Organ Donation

[Dean Pomerleau]

Don't view organ donation as giving part of yourself to keep a total stranger alive. It's really teaming with a stranger to keep part of you alive. --Anonymous

 

You can't take it with you - become an organ donor.

 

[Thomas G]

I'm curious Dean, have you considered being a living donor?

 

A dozen years ago I read this New Yorker article about Zell Kravinsky. It has been haunting me ever since. Our healthcare system doesn't make it easy to do this in some important ways, like providing follow-up care if there is a complication after you have officially "recovered" from the surgery, or providing adequate paid leave from work.

[Dean Pomerleau]

Thomas,

 

I've never heard of Zell Kravinsky before. What a wonderful story, and what a fine human being. Thanks for sharing his story.

 

It reminds me of mathematician George Price, who did groundbreaking work in the evolutionary origins of altruism. Price helped show from the "selfish gene" perspective, it isn't worth it to sacrifice yourself life for a single brother (who shares only ~50% of your genes), but it is a win (for your genes) to sacrifice yourself for two brothers, or eight first cousins. It is known today as the theory of "kin selection" and it is the one (and only) explanation for altruism that is widely accepted among evolutionary biologists. The alternative "group selection", in which an unrelated-conspecific in a group acts to benefit another, genetically-unrelated, group member is still hotly contested and viewed quite skeptically by many biologists.

 

Towards the end of his life some say Price went a bit nuts; apparently becoming obsessed with altruism and the rather cynical implications of the "kin selection" theory he helped develop.

 

It appears he wanted to prove his own equation wrong, by going to ever-greater extremes of altruism towards total strangers in an (apparent) effort to show that it's possible (for humans at least) to break free from the chains of their genetic programming to help others without benefit to themselves. In fact, Price gave away all of what little money he had to total strangers, alcoholics of the streets of London, and inviting them into his small apartment to live. They took advantage of him, leaving him depressed and penniless. He slit his wrists shortly after the holidays in 1974.

 

Price's story did not end well, to put it mildly. One wonders if altruist organ donation might have been a better route for Price to take in order to prove his point, particularly since he didn't have much money to give away in the first place.

 

If, like Price, someone ever became frustrated by their inability to make a difference in the world, it could be argued than an anonymous non-directed organ donation, particularly to start a long kidney chain like in the video above, would be about the best thing one could do to benefit humanity and demonstrate that existence of altruism beyond that explained by cynical kin selection. It requires no money & no skills, only courage. Not only does each recipient in such a chain get about an extra 10 years of life, but I've also read that for each person who receives a new kidney, it saves between $500K and $1M in healthcare costs to society that would otherwise result from life-long dialysis.

 

But it probably isn't something any true, dyed-in-the-wool life-extensionist would ever consider. While the risk of death from a kidney donation is relatively small (some estimates say about 1/500), is still far higher than any other voluntary activity than most people would ever consider, particularly folks concerned about their own longevity.

 

After surgery, you are stuck in a germ-ridden hospital for up to a week where the food is terrible and unhealthy. After you go home, the recovery can be relatively long and painful, sometimes up to several months, during which time normal activities are difficult or impossible. Plus afterwards you've only got one kidney, which could result in serious, even life-threatening, health complications down the road. On the bright side I've read that if you've previously donated a kidney, you do get promoted to the head of the line if you ever need one in the future.

 

I'm curious Dean, have you considered being a living donor?

 

Seriously Thomas? One can dream of being that kind of person. But I'm far too much of a selfish coward to ever consider doing something that noble. Can you imagine volunteering to be cut open and have a perfectly good organ pulled out of your body? Gives me the chills just thinking about it...

 

--Dean

[Gordo]

But you ARE a living donor, you give blood.

[Dean Pomerleau]

Touche' Gordo!

 

I am a regular blood donor, and I'm happy to do it. But blood donation isn't in the same league as brave souls who donate a kidney or liver. In fact, for men at least, it can be argued that shedding excess iron through regular blood letting is beneficial, rather than detrimental to one's health. So blood donation is far from the selfless altruistic act that George Price was looking to demonstrate.

 

In fact, even the incredible generosity demonstrated by the man who started the kidney chain in memory of his deceased son in the original message at the top wouldn't quite qualify as the kind of pure altruism that Price appeared to be seeking to demonstrate. While it would be considered by most people to be a great example of group selection (since he helped people in his society genetically unrelated to himself), even that could be skeptically challenged by advocates of the "kin selection"-only theory like Richard Dawkins, since the social approbation the donor received for starting the chain clearly increases his social status (he was on TV, after all), which, at least in evolutionary times, would have translated to reproductive fitness for him and his genes.

