“Being a good surgeon, that was always my dream,” he wrote. He explained his ayurveda degree: His high school exam scores had been just shy of what he needed to get into medical school. He bragged about his self-taught skills. “I helped recipients get well, and in turn they helped donors lead somewhat better lives.”
Kumar’s defense echoes arguments made by those proposing legalization of the kidney trade, such as Oxford ethicist and philosopher Janet Radcliffe Richards. In a 1996 paper in the Journal of Medicine and Philosophy, Richards wrote that it was a fallacy to view the trade in terms of the “greedy rich” and the “exploited poor.” Such misplaced moral indignation, she wrote, “leave[s] behind one trail of people dying who might have been saved, and another of people desperate enough to offer their organs thrust back into the wretchedness they were hoping to alleviate.”
The debate is not an easy one to settle, as I learned when I met with Govind Verma (not his real name), a father from Delhi whose 8-year-old son, Rahul, received a transplant from Kumar in January 2008. After I repeatedly rang the doorbell of his house one morning, Verma appeared on a second-floor balcony and nervously looked down at me, then reluctantly ushered me into his living room. In a tremulous voice tinged with guilt, he told me that his son’s kidneys had failed at age 5 from infections caused by urinary reflux. The boy hardly went to school. In the fall of 2007, Verma took him to Chennai in hopes of getting a transplant, but the surgeon was arrested, and kidney sales in that city were stopped. A family acquaintance sent him to Kumar, who, out of sympathy, charged a discount price of $12,000 for the job. Rahul no longer needed dialysis, Verma told me, and was seeing friends again. “I had no choice,” Verma said. As he led me out to the gate, his eyes shone with tears. “There were times when I thought of killing myself,” he said, motioning with his hand to suggest jumping from the balcony upstairs.
Rahul’s life may have improved, but none of the donors I met in Meerut or Mumbai seemed to have climbed out of poverty. Rakesh, a homeless man in Meerut, said the $1,000 he got after being tricked into giving up a kidney allowed him to buy drugs and alcohol for two months without having to work. Along with two other homeless donors, he was living in the compound of an abandoned government building. He told me that he was too ashamed to go back to his village.
What I found is borne out by Madhav Goyal, a Johns Hopkins doctor and bioethicist who interviewed more than 300 Indian men compelled to sell their kidneys in the mid-1990s. The bulk of their fees—an average of $1,070—was used to settle the debts that had driven them to make the sale in the first place. The rest was gobbled up by basic needs like food and clothing. Using the cash to start a small business, such as a tea stall or an auto-rickshaw service, remained a pipe dream.
Free-trade proponents argue that donors would fare much better under a government-regulated program, which could provide incentives such as lifelong health insurance or college tuition for the donor’s children. Scheper-Hughes counters that the concept amounts to a “kidney tax” on the poor, exacting an unfair price for basic services and opportunities. She points to Iran, which has allowed kidney donations for cash since 1988, virtually eliminating the waiting list for the organ. A survey of 500 Iranian donors who received $1,200 and a year of medical insurance from the government found that their quality of life, as measured by factors like financial condition and psychological health, remained poor three to six months after the donation. “Nobody denies that most donors live in extreme poverty; many are drug addicts,” says WHO’s Noël. “There is candid recognition in Iran now that the scheme is working well only for the recipients.”
Indian officials find it hard to imagine a financially compensated donor program that would be free of exploitation. Singh, the CBI lawyer, says that initially, recipients might pay the price set by the government, but soon they would start looking for bargains. It would amount to giving the likes of Kumar a hunting license, he argues.
Sale of an organ will always be “an unequal transaction,” CBI director Vijay Shankar, who has since retired, told me. Legalizing the trade would further institutionalize India’s glaring social inequalities while providing an unfair advantage to rich nations like the United States (see “A Transplant Tourist,” below). His words echoed in my head the next morning when I stepped outside my hotel in Gurgaon, where guests were eating a breakfast of aloo parathas, omelets, and juice. At the hotel gate, a man from the shantytown across the street was sharpening knives for the hotel’s kitchen, a weekly assignment that earned him $3. As sparks flew from his grindstone, he told me that even with Gurgaon’s booming economy, he was struggling to feed his family. When he rode off, I imagined how life would change for him if he sold a kidney.
A TRANSPLANT TOURIST
When H. Q., a 46-year-old accountant, was diagnosed with end-stage liver failure at Mt. Sinai Medical Center in New York City, he was given a single option: Wait for a new liver in the United States, where thousands of others were already queued up ahead of him. A year later H. Q.’s illness had worsened, but no donor had emerged. That is when friends suggested he pay for a transplant without the wait, by going to China.
Desperate, H. Q. became a transplant tourist, securing a liver—probably from an executed prisoner—in 2004. Yet the procedure left him with a bacterial infection so severe that the new liver, too, was irreparably damaged. Ultimately, H. Q. needed a second transplant to survive.
In all, more than 100,000 Americans are waiting for transplants across the range of organs—heart, lung, kidney, intestine, pancreas, and liver; some 12 percent will die before their turn arrives. As a result, hundreds of Americans underwent transplants abroad between 2004 and 2006, according to the Scientific Registry of Transplant Recipients.
“Transplant tourism from the United States is growing in direct correlation to the organ shortage,” says Mt. Sinai liver doctor Thomas Schiano, who published H. Q.’s case in Liver Transplantation in 2010. “The bottom line is that governments have to find solutions to provide transplants to those who need them,” Luc Noël of the World Health Organization says.
H. Q.’s botched procedure highlights the murky ethics involved. Did his Chinese donor give permission? Did the lure of profit from an organ sale hasten an execution? Doctors at Mt. Sinai had to decide whether to provide a precious replacement organ to someone who had already bought one under this kind of cloud.
“It’s a tough call, but we were dealing with a patient who was going to die,” Schiano says. “The ethics committee decided it would be wrong to withhold the standard of care that we would normally provide, so we proceeded.”