Jeffrey Punch has been a transplant surgeon at the University of Michigan since 1986. He posted a critique of the Organ Keeper web site on the bit.listserv.transplant Usenet, which serves mostly as a support group for transplant patients and their families. Dr. Punch's critique is provided below, along with the Organ Keeper response, Dr. Punch's rebuttal and the Organ Keeper rebuttal.
Organ Keeper: If your intent was to change my opinion, why didn't you email the message to me or submit it to the Organ Keeper Guestbook? It was only by chance that your posting to the transplant Usenet was brought to my attention. It seems that your main objective is preaching to the faithful.
Punch: Actually, it was sent to you originally, but since you didn't respond, I posted it in a public forum. By the way, if you really intended to discuss the issues as you claim to, why didn't you send me your rebuttal or post it in the same forum?
Organ Keeper: Okay, you can settle this petty dispute by forwarding to me the original email message you claim to have sent. In response to your question, I knew that you would eventually see my response on the Organ Keeper web site. Furthermore, my response was directed toward the public at large, not just members of the transplant community who would have flamed me tirelessly.
Organ Keeper: A terrorist is one who systematically uses violence in order to coerce a population or government to grant his demands. The Organ Keeper web site does not recommend or condone violence as a means of achieving political goals; it is dishonest for you to suggest otherwise. Next, the purpose of Organ Keeper is not to discourage donation, but to promote compensation for those who provide a scarce and valuable resource. I would like to see today's Organ Keepers become tomorrow's Organ Providers.
Punch: On http://www.organkeeper.com/fairness.html you state: "Until the system becomes more fair, individuals can opt out by becoming Organ Keepers. If enough individuals become Organ Keepers, this will force lawmakers and policy makers to develop a system that is fair to organ providers and their families." Are you joking? How can you possibly say that the purpose is not to discourage donation when you are advocating "organ keeping"? At the very least, in the short term your plan would decrease donation. The people that die waiting in the short term while lifesaving organs are being "kept" by the corpses of the dead keepers do not die violent deaths, but a more unpleasant lingering, painful death. Do you not see the parallels with terrorism? How else do you think Organ Keepers will "force a change" unless it is by decreasing the supply of organs? Your plan is like burning down preschools full of children until the government finally passes a law requiring smoke detectors in preschools. In the long run, it could save more lives over the next few centuries. One just has to be willing to intentionally toast a few toddlers to make one's point.
Organ Keeper: Congress could legalize donor compensation tomorrow, which in my opinion would immediately increase the number of people willing to be organ providers (including me). Anyone wanting to donate for purely altruistic reasons would still be free to do so. How many more people would die? Zero. How many more people would live? Let's find out. In response to your "smoke detector" analogy, the current system is akin to soliciting donations of used smoke detectors, but prohibiting preschools from buying them when the number of donations falls short.
Punch: No. They are not refusing to donate under the guise that it will increase donation in the long run. The vast majority of people are simply ignorant of the truth about donation.
Organ Keeper: That is exactly why I created this site, to publicize certain aspects of "the truth" that most transplant-related sites totally ignore. Perhaps many of those who are inclined to donate under the current system will now have second thoughts.
Organ Keeper: I do not claim to have invented or improved upon the concept of paid donation. However, I am proud to say that Organ Keeper is the only web site devoted to promoting donor compensation, versus hundreds of web sites that support the current system of procuring and allocating human organs. As far as studies go, a paper study can be found to support almost any position. But where in the US or any other advanced country has organ donor compensation ever been tried? Blood donors are paid in cash or refreshments, public television donors receive tote bags, and campaign donors get private audiences (or more). Why? Because everybody knows that the promise of small rewards stimulates altruism. I believe that this universal practice can be applied equally to organ donation.
Punch: Altruism, by definition, cannot be stimulated by reward. But that is merely a semantic point. The compensation for living people to take time out of their busy lives and wait for the plasma to drain is just that, compensation. There is no cost to the donor for donation after their [sic] death; therefore, nothing can be "compensated". Study after study, paid for by people that hoped to find out that paid donation would increase donation overall, have concluded that an offer of compensation is more likely to have the opposite effect--to decrease donation. People refuse to donate for many reasons, among them the concern that the "value" of their organs will encourage a premature declaration of death. Clearly, introducing value in the form of payment to one's estate would exacerbate this concern.
Organ Keeper: Public acceptance of paid donation would inevitably increase if safeguards were instituted to prevent abuses. Aside from that, paid donation is just one of several alternatives outlined in the Organ Keeper web site. For example, how many studies show that granting "preferred status" to those who agree to donate will likely decrease the supply of organs? What is so objectionable about the concept of preferred status?