 

The only way to truly demonstrate selfless altruism would be perform an act of sacrificial kindness (e.g. non-directed kidney donation) completely anonymously, without the recipient, or even one's own friends & family knowing about it. The ultimate generosity of even that action could be questioned by a cynic / critic of truly selfless altruism, since the positive feeling of self-esteem one would garner from such a completely anonymous act of sacrificial kindness would (presumably) be highly rewarding on its own, quite independent of any external reward or recognition.

 

Ironically, the psychophysical reward systems that homo sapiens has developed to promote (semi-)altruistic behavior would seem to preclude the demonstration of purely selfless altruism, free from the taint of any form of positive reinforcement.

 

It seems like a fair trade though, considering how well it has served humanity; allowing us to organize into reasonably effective social groups that are far larger than those formed by our primate cousins, who haven't developed such an elaborate internal reward mechanism to promote pro-social behavior towards unrelated members of their tribe or group.

 

Happy New Year everyone. Let's all resolve to be kinder in the new year, in whatever form we can muster. Lord knows our world needs more kindness right now...

 

--Dean

[Thomas G]

Dean, it seems best for your longevity, and the longevity of everyone else, to try to create the kind of society in which no one has to worry ending up on dialysis for months or years due to kidney failure. We have a radical abundance of kidneys. We are downright lousy with kidneys. Most of us have two, and most of us only really need one. That we cannot find a way to solve this problem reflects pretty poorly on all of us I would say.
 
There are some pretty difficult problems to solve, but this seems like one that is, at least theoretically, very simple to solve. In our healthcare system there are fewer than 100,000 people currently on the kidney waiting list in a population of roughy 319 million. I know that not everyone has two kidneys, but still conservatively we're talking about a supply of 620,000,000 in which we cannot find 100,000 kidney matches. That makes me ashamed really.
 
For the record I still have two kidneys, but ever since I read that article I've felt certain that I really ought to only have one.

 

 

 

The only way to truly demonstrate selfless altruism would be perform an act of sacrificial kindness (e.g. non-directed kidney donation) completely anonymously, without the recipient, or even one's own friends & family knowing about it.

 

I agree, but it gets tricky. From a strictly practical sense I think you would need at least a few family or friends to know about it. It takes some support to recover, and it could be a potentially cruel thing to do if done in secret and something went wrong. It also seems pretty impossible to do it in secret. But I agree it would be better to do it secretly with a few people in on the secret.

 

But even if you could do it completely secretly, you would know and would have a tendency to pat yourself on the back for being such a good person. You would pat yourself on the back even more for doing it secretly. In order to really do it secretly, you would have to keep the secret from yourself. To do it in such a way that one hand doesn't know what the other is doing.

 

But it gets even more paradoxical than this. If going public would lead to more donations, than in a sense one becomes morally obligated to go public. Receiving the social approbation in this case would not be a selfish act so much as it would be a constant humiliation but one that is done in order to take one for the team. I'm not sure if it is even possible to start a chain like the one above if you do it anonymously. Maybe it is, but my sense is that there is a fair amount of coordination and PR work and family discussions that go into coordinating all of this and that that would be impeded by trying to do it all anonymously.

 

​Yet keeping it anonymous is the only way to really be generous to the recipient. Without wanting to or intending to such a dramatic gift cannot help but put the recipient in an difficult position of being in debt in a way that is impossible to repay. The kinder thing to do would be to remove that obligation as much as possible by removing the identity of the donor, although even there it there would still probably be a strong feeling of debt, it would just be a bit fuzzier on who you are indebted to, maybe taking on a vaguely cosmic dimension. All the more reason to normalize and streamline kidney donations. It should just be something everyone does, sort of like jury duty. Or if we could make it more like giving blood.

 

I have no idea if altruism is possible in a strictly defined abstract sense. I'm not particularly interested in that question. I find the messiness of the concrete social problems at work, and how in one way they are really easy to solve, much more interesting.

 

At any rate I was curious to get your take. One thing that I admire about Kravinsky is that once he seems convinced that a certain course is best, he does it as if there is hardly any other option. It seems like the kind of people who are drawn to CR have a similar personality trait. CR is a pretty weird thing to do and even a lot of doctors and scientists who find (or used to find) the evidence convincing didn't practice it themselves, but there are some people who find a smaller gap between the science and the practice in a way that reminds me of Kravinsky.

Edited December 31, 2016 by Thomas G

[Thomas G]

I don't want to get political, but this boils my blood: In U.S., Undocumented People Can Donate But Not Receive Organs.

 

 

 

The 37-year-old single mother is desperate to get a transplant so she can get well enough to nurture and provide for her three children again – something she hasn’t been able to do for the last couple of years. 

But her undocumented status disqualifies her from getting on the organ transplant list, endangering her life.

