Regulated market for kidneys in Iran

Al Roth points to this fabulous paper on the topic. It is written by  Farshad Fatemi at the Sharif University of Technology. It is one of those different papers you would just love to read. It comes as a real surprise that Iran has a well developed kidney market for n20 years.

Some basics first:

The most effective treatment for End-Stage Renal Disease (ESRD) is a kidney transplant (Renal Replacement Therapy: RRT). The only alternative treatment is dialysis and RRT is the only way for the patient to live without needing dialysis on a regular basis. Some researchers predict that the number of patient with ESRD will reach 2 million worldwide by 2010 (Nwankwo et al., 2005). In the US, it is predicted that more than 40% of patients may die while on the waiting list (Matas, 2006). Xue et al. (2001) predict that more than 95,000 patients will be on the waiting list for a kidney transplant by 2010; the figure was more than 65,000 in 2007.

 There are two sources for a kidney transplant, cadaveric kidneys and kidneys from the live donors. Cadaveric kidneys can be harvested either from a brain-dead patient (whose heart is still beating) or cardiacally dead patient; the latter is considered to have a lower quality. Since a normal person can live on just one kidney, she can decide to donate one of her kidneys. The incentive to donate a kidney can be altruistic or obtaining money by selling a kidney. Altruistic kidney donation is mostly a case for emotionally related donors where the donor donates her kidney to either a relative or a close friend. In order to match a kidney from a donor with a potential recipient, their ABO and RdH blood types as well as tissues should be compatible.

He points to studies which show live sources have a better quality than cadavers. 

While the 10 year graft survival probability for live kidneys are 54.7%, the same figure for a cadaveric kidney is only 39.2%

Efforts are being made to increase kidney supply in the world. Either countries have opt-in or opt-out system:

In order to increase the kidneys available from cadavers, two different systems adopted. The most popular one is the opt-in system where people, who wish to donate their organs after their death, sign up to the scheme. For example it is estimated that in the UK one in five people (more than 13 million) signed up to the scheme (Boseley, 2006). This voluntary scheme is run in many countries but usually the donor’s wish is not enough to guarantee that the donation will take place after the donor’s death, since in many cases the consent of next of kin is also required, either by the law or informally. There are campaigns for encouraging organ donations in many countries. However, the shortfall of the number of organs available through this system in recent years is an issue;

The alternative system is the opt-out system which is practised in some European countries, including Spain and Austria. In this system, the donor’s consent is presumed and a person needs to opt out the scheme if she does not want to donate her organs after death. UK also considered switching from opt-in system to this system, where it is under legal and political consideration (Wintour, 2008)

One legitimate argument against this system is that presumed consent means that the state is considered the owner of the body of deceased person. Some consider this to be a problematic assumption (Becker & Elias, 2007). Abadie & Gay (2006) develop an economic model to investigate the effect of presumed consent on the donation rate, their model predicts that the opt-out system may have a positive or negative effect on the rate of donations comparing to opt-in system depending on the model assumptions, however, their empirical analysis for 22 countries over a 10-year period shows after controlling for other determinants, presumed consent legislation has a positive and significant effect on organ donation rates.

Some countries have adopted a different definition of death to get better organs:

Another measure to boost the number of donations is an expansive legal definition of death, such as Spain uses, allowing physicians to declare a patient to be dead at an earlier stage, when the organs are still in good physical condition. This is controversial and has been mentioned as the main reason for individuals not wanting to participate in organ donation schemes.

As a result of this procedure, putting extra effort and resources in procurement process, and the presumed consent system, Spain has one of the highest rates of cadaveric donations in Europe. (See Table A1 in appendix) In summary the high rate of kidney donation in Spain is due to presumed consent policy, enhanced infrastructure for donation, expansive legal definition of death, and more road accidents. However there has been no study to estimate the contribution of each factor.

How about the market in Iran? Live donation is legal across most countries but selling kidneys is legal only in Iran.

In Iran a regulated system for kidney donation with monetary compensation was introduced in 1980s. Under this regime the donor receives a monetary compensation from the recipient and enjoys additional monetary and non-monetary bonuses from the government. The system has been criticised harshly (i.e. Harmon & Delmonico, 2006 and Zargooshi, 2001) as well as receiving some warm support (i.e. Daar, 2006 and Mahdavi-Mazdeh et al., 2008) both inside Iran and internationally. Ghods & Savaj (2006) is one of the most recent papers which tries to reason in support of the system by highlighting the benefits and answering some of the critics. Data show that in 2006 1858 kidney transplantation took place in Iran. 13% and 12% of these transplants were harvested from cadaveric and emotionally related live sources respectively and the other 75% was from unrelated live donations

The author adds there is lot of discussion in medical journals but nothing much in terms of economic perspective. Infact there are some false things associated with Iran kidney market that govt does not allow cadaveric donation on religious grounds.

There is an excellent literature review of kidney and organ markets. There is research on pricing kidneys and organs:

The early discussion on the economics of a market for human body parts goes back to 1970 when Titmuss argued that buying and selling blood has an adverse effect on the quality of the blood (Titmuss, 1997). Titmuss compares the data from the British system (where paying for the blood was illegal) with the American system (where blood donors got paid) and argues that the latter had a lower quality of denoted blood. Titmuss points out that a significant fraction of the American blood came from individuals with hepatitis and other diseases that could not be screened out, and the blood given under the British system tended to be healthier. Titmuss also argued that monetary compensation for donating blood might reduce the supply of blood donors. This hypothesis often referred to as crowding out effect.

Becker (2006) argues that even if Titmuss was right about the quality of the blood, the American system provides more blood per capita than British system. This means that the crowding out effect is not present. However, the quality of blood is not a major problem now, since the modern screening methods can guarantee the blood is not contaminated.

Superb again. And how did Iran end up developing a kidney market?

The 1979 revolution in Iran was followed in 1980 by an eight year war with Iraq. Dialysis equipment was scarce because of economic sanctions and lack of funds for imports (Nobakht & Ghahramani, 2006). As a result of these events, nephrologists were encouraged to perform kidney transplants. At the beginning, the process relied on few cadaveric kidneys available, along with emotionally related donors. But the large number of patients on the waiting list forced the authorities to establish a regulated market for living unrelated donations. The efforts of charities, established and managed by dialysis patients and their close relatives, helped to develop the market. Table 2 shows a clear picture of the development of kidney transplantation in Iran. It is notable that over a period of 10 year (1996-2006) the rate of cadaveric and live donation increased by 35.1% and 8.1% annually. Cadaveric transplants accounted for 1.6% of total number of transplantation in 1996, this figure reached 13.1% in 2006.

Superb stuff. Read the paper for how there are various institutions that enable this market to perform. There is  market-making as people are matched for blood type, emergency cases etc. Pretty useful stuff.

Some lessons for countries that have black markets for organs which are corrupt and inefficient. What a paper!