Organ Keeper: Your first comment is a red herring. At present, the only countries that allow paid donation are those that lack the advanced medical infrastructure needed to ensure high transplant success rates. They also lack effective legal systems required to enforce contracts between organ donors and recipients. Next, if financial incentives can influence even a few people, what's wrong with that? It's like paying those who have a rare blood type to donate while others give away blood for free. You admit that "some system of exchange" might be good. Why not be more specific? It should be noted that even free markets require regulations, although one should not assume that regulations must be imposed by government. Trade associations can regulate themselves quite effectively, especially when backed up by courts that will enforce voluntary agreements among association members.
Punch: Your statements are factually untrue. Paid donation is not illegal in several eastern countries. A recent paper (Clinical Transplantation 1997: 11: 536) on commercially motivated kidney transplants documented a success rate comparable to that obtained by standard cadaveric donation. Unfortunately there was a 5% rate of new HIV infection among recipients. When people are motivated by money rather than altruism they are apparently more willing to lie about their medical and sexual history. This is a major practical problem with paid donation. Not to mention the fact that a program to pay family members for their next of kin's organs is a potential motive for murder. People are murdered for much less than the price of a standard funeral. As I said, for years people that seriously care about donation have wanted to figure out a way to provide payment for donation in order to increase the supply of organs. The response by policy makers has always been to request data suggesting that paid donation would function to increase the organ supply. To date, the studies have shown overwhelmingly to the contrary. As far as what sort of compensation I think might be appropriate, I think I could support a limited trial of directly reimbursing a reasonable amount of funeral expenses to the funeral home in return for consent to donate. Potentially this sort of token reimbursement would not be perceived as threatening by the donor's family.
Organ Keeper: I was unaware of commercially motivated kidney transplants in certain countries. Regarding HIV infections, a simple blood test by the patient's personal physician (who does not have a financial interest in the transplant) would eliminate that concern. Furthermore, even a 5% chance of contracting HIV may be an acceptable risk for many end-stage renal disease patients, especially those who can afford drugs that suppress the AIDS virus. Overall, the facts seem to indicate far more benefits (i.e., life for the patient, financial security for the kidney provider) than drawbacks (slight chance of the patient contracting a nasty disease). I find laughable your suggestion that people will murder family members to get compensation for their organs. One's organs are usually worth a small fraction of the value of one's estate, so why not just murder to get the estate? I am glad to see that you support a form of paid donation, although you carefully avoid using the term. Please reconcile this with your statement above that studies "have concluded that an offer of compensation is more likely to...decrease donation."
Organ Keeper: You are disingenuous to state that donor compensation does not work, considering that it has never been tried in any advanced country. Because of the many uncertainties, this web site offers a palette of options rather than recommending a single approach. The best system may be a combination or variation of the ideas within. Contrary to your statement, Organ Keeper has already changed the way thousands of people view the human organ industry. It has done so by moving this discussion beyond the cloistered world of philosophers and ethicists, into the accessible world of the Internet. For the record, John Galt is the hero of Ayn Rand's magnus opus, Atlas Shrugged.
Punch: Admittedly the statement that compensation does not work was overstating the known evidence. However, I stand by the statement that the available data indicates [sic] that paying donor families outright is likely to decrease donation. In support of the paid donation concept you quoted Carlstrom and Rollow on one of your pages. I found it interesting that in footnote 16 they state that "The extent to which payments would elicit donations is unclear". Having admitted that in the fine print, it is preposterous that they conclude that "Additional incentives, including monetary, are required if cadaveric organ donations are to increase substantially." The Washington Post [sic, Washington Times] columnist similarly advocates paid donation without any supporting argument for why donation would increase. It makes sense only to those that have not researched the reasons why people don't donate.
Organ Keeper: Let's admit that nobody really knows what will happen when people are given incentives to donate. That is why there should be trial programs examining alternatives to the current system, which we agree is far from perfect.
Organ Keeper: There is in fact a very high cost to donation. It is the money that someone is willing to pay for an organ but is prevented from doing so by threats of legal sanction. In a process referred to by economists as "shifting rents," some of this money goes into the pockets of transplant surgeons and other human organ industry employees. The nonliving donor will not suffer financially, but his heirs certainly do.
Punch: It is only "rent shifting" if offering to pay donor families would increase donations. And by the way, do you think the transplant surgeons would make more money if there were more organs to transplant, or fewer? The limiting resource to doing more transplants is more donors.
Organ Keeper: You have it all wrong. Rent shifting is a natural byproduct of rationing and monopolistic power, both of which characterize the current allocation system. Answering your question, transplant surgeons deserve whatever they can get in a free market, as opposed to the present unfree nonmarket. Furthermore, average transplant costs would be lower if there were more available organs AND more price competition among transplant centers.
Organ Keeper: I have no objection to the fact that physicians and drug companies profit from their skills and products. What I find objectionable is that the donors and donor families who make it all possible are legally excluded from making a dime off the $8 billion per year U.S. transplant business. With an annual salary of $120,098 (as reported by the University of Michigan), Jeffrey Punch is a prime example of someone who benefits greatly from the current system. It is no surprise that he is a vociferous opponent of any proposal that might shrink his slice of the $8 billion pie. By the way, Jeffrey Punch is paid almost as much as the Governor of Michigan! His reference to "the grumbling herd" went right under my head.
Punch: I am a salaried public employee. I think my compensation is fair given what I could make in the private sector should I so choose and given the hours I work. Have you seen the figures for the average private practice income of a surgeon with three specialty certifications and 14 years of training?
Organ Keeper: We should all thank you for being content earning a salary much lower than that of your more materialistic colleagues. The poorest families who consent to donating the organs of their violence-stricken children are especially grateful that you have forsaken a large fortune in favor of a small one. I do not know the average transplant surgeon's salary. Please tell me so I can include it on the web site.
Organ Keeper: In his final paragraph, Jeffrey Punch finally reveals his true feelings and motives. Rather than engaging in an honest intellectual debate, in an emotional outburst he crudely attempts to demonize the creator of Organ Keeper. Perhaps Dr. Punch should consult his colleagues in the Division of Psychiatry on how to control anger. Feel free to contact Dr. Punch using the email address and phone number he provided below.
Punch: Watching my patients that desperately need transplants die tends to make me grumpy. Especially when I find someone encouraging people to not donate. One of my pet peeves is when a newcomer turns a limited amount of energy to the topic of organ donation and decides there are quick easy fixes. Forbes magazine did this a few years ago. Then, when they find out that their assumptions were wrong and that logic and economic theory won't always tell you how the public will behave, they lose interest and go on to some other cause. Either you and I are on the same side: trying to increase donation, or we aren't. If we are on the same side, I am more than willing to help you promote donation if you change your tactics. I cannot condone holding those currently waiting hostage in the hopes of a better system at some point in the future. All you are succeeding in doing is persuading gullible individuals that they shouldn't donate since they won't get anything for it. The eight year old we buried last week would have preferred that you didn't do that.
Organ Keeper: One does not need a degree in medicine or bioethics in order to understand the issues involved. Before going online, I spent six months researching organ procurement and allocation using the Internet, medical journals, etc. The ideas presented are a collage, gleaned from many sources and assembled to the best of my ability. I have not lost interest in the cause; this site has been online since April 1998 and will continue indefinitely. With respect to being on the same side, I do not want to be allied with someone who confuses intellectual honesty with murderous intent.
Jeff Punch
Division of Transplantation
University of Michigan
jpunch@umich.edu
734-936-9623
Organ Keeper: I have responded to virtually every email sent to me, and I always sign my true name. I want people to focus on the message, not the messenger. Those around me are fully aware of the Organ Keeper web site. However, if it is so important for the world to know, my name is Duane Horton. I am an engineer, living and working in Rhode Island. If I, my wife or two children should ever require an organ transplant, I hope that there will be a system in place that maximizes the likelihood of obtaining the needed organ. For now, that system is only a distant dream.
“[W]hile ... his "salary" is ~$120,000, he is likely paid considerably more. One of the aspects of academic medicine practiced at state-affiliated medical centers is that while the physician may be a state employee, he or she is also a member of an affiliated clinical practice plan which is supported by professional fees. As such, based on national estimates for physicians with his certifications and experience, the quoted $120K figure is probably only one-half to one-third of his income.I do not have any axe to grind with physicians or Dr. Punch; but as a health care management consultant and attorney, I am well aware of the devices used to compensate individuals in health care. While Dr. Punch's income is a private matter between him and his employers, his response [above] would suggest to some readers that he only brings home $120K per year. Deservedly, transplant surgeons are paid considerably more than that.”
Transplant surgeons certainly deserve high salaries. However, the issue at hand is whether organ donors and donor families, without whom this huge industry would not exist, deserve nothing in return for their valuable contributions. In contrast, Dr. Punch and his colleagues are paid princely sums. As an engineer, I made approximately $59,500 last year. Please tell us, Dr. Punch, what was your total earned income for 1999?