Edited December 31, 2016 by Thomas G

[Dean Pomerleau]

Thomas,

 

Thanks for your thoughtful reply. A couple comments:

 

From a strictly practical sense I think you would need at least a few family or friends to know about it. It takes some support to recover, and it could be a potentially cruel thing to do if done in secret and something went wrong. It also seems pretty impossible to do it in secret. But I agree it would be better to do it secretly with a few people in on the secret.

 

Yes, complete secrecy from everyone including family and doctors would be impossible and irresponsible. Keeping it as secret as possible seems like the best one could hope to accomplish.

 

But even if you could do it completely secretly, you would know and would have a tendency to pat yourself on the back for being such a good person. You would pat yourself on the back even more for doing it secretly. In order to really do it secretly, you would have to keep the secret from yourself. To do it in such a way that one hand doesn't know what the other is doing.

 

Yes - that was my point above. We are hardwired to get an internal reward signal when we do something kind. There seems no way to give informed consent to the procedure without even telling oneself of one's own plans, and therefore opening oneself up to the internal reward signal that would naturally accompany such an altruistic choice.

 

If going public would lead to more donations, than in a sense one becomes morally obligated to go public. Receiving the social approbation in this case would not be a selfish act so much as it would be a constant humiliation but one that is done in order to take one for the team. I'm not sure if it is even possible to start a chain like the one above if you do it anonymously. Maybe it is, but my sense is that there is a fair amount of coordination and PR work and family discussions that go into coordinating all of this and that that would be impeded by trying to do it all anonymously.

 

Agreed, part of the benefit of such a selfless act would be to garner attention to encourage others to follow suit. But it seems conceivable that one could donate a kidney anonymously, and even start a kidney chain (via kidneyregistry.org) and participate in PR (also anonymously) to encourage others to do the same, or at least register to become a (posthumous) organ donor.

 

Yet keeping it anonymous is the only way to really be generous to the recipient. 

 

While I think I see your point (i.e. it's less burdensome to feel indebted to an anonymous stranger than a specific individual), I think there is a significant downside to complete arms-length anonymity for the recipient as well. My understanding is that many organ recipients feel a great deal of gratitude and would like to thank their donor, but are sometimes unable to because of the donor's desire to remain anonymous. 

 

Again it would seem like an altruistic donor could remain engage with the recipient(s) without revealing his/her identity. But of course that would boost the "warm fuzzy feeling" the donor would receive from his/her action, making it arguably less purely altruistic. As you point out, such moral calculus is fraught with difficulty, which is one reason strict utilitarianism is such a pipe dream.

 

Interestingly it seems the type of person who could hope to perform an act of pure altruism in the Kantian sense would be a utilitarian "effective altruist" with profound autism. Such a person would realize they have one more kidney than they need (as we both have), do the "moral calculus" to see that others could benefit from it, and go through with the donation without feeling a positive reward for having done so, as a result of their profound autism. The fact that such a crazy scenario would be the only way an act could be judged truly moral from a deontological perspective is why Kant's moral philosophy has always seemed so strange to me.

 

At any rate I was curious to get your take. One thing that I admire about Kravinsky is that once he seems convinced that a certain course is best, he does it as if there is hardly any other option. It seems like the kind of people who are drawn to CR have a similar personality trait.

 

I agree, Kravinsky shared many traits with CR folks. But it would seem at the same time most CR folks value their own health, well-being & longevity too highly to consider such a sacrifice to help a stranger, at least while they are alive. Sadly, I must admit I'm one of such person.

 

But I'm all for encouraging more people to register to be posthumous organ donors (like I am, and presumably you are too). One practical way to encourage this would be to do what many European countries do, and make it an opt-out option rather than an opt-in option when one gets a driver's license. That alone would increase the supply of organs tremendously, at least until self-driving car makes the death of young and middle-aged people far less common, as Slate just pointed out. Fortunately for the organ donation trade, but sadly in general, it is still many years before self-driving cars will make highway deaths a thing of the past.

 

--Dean

[Thomas G]

I'm still not sure how to embed video, but here's a good case for kidney transplants. The case is overwhelming really. This is pretty much the excuse-making state I've been in for the last ten years:

 

 

 

I had it in my head as a kind of abstract goal for years, but I kept putting off the donation. I couldn’t do it in college, since I couldn’t take the time off from exams and papers. I didn’t want to do it in my summers, when I was interning in Washington, DC. It just came to seem like such an extravagant step to take, one that I couldn’t find time for. This was just excuse-making, in retrospect. But it was effective excuse-making.

 

Edited April 11, 2017 by Thomas G

[Dean Pomerleau]

Thomas,

 

I've embedded the Vox kidney donor video below. It is an amazing story. He expresses exactly how I feel about the morals of donating a kidney. Thanks for sharing it. Truly inspirational.

