Sally Satel, Politically Incorrect MD, Part II

GUEST: Sally L. Satel, M.D.
VTR: 12/14/2006

I’m Richard Heffner, your host on The Open Mind.

And last week I introduced today’s guest, Dr. Sally Satel, as the Washington DC practicing psychiatrist and Resident Scholar at the American Enterprise Institute who has written such wonderfully provocative books as PC, MD – How Political Correctness is Corrupting Medicine, and One Nation Under Therapy – How The Helping Culture is Eroding Self-Reliance, that book authored with Christina Hoff Sommers.

Now, there’s nothing “politically correct” about Dr. Satel, and I would like her to illumine that point further in reference to her attitude toward buying and selling human organs. You have a stake in that question …

SATEL: Oh, yes.

HEFFNER: … don’t you?

SATEL: Steaks and Kidneys, it’s the name of a book …

HEFFNER: Don’t …

SATEL: … I just came out.

HEFFNER: Don’t joke.

SATEL: Out very much. No it is not funny at all. And yup I do have a stake in it. I ended up getting one … a kidney last March … and although I had known a little bit about the system and the problems with it … this very long waiting list that people go on for a cadaver donor mostly …

HEFFNER: What are the numbers?

SATEL: I hadn’t thought about it that much until it … you know … struck.

Well, you can go on the website of UNOS … United Network Organ Sharing network, which keeps the national list through HHS. And as of yesterday, I believe, 94,000 people were waiting for an organ, that meant a kidney or a liver, a heart, lung, then you get into pancreas and even intestines. But the … by far kidneys dominate the list. There are about 73,000 people waiting for a kidney, and just last month … or six weeks ago it was 68,000. So it went …

HEFFNER: So the numbers …

SATEL: … up 5,000 that quickly. And, in fact, if you, you know, plot out the, the demographic trends, the supply and the demand diverge more each year. We rely on deceased organ donors … people who’ve tragically been killed in car accident, or violent death … which sadly produces some of the … become the better donors because, you know, for example, if you’re shot in the head …and you’re young … your organs are largely well preserved. In fact, as a morbid aside, a colleague who worked in New Orleans was telling me that when they changed from regular guns, you know, one shot pistols to automatic weapons, the supply of organs went down because people were then killed in such a way that, you know, their whole body was …

HEFFNER: Perforated.

SATEL: … affected. Yeah. But … and we also rely a lot … almost … last year it was almost half and half … living donors versus these deceased donors. And, you know, the, the numbers are chilling. Every day 11 people die because they can’t get a kidney and 18 people total on the list. And, as I say, it’s getting worse and worse. Some people get so sick while waiting that they are taken off. Every one … pretty much is on dialysis …

HEFFNER: Why take them off?

SATEL: Oh, because that means they would be such a bad surgical risk, you’d waste an organ and these are such precious resources.

In New York City the wait is up to 8 years. And that is … that’s … for a lot of people if they’re over 50 or 60, who are on dialysis, that will, that will outlast their lifespan on dialysis.

So it is a tragic problem. Frankly, ever since we’ve been doing organ transplants, the first one was in 1954, that was identical twins at Harvard. It was really quite amazing.

But the first cadaver one … that was in 1962, and as they perfected it … probably about 1980 it became more routine because immunosuppressive drugs became so much better. From day one there’s shortages. And …

HEFFNER: And what would you do about that?

SATEL: Well, I really think that there’s no question but that we have to start experimenting with incentives for donors. We’ve really reached the limits of altruism. Which is wonderful, that’s why I have a kidney. My wonderful friend Virginia Pastoral who’s a columnist for the Atlantic Monthly and just a … well, a tremendous person … there’s almost inexpressible gratitude. You can imagine.

But thank goodness she came along. And she came along after I was rather desperate. I ended up going online trying to find a, you know, kidney. And thank goodness a third person just told her that I had this problem. We weren’t even all that close, though I had always admired her greatly … she lives in another state.

So she came through for me. But not everyone has a friend or a family member. A lot of times it’s just … a family member would love to give you a, a … part of their liver … which is something you can also give.

As a living person you can give part of your liver, clearly a kidney … people can live perfectly well with one … and your liver regenerates, actually, so … and you can give part of a lung. But those last two, liver and lung … living donations … are, are complicated.

