of Minnesota Medicine.