 

For anyone contemplating making such an altruistic donation, definitely consider going through the National Kidney Registry, in order start a chain as he did. On average, non-directed donors start chains of 5 to 6 patients long and sometimes the chains can be much longer, like the 12-person chain in the video I posted in the opening message of this thread. Plus, according to NKR policy, any non-directed donor who ever needs a kidney in the future (i.e. if their remaining one fails) gets to go to the top of the list for a new one. This 'kidney insurance' is a benefit that no other hospital or paired exchange organization in the country offers, and that I'm sure CR Society members would appreciate.

 

--Dean

 

[Thomas G]

Thanks Dean. What is the process for embedding videos on this forum? I've tried a couple times and haven't been able to figure it out.

 

Here is one thing that caught my eye in the article: 

 

 

 

...everyone who donates a kidney has to switch to acetaminophen (Tylenol) rather than aspirin or ibuprofen for over-the-counter pain relief for the rest of their lives. Neither of those seemed like a particularly big deal; my brand loyalty to Advil shouldn’t keep someone from getting a kidney.

 

Given the potential health benefits of regular aspirin doses (like for the prevention of cancer or heart disease) this is a bit of a bummer. Not that it should be a deal breaker, but I didn't know about this.

 

Also this:

 

 

 

Indeed, there’s no good evidence that donating reduces your life expectancy at all.

[Dean Pomerleau]

Thanks Dean. What is the process for embedding videos on this forum?

 

It's simple. Just paste a URL into your message directly, of the form (with 'https' in place of the 'bttps' I switched it to so it wouldn't embed):

 

bttps://www.youtube.com/watch?v=x7EglP5A2Hg

 

quoting from the article "Indeed, there’s no good evidence that donating reduces your life expectancy at all."

 

Well, that may be true. But donating a kidney is not without its documented long-term risks (ignoring the short-term post-surgical risks).

 

According to the full text of [1], the lifetime risk of end stage renal failure (ESRD) in the general population is about 1:30 (326/10,000). Kidney donors are only about 1/3rd as likely as the general population to suffer ESRD, at a risk of 1:111 (90/10,000) . But kidney donors are not the general population, having been meticulously screened for good health. In a fairer comparison, [1] found that kidney donors have a risk of kidney failure that is about 6x greater than matched healthy non-donors (with two healthy kidneys) whose risk is only about 1:700 (14/10,000).

 

A 1:111 risk is pretty low, but certainly not negligible. That's why the NKR's 'kidney insurance' is a nice perk for non-directed donors.

 

--Dean

 

-----------

[1] J Am Soc Nephrol. 2015 May;26(5):1017-9. doi: 10.1681/ASN.2014030227. Epub 2014

Sep 25.

 

Reassessing medical risk in living kidney donors.

 

Gaston RS(1), Kumar V(2), Matas AJ(3).

 

Author information:

(1)Division of Nephrology and Comprehensive Transplant Institute, University of

Alabama at Birmingham, Birmingham, Alabama; and rgaston@uab.edu. (2)Division of

Nephrology and Comprehensive Transplant Institute, University of Alabama at

Birmingham, Birmingham, Alabama; and. (3)Department of Surgery, University of

Minnesota, Minneapolis, Minnesota.

 

The short- and long-term effects of unilateral nephrectomy on living donors have

been important considerations for 60 years. Short-term risk is well established

(0.03% mortality and <1% risk of major morbidity), but characterization of

long-term risk is evolving. Relative to the general population, risk of

mortality, ESRD, hypertension, proteinuria, and cardiovascular disease is

comparable or lower. However, new studies comparing previous donors with equally

healthy controls indicate increased risk of metabolic derangements (particularly

involving calcium homeostasis), renal failure, and possibly, mortality. We

discuss how these results should be interpreted and their influence on the

practice of living donor kidney transplantation.

 

Free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413760/

DOI: 10.1681/ASN.2014030227

PMCID: PMC4413760

PMID: 25255922

[Thomas G]

Hmmm, okay, I've tried pasting the URL before and all I've gotten is the URL. But I'll try again: 

 

I would say that the kidney insurance is a net lifetime extender. The risk for kidney failure is low, but if you are unlucky enough to have a kidney fail you are facing grim prospects going on the bottom of the waitlist. If you donate a kidney and get to move to the front of the waitlist your risk might increase sixfold, but the chances of getting a transplant would increase more than sixfold. Not that this is the right motivation for doing it, but I do think it eliminates a reason not to do it.

[Thomas G]

It worked! Not sure why it didn't work before.

[Dean Pomerleau]

Thomas,

 

Regarding the video embedding, the forum software is pretty particular about the format. It has to look exactly like:

 

bttps://www.youtube.com/watch?v=x7EglP5A2Hg (with 'b' replaced by 'h' in https). URLs with the form .../www.youtu.be/... won't work, for example.

 

I would say that the kidney insurance is a net lifetime extender. The risk for kidney failure is low, but if you are unlucky enough to have a kidney fail you are facing grim prospects going on the bottom of the waitlist. If you donate a kidney and get to move to the front of the waitlist your risk might increase sixfold, but the chances of getting a transplant would increase more than sixfold. Not that this is the right motivation for doing it, but I do think it eliminates a reason not to do it.

 

I disagree, for several reasons. First, there is risk of both death (1:3000) and serious but treatable health complications (~1:25) in the short term as a result of kidney donation, that makes the "kidney insurance" less of a good deal than you might expect in terms of expected lifespan (or healthspan) extension. Plus you have to go through several chest x-rays and CT scans to be evaluated as donor, increasing your long-term risk of cancer a bit.

 

Also, to qualify for a new kidney as part of the insurance program, yours would have to fail first, which is usually a long & slow process, with many negative (and life-shortening) side effects. Therefore dramatically increasing your risk of ESRD (by 6x) just so you can get a new kidney quickly in the off chance (1:700 for healthy people) that your kidney fails, is a very bad deal in terms of both quality and quantity of life.

 

Finally, in the unlikely event you (as a healthy person) ever need a kidney, if you are lucky enough to have a family member or friend willing to donate a kidney on your behalf, you can participate in the NKR as a recipient/donor pair, even if you aren't a match for each other. On average, such non-matching pairs only have to wait 2-3 months on the list before the recipient gets a new kidney, not dramatically longer than an non-directed donor would have to wait when placed at the head of the list. So again, the increased risk of ESRD in non-directed donors isn't worth the small advantage in wait time you'd get by going to the head of the list as an non-directed donor.

 

Of course, if you are a loner, without friends or family willing or able to donate a kidney on your behalf so you could join a paired exchange program like the NKR, you could end up waiting a long time for a new kidney since by UNOS rules you would likely go to the bottom of the deceased donor kidney waiting list. Waits of 5+ years (much of it spent miserably on dialysis and a very restrictive diet) is not uncommon in such cases. So in the end, there is a small and rather tenuous case to be made that someone might try to game the system by donating as an non-directed donor via the NKR now to (potentially) help themselves get a kidney later. 

 

Interestingly, from a utilitarian perspective, everybody wins in this latter scenario. The risk-averse loner donor gets insurance that she'll get a kidney quickly should she ever need one. It is like she made a (long-delayed) donation to herself. Or perhaps like she's loaned out her kidney for a few years to let someone else who needs it use it for a while :-).

 

But in all likelihood (110 chances in 111), she'll never need one, even though she's now down to one kidney. In the event she never does, her non-directed donation will have helped many people in need of a kidney by starting a chain. Win-win for everyone.

 

--Dean

[Thomas G]

Okay you make a good case, but it still seems like the wrong question to focus on.

 

The bigger danger here I think is that somebody I know and love will someday need a kidney and if you make a non-directed donation now you take yourself out of the pool of potential donors for someone you care about. Not that someone I know and care about is any more important than a stranger. But I would feel guilty and like I could have potentially helped and am now unable to help. And that cared for person wouldn't get to skip ahead to the front of the line.

 

It does rub me the wrong way to see the videos above where non-directed donors get spotlight. That's got to be uncomfortable. But I think they made the case the right way in the Vox video that the point is to get more and more people to do it. If donating a kidney became no big deal, more like donating blood, then there wouldn't be any hero glorification put on the donor and we wouldn't have to worry about having a loved one one day need a kidney because there would be plenty to go around. It does make me mad that there are 100k people on the waitlist in the US with a population of 310 million. How awful sick selfish and dysfunctional of a society. It mad enough to want to normalize kidney donation, even if it means the stupid spotlighting.

[Dean Pomerleau]

Thomas,

 

The bigger danger here I think is that somebody I know and love will someday need a kidney and if you make a non-directed donation now you take yourself out of the pool of potential donors for someone you care about. 

 

Yes, your concern about family or friends saying "What happens if I ever need a kidney and you've given yours away?" is one factor that likely discourages some would-be donors.

 

The NKR has an 'advanced donor' program now, that allows a donor (who is no longer considered an NDD) to designate up to 5 specific people (perhaps limited to direct family members) who would go to the top of the NRK list should they ever need a kidney. As I understand it, the current policy allows such an advanced donor to name only people who are clearly likely to need a kidney in the future - e.g. people who've received a transplant already, or who have signs of poor kidney function, or who have a hereditary condition making them likely to need a kidney down the road. In fact the NKR just published a paper about their advanced donor program. I've heard (but don't quote me on this) that the NKR is considering expanding the voucher program to allow a donor to list healthy family members as potential recipients of the kidney that an advanced donor has 'banked' should they ever need one in the future. That would be a way to alleviate the 'what if...' concern you outlined.