But a kidney procedure is … obviously it has some risks, but negligible … doesn’t shorten one’s life in anyway. But, I was saying that someone might want to give you a kidney, but part of their liver, but they have diabetes … so they can’t do it. And if, if they’re in your family, there is a good chance they might have the same condition you do. Or people are the wrong blood type. So, you know, there are just reasons why people can’t. Bottom line is there’s a significant shortage and I think the … we have to start looking seriously into motivating people to donate by offering them some kind of valuable … what’s called “valuable consideration” in the law.

HEFFNER: Well, you mentioned the phrase “bottom line” and that is what people say in opposition to the notion of buying, paying for organs, isn’t it? How do you respond to it?

SATEL: Well …

HEFFNER: I don’t know what I think, so if you’re gearing yourself up to protect yourself against someone who’s hostile …

SATEL: Oh, no.

HEFFNER: … to the idea. I don’t know.

SATEL: Yeah. Well, a lot of people don’t know, and they never thought about … who would think about this before, you know, unless you’re personally touched by it, you really give it … maybe you give it some academic thought if you read about it in an article, but … and, and I certainly acknowledge that … you know a whole lot of people … excuse the pun, but kind of have a visceral reaction to the idea of buying and selling.

Well, I’d spell out what, what a potential market could look like. But I also try to talk with someone about what it is exactly, you know, that, that bothers them about it.

I mean some people will say, you know, well it, you know, it commoditifies the body and there’s just something repugnant about that. Really inchoate, but repugnant. And I, you know, acknowledge that. It’s … we certainly are talking about the involvement of, if not cash, then … some kind of … some kind of benefit that a person would want … a tax deduction … tuition voucher for children or something like that. But, you know, I would say, “All right, well maybe you find that offensive, that the whole notion somehow bothers you”, and I, I guess … I do respect that … I, I … but, I’m jus as repulsed, if not more by the idea that there are these 11 people dying a day, you know, that we could save. And essentially why should your … on what grounds would your sense of repugnance trump mine?

Well, you know, it really doesn’t and the ideas to accommodate both of us, people whose minds will just never be changed. I mean they’re, they’re good people, but this is how they feel and they feel strongly. And, so I would argue … “Well, if, if, if that sense of, of distaste can’t be offset … you know you can’t just … basically almost everything in bioethics is trade-offs … and if, if you cannot … if this is not a sustainable tension to you, that you don’t like the idea of it, but you realize the good is so much better … if you can’t negotiate that kind of symmetry, or asymmetry, then, then fine. Then let us have our preferred systems in parallel. And there would be an altruistic system … there always would be. And then there’d be one for … incentives. You know I’m not talking about an E-bay system. This is another thing that people think, they think “Well only the rich will be able to get kidneys.”

HEFFNER: Well, what about that argument … because once I knew that Sally Satel was coming here and once I knew, as I began to read what you’ve written, that you’ve had this experience, I knew I certainly didn’t want to leave it out of our discussions. I began to ask around what people thought about this …

SATEL: MmmHmm.

HEFFNER: And … not distaste, but the question of rich and poor ….

SATEL: Sure.

HEFFNER: … was the one that came up …

SATEL: And that …

HEFFNER: … most often.

SATEL: Yes. That a common one, but there’s the, the commodification, then the exploitation and then the injustice. And so we’ll get to the exploitation problem, but, but now the, the unfairness of it, the imbalance.

Well, that’s certainly true, if, if you had a system that was essentially private contract … like surrogate mothers. Only rich people get to engage a woman to have their baby. But, in this particular situation that’s not the system I’m advocating. I would actually have the government be the purchaser. And so there would be no distinction between everyone waiting on the list. The government would buy their kidney and the money that the government could use is there in abundance because it’s already going for their dialysis treatments. Which cost between $66,000 and $75,000 a year, every year …

HEFFNER: MmmHmm.

SATEL: … a person’s on dialysis. Some economists have done a kind of pricing analysis of what a kidney might be worth and the, the prices range from $15,000 to $50 … personally I like the idea of $40,000. But …

HEFFNER: How, how do you …

SATEL: How do I come up with that? No …

HEFFNER: Any figure.

SATEL: Just …

HEFFNER: Fifteen. Forty. Fifty-five.

SATEL: For me … to me it’s just, it really is just intuitive. But, but if you had an economist on, I’m sure he could show you how he priced it. That’s not my expertise.

But the point is to offer something that’s valuable to people are taking a risk and giving something of enormous value. I mean … the irony here is that every person in the whole transplant apparatus gets paid and gets paid a lot.

The surgeon does. And, of course, he should. The, the agency … if we’re talking about cadavers, that get the organs, get paid. Obviously the hospital gets paid. I mean and, and, again, all of these people should.

But why … but the one person … the one, the one figure in this chain who’s providing this thing of enormous value and again, taking a personal risk … they, you know, get nothing. Which is an irony.

But again I’m not … back to your original question which would it … disproportionately benefit the wealthy? No. Because everyone, almost everyone waiting for a kidney is already on dialysis. And that is a government entitlement. So they’ve essentially got a voucher, really … you’ve got your Medicare, Medicare voucher that’s paying this … about $70,000 a year … just pay the donor some amount … and I’m not even talking about cash payments, either. I feel … I like the idea of offering people something that would be of …

HEFFNER: Value.

SATEL: … value to them. Let’s say, as I said before, maybe a tax credit, or 401(k) deposit.

HEFFNER: Why, why are you pussyfooting around about this?

SATEL: Why? Or, I was going to say cash payments over time. That’s just a compromise position.

HEFFNER: But a compromise between what and what?

SATEL: Oh, a compromise between not doing it at all and giving a check, you know. And I don’t mind, I don’t mind. I’d give you a check. I think if you’re … if, you know, are competent enough to make a decision to give a kidney and again, we would talk about a several month long education period. Make sure you understand the risks. Make sure it’s informed. Make sure no one’s coercing you to do this. Give you ample time to pull out, if you … you know, if you want.

Someone who goes through that conscientiously and, and is a free agent, I think is probably competent to handle a check.

HEFFNER: But at the moment, that is not permitted.

SATEL: Oh, no. It’s against the law. It’s against the law. This phrase “valuable consideration” is of the 1984 National Organ Transplantation Act, which says that “no valuable consideration” may be exchanged. And that means anything … a car, money …

HEFFNER: If you look back at the legislative history …

SATEL: MmmHmm.

HEFFNER: … what do you learn about the motivation for that provision of the law?

SATEL: Ah, yeah, that’s an interesting question. One of the, one of the incidents that spurred that … there are several things. But, but one was right before, right in the eighties there was a physician in Virginia, who was trying to start up something called the International Kidney Exchange, where he would be a broker and he would help get people kidneys for a price.

HEFFNER: Commercially.

SATEL: And, yeah, that would only have benefited the rich, and that was offensive to the Congress. And … but the other is more conceptual and it really stems from the way we have dealt with blood since the seventies. Which is to say a totally altruistic based system. And that …

HEFFNER: Interns don’t sell their blood anymore? Or medical students?

SATEL: No, actually … you can sell some blood, but it’s mainly plasma. It’s kind of ironic, there are two parallel kinds of set ups. Blood is almost always volunteered, but plasma is paid for. (Laughter) And, ah … but in the early seventies a British … not an economic, but a public health administrator … a public administrator named Richard Titmas who’s at the London School of Economics … he wrote a book called The Gift Relationship and it was all about blood policy and he was comparing the United States with England … where … and we did buy blood almost exclusively up until the seventies. And he was showing how the United States had a much poorer quality blood supply compared to the UK. And he was arguing that this was because it was freely given in the UK and he also was very … he was a Fabian, I believe … had socialistic tendencies …

HEFFNER: Is that a curse word?

SATEL: No, no it just explains why he felt so, so strongly and sincerely that, that altruistic acts are almost essential for a community, that they reinforce each other and this is a sign of social health of a community, that things are given, given freely.

And, and truthfully … if, if people were giving organs freely I wouldn’t … I’d have no interest in, in, you know, promoting this idea. It is purely practical. There is purely an end point which is to get more transplantable organs. And, and I don’t even care if people … if fewer people give it freely. Some people say “Well this will crowd out altruistic donation. If people know they can get paid …”

I don’t care. I care about the net number of organs. That’s what we care about. So, if it crowded it out to the point where we had a decline that would be … well then the experiment would be a failure and then we’d stop. But I don’t mind what people … I don’t care about people’s motivations. The point here is not to harm anyone, to preserve the rights and the health, of course, of a donor … but it’s always in the service of making more transplants available.

HEFFNER: This reference to “Fabianism”, socialism … has anyone been critical of your feelings about government supplying … the way you solve this problem?

SATEL: Even my Libertarian friends, you know, realize that this … you know, it is such … I should say I’m far from the first person to come up with … even back in the mid-eighties people were talking about incentives.

HEFFNER: Well, you started talking about your Libertarian friends.