 

It does rub me the wrong way to see the videos above where non-directed donors get spotlight. That's got to be uncomfortable. But I think they made the case the right way in the Vox video that the point is to get more and more people to do it. 

 

I agree, it has got to be uncomfortable to be spotlighted like that, but I think Vox handled it well. The donor didn't come across as tooting his own horn, and in fact he (and his family/friends who were interviewed) went out of their way to avoid doing that - making it seem like no-big-deal. And such coverage is the only way to get the word out to the general public about the possibility of donating a kidney, and the good you can do by doing it.

 

But however well done and beneficial the coverage in terms of normalizing kidney donation, I think if I ever found the courage do donate like he did, I'd definitely want to avoid that sort of PR. In my mind it somehow cheapens the act by being in the spotlight like that.

 

--Dean

[Thomas G]

 

 

But however well done and beneficial the coverage in terms of normalizing kidney donation, I think if I ever found the courage do donate like he did, I'd definitely want to avoid that sort of PR. In my mind it somehow cheapens the act by being in the spotlight like that.

This is how I feel too. But I think I only feel this way because donating an organ is treated like such a big deal. Like sacrificing your firstborn. Only saints would do it, and only craven egoists would want the spotlight on them to show how saintly they are. But I think one reason why it is so rare is because it hasn't been normalized. It should be no big deal. Treat it like getting a flu shot to help the herd immunity or donating blood. Lots of press for lots of people could do that. Make it an ice bucket type challenge. Cold ice is uncomfortable, but kidney extraction is more uncomfortable :)

 

It seems like a big shift, but if we look at something like bullying only a few years ago barely anyone was talking about it. Now everyone is talking about it, knows why it is a problem, and is learning to flag it when they see it and change the social norms around bullying. It's not all that hard to imagine the same thing happening here.

 

Somehow it is easier to think about donating a kidney than to be spotlight. That guy in the Vox video had the right spirit.

[Dean Pomerleau]

Thomas,

But I think one reason why it is so rare is because it hasn't been normalized. It should be no big deal. Treat it like getting a flu shot to help the herd immunity or donating blood. Lots of press for lots of people could do that. Make it an ice bucket type challenge. Cold ice is uncomfortable, but kidney extraction is more uncomfortable :)

 

I don't think kidney donation could or should ever be normalized to the point of being treated the same as getting a flu shot, donating blood, or participating in the ice bucket challenge. While still modest, both the short-term and long-term risks of kidney donation are much higher. Plus it usually takes several weeks and sometimes several months to recover, not to mention lost wages, burden on one's caregiver, etc.

Morally, it is still the right thing to do if you are healthy and courageous enough, but the risks shouldn't be underplayed, since it might mislead those who aren't very quantitatively inclined, preventing them from giving completely informed consent.

Driving is one of the most dangerous activities health-conscious people engage in everyday. One accurate way to think about the mortality risk of kidney donation: Your short-term risk of dying during the surgery (~1:3000) is ~3x higher than dying in a car crash in any given year.

--Dean

[Gordo]

I think kidney donation from a healthy person is a beautiful and altruistic thing to do.  Risks of kidney donation seem low, but they are still there.  Some donors will die within 90 days due to the usual surgical risks (hemorrhage, infection).  Long term there is increased risk of kidney related problems compared to other healthy folks as Dean pointed out.

 

Couple of anecdotes:

http://breaking911.com/18-years-old-donated-kidney-now-regrets/

http://www.trinidadexpress.com/20170312/news/kidney-donor-horror#main

 

I would not hesitate to donate mine to a loved one.  I'm not there when it comes to donating to a stranger though...  I like the capitalist model truthfully (currently illegal in the United States) - if you really want to solve the problem of too many people needing kidney transplants and too few people willing to donate, you should allow payments to healthy donors - at first glance this might seem like it would give an "unfair" advantage to people of means, but this is exactly the wrong way of thinking about it - most donations come from the deceased or from a close relative, those kidneys are going to get to people on waiting lists no matter what, but what if that waiting list was dramatically smaller because everyone who could afford it purchased a kidney from the free market?  The net result would be a lot more people getting the transplants they need (including people who can't afford to pay for one!).  Also I feel like the free market would quickly adjust the price down to something almost anyone could afford - I'm sure there are plenty of people who would sell a kidney for $5,000 to $10,000, put that on a payment plan and it's not a burden to anyone, most cars cost more... if you really wanted to get creative you could even have an immigration policy that promoted kidney donation - free US citizenship to any healthy qualified person willing to donate a kidney?  Why not?  How about reduced prison sentence time for kidney donation?  If you really want to solve this problem and help people, there are simple ways to do it.

 

 

Edited April 12, 2017 by Gordo

[Dean Pomerleau]

Gordo,

 

Couple of anecdotes:

http://breaking911.c...ey-now-regrets/

http://www.trinidade...nor-horror#main

 

An increased chance of hernias, particular in the first few months after donation, is definitely another risk associated with kidney donation, as your second link describes (although the donor says he has no regrets despite his complications). 

 

The first link emphasizes exactly what I discussed above, namely that relative to the general population, kidney donors do not appear to be have an increased lifetime risk of kidney failure. But relative to healthy people, kidney donors are at an increased risk (~6x) of needing a new kidney someday.

 

These risks of donating, along with the others we've discussed, should never be ignored or taken lightly.

 

  I like the capitalist model truthfully (currently illegal in the United States) - if you really want to solve the problem of too many people needing kidney transplants and too few people willing to donate, you should allow payments to healthy donors

 

You really are a Libertarian.

 

I'll grant you that you make some good points, but once again I think we'll have to agree to disagree. Beyond the inequity issues, I've read a number of horror stories from countries in which selling kidneys is legal (e.g. Iran and India) and where coercion and forced sale by the desperately poor is commonplace. Becoming a donor for either a loved one or a stranger is a hard enough ethical decision to make without financial incentives. Adding money into the mix would make it hopelessly complicated and fraught with ethical dilemmas.

 

You may disagree, but from my perspective there are some aspects of life that should remain outside the scope of financial market forces. Organ donation is one of them.

 

--Dean

[Thomas G]

Gordo, I recommend listening to this episode of This American Life (here's the transcript) about someone who worked for the Cato Institute, tried to donate her kidney to a loved one and found it frustrating and maddening. She was disqualified from donating because she would have to hire help to run her farm while she recovered and she innocently enough suggested that her friend, who she was donating the kidney to, could help her pay the person she needed to hire. This automatically triggered an ethics issue since on a technical basis what she was suggesting amounted to selling her kidney. It's clear to me that she was just thinking out loud trying to solve a practical problem in a practical and innocent way. I'm sympathetic to her frustration and anger. Because the transplant was denied, her friend got sicker and eventually was too sick to even qualify for a transplant. He ended up dying. From one perspective you could say that they did put a price on his life and killed him by preventing this practical work-around. By trying to prevent putting a price on an organ, they ended up putting a price on his life.

 

This libertarian thought the solution was to create a market for kidneys. Abstractly this sounded like a good idea to her. Iran actually does this and she wanted to learn more about it. But when she saw what this looked like in practice, she came away thinking she wouldn't recommend it anymore.

 

What was clear in Tehran is the balance of power was clearly off in favor of the recipients.

 

My main worry is that selling organs would effectively create economic coercion, especially in a society that is already highly unequal.

 

It seems far better to me to normalize kidney donation and flood the system with an adequate supply. Having paid medical leave for the donor and their family seems an essential component that we currently don't have.

[TomBAvoider]

We all have different perspectives, and I guess that's what makes the world go around. Yes, I'm a health-nut, and I fully recognize the suboptimal outcome for a donor - kidney function declines with age (just look at GFR by age), losing one is a definite handicap. However, I do have higher priorities. And so, I would have no hesitation about donating a kidney to my wife or loved one. For that matter, I always found the obsessive focus on blood relatives a bit weird. I do not recognize the impulse to spread my - and my kind's - genes around. I have no kids, and no desire to have kids. I am supportive of my parents, because I feel a debt of gratitude - after all, they made tremendous efforts on my behalf. But I feel no compulsion to associate with memebers of my extended family - my criterion is extremely simple, would I be friends with them if they weren't relatives? If not, then I'm not going to hang out, just because they're blood relatives. Being a blood relative, beyond parents to whom I feel a debt of gratitude, is not a factor in my actions or attitudes toward them. And therefore the entire gene-promotion altruism nexus is not something that resonates with me at all, not in the least. And so, too with donating to a blood relative - I could certainly see myself donating to a dear friend, and not sharing genes doesn't factor into it for me.

 

But there is a flip side to it for me - I'm not interested in being a living donor to a stranger. And my reason has nothing to do with poor imagination - the common fault of only having empathy for those whom you know, a failure of imagination. Rather, it is because I would actively not want to donate to some people (although since I am a donor on my drivers license, it's out of my hands in case of death). I don't know a stranger and so there's a risk of it being a terrible person, that had I known them, I'd actively not donate to. People immediatly object to this, because altruism means blah, blah, blah. but I disagree. If someone is a horrible person - think of extreme examples from history - would you really want to help them out just because "altruism, humanity and higher principles"? I would argue that ethically you are obligated not to help Hitler, and in fact do all you can to obstruct them - maybe steal their perfectly healthy kidney so they'll die faster. You would promote the overall good of humanity, and therefore the ethical obligation goes the other way - toward NOT helping. I feel as strongly about that, as someone else feels about helping "everyone" principle. I strongly disagree with helping "everyone".