SATEL: But, oh, yeah, even they concede …”Listen, this is such a prickly idea”. The one that’s getting more and more and more support by transplant surgeons and legal scholars and even some bio-ethicists, that they concede that this would be the most reasonable first way to go.

HEFFNER: Any indication that if this were to become a reality, it would solve the problem of numbers of kidneys available?

SATEL: Ah, well … you know, I can’t … I really can’t do a projection for you, but you certainly don’t have to be Milton Friedman to know that when you offer some reward that you will get more of the thing you were offering for.

So I do think, I think that there’s good reason to believe that it would make a substantial dent … I could summon an analogy … Iran, of all places … is the only country with a legal organ market. And they don’t have any waiting lists. So, while there are some problems with their, their market …and the main one being that they don’t offer health care for the donor afterwards … he or she is on his own and there are no employment protections. So if you had to miss work you would get fired and they do the most intrusive kind of surgery.

Now, here I said … remember I said that the donors now are operated on laproscopically … my donor was driving 90 miles three weeks later to give a talk and working on her column a week later. And it was, you know …

But in Iran they do this massive lateral, flank incisions that take weeks to heal from. So, the, the … you know, I wouldn’t replicate that system by any means. But they do offer money, a combination of government stipend and also whatever the person can negotiate with the recipient. And they don’t’ have a waiting list. So, as I said, it’s not a system I would adopt … just as it is. But it shows that, you know, these kinds of incentives can work.

HEFFNER: The medical experts in the field … do they see anything else in the future?

SATEL: You know, that’s, of course, one hopes that we look back on this and say, “How primative. We had to get organs from our friends and from cadavers.” But you know it’s not around the corner, at all.

For a while … well, people are still doing research on what’s called zeno-transplantation … animals … probably pigs. And they’re not making that much progress. I’m sure they’ve made more progress … every year they get … incremental. But nothing approaching what we would need.

There is no kind of filter … I mean that’s what the kidney is, basically. But, it’s an incredibly complex organ. It’s, it’s easily second after the brain … a distant second because the brain is just, you know, awesomely complex. But the kidney is a pretty darn complicated organ. People don’t think about it very much. But … and there’s, there’s no micro filter on the horizon and dialysis lines are getting bigger and, as I said before, the waiting list is getting longer …

HEFFNER: Given those facts …

SATEL: MmmHmm.

HEFFNER: … those real numbers, do you see any change in the near future? Do you see any political …

SATEL: Yes.

HEFFNER: … climate …

SATEL: I do. As you alluded to earlier, I am fairly new to this. But my, my impression has been confirmed by people who’ve been in this area for years, which is that there really is becoming more and more dissatisfaction, especially among nephrologists and transplant surgeons, that something has to be done, that there’s almost a moral imperative to at least experiment.

And for, just for example … last July there was the World Transplant Congress in Boston and the President of the American Transplant Society actually came out in favor of at least experimenting with incentives. He, you know, he basically said you’ve got two consenting adults, in an engagement that would be mutually beneficial to both … beneficial, as in saving the life of another … and, he said, “it’s time we think about that.”

The new President of the American Society of Transplant Surgeons, Dr. Arthur Madeus is writing quite a bit about the imperative to, to experiment with the market.

The President’s Council on Bio-Ethics … I don’t think they’re notoriously timid about these kinds of things so I don’t think they’ll come out in favor, but they had wonderful debates with very, very persuasive proponents. And they’ve really softened. I mean they really are giving it much more thought than they would have before. And other …

HEFFNER: Do you …

SATEL: … organizations, as well.

HEFFNER: … do you as a person who’s thought a lot about ethics in terms of your psychiatric practice … do you see anything relating to a slippery slope concern here?

SATEL: I mean I suppose one always has to nod towards it, but that doesn’t worry me. This law was created in 1984, it’s 22 years later, it hasn’t budged. So, it’s so hard to get this to change that I don’t worry about … I don’t worry about it spiraling out of control. But I should have asked you … when you say “slippery slope”, a slippery slope towards what? Towards selling hearts? Towards selling human beings?

HEFFNER: Towards any kind of commercial relationship here in terms of … in areas where we haven’t thought of those things before.

SATEL: Well, here … you know, it’s very important to recognize that with, with organs, living organs, there are lots of mediating institutions.

So, for example, let’s say you needed a heart … I was … and I was suicidally depressed and I thought … and you know some people do plan their suicides and I thought “Well before … why don’t I give you my heart?” And we talked aobut it and I was a sane as anyone could be, you know, in that situation … and, and we decide … forget