 

There are all sorts of terrible people out there. I don't mean Hitler level, but would you donate to a child molester just because they're your relative - promote their genes and all that nonsense? I wouldn't. And therefore, I would never simply sign up to some list as a living donor with random people as recipients (there was a scandal some time ago, where a Japanese gangster bribed his way to the top of the line for a liver at UCLA). And unlike Dean, I don't feel that that makes me a coward or selfish - I think the opposite, I think those who have no desire to do the hard work of investigating where their donation - of a kidney, of money, of resources ends up, whether it actually hurts humanity. Would you donate to a terrorist, or money to a terrorist group even if that money goes to support their innocent children? I wouldn't, because I recognize that it's an additional motivating factor ("my kids are taken care of"), and though the kids will suffer, it is he (the terrorist) who made that decision. That is why I strongly disagree with Dean - I don't feel a coward, since I'm willing to donate to a friend (and so, can overcome my fear). I don't feel selfish - because I do not wish to make humanity overall worse off by donating to a terrible person.

 

And there you have it. Gordo has his motivation, Dean his, and I mine. We're all different, and we can try to understand each other's perspectives, but ulitmately, as Dean put it - we must agree to disagree. 

[Dean Pomerleau]

Tom,

 

And unlike Dean, I don't feel that that makes me a coward or selfish - I think the opposite, I think those who have no desire to do the hard work of investigating where their donation - of a kidney, of money, of resources ends up, whether it actually hurts humanity. 

 

Interesting perspective Tom. Thanks for sharing it. I wouldn't characterize your attitude as cowardly or selfish either, just cynical.

 

I personally tend to give people the benefit of the doubt. If someone altruistically donates a kidney and starts a chain that helps 5-20 people get the kidneys they need to live a longer & healthier life, my presumption is that since most people are basically good and don't deserve to suffer, the result of that donation will be a large net positive effect on society, even if there is one or two 'bad apples' in the bunch.

 

Put another way, I strongly suspect the number of basically good people waiting for a kidney, just simply trying to get along, and do the best they can given a difficult situation, far outnumber the terrorists, child molesters or flat-out "terrible people" languishing on dialysis waiting for a new kidney so they can get back to their nefarious pursuits.

 

I thought someone like you Tom would make the more reasonable and compelling (for some) argument that strangers don't merit your kidney and/or wouldn't give your kidney the treatment it deserves since a good fraction of kidney failure patients got to the point they're at because of bad lifestyle choices (e.g. poor eating and exercise habits that result in obesity, high blood pressure and/or type-II diabetes).

 

I would buy that argument as both more sincere and rationally-based than your worry about giving your kidney to the next Hitler, Jeffrey Dahmer or Dylann Roof.

 

--Dean

[TomBAvoider]

It's possible - indeed likely - that I have expressed myself poorly. I didn't mean to say that the only people I would not donate to would be Hitler or Hitler-lite. I mean run of the mill terrible people - by my definition. I have acquaintances at work. I'm not even friends with most, but some I know to be really fine people - and guess what, I'd consider donating a kidney to such a person, even though we are not even friends. But there are also people at work to whom I would absolutely not donate - I'm thinking of a couple entitled jerks (one of whom incidentally is a Trump booster). They rise nowhere near to the level of a Dahmer or the like. They're just run of the mill terrible people with whom I would not assciate if I didn't have to (because of work). That's what I meant. Much bigger net. And yes, that net would include those who abuse their health with full premediation, and then try to make it uncomfortable for people who don't join them (here I'm thinking of a situation just last weekend, where a guy was making a big deal out of the fact that I wasn't interested in drinking his vodka). 

 

That's what I meant by "hard work" of seeing who ends up with your donation. Yes, I do believe non-deserving recipients are a not insignificant part of the population... for that matter, it's really not about Hitler. After all, Hitler was just one man. What made him terrible, were the "ordinary" people who were his enablers and his fans and his enthusiastic order-takers. I wouldn't donate to any single one of them. Remember, terrible people do end up often chosen by the majority - including Hitler. I want nothing to do with that majority. People who turned their eyes away while the Jews were lead away, or who even joined the crowd of abusers. That's the majority. And likely the majority on those lists. So sorry, but no way, no how am I going to get my kidney ripped out, so that Joe the Plumber can get an extra 10 years to waste oxygen or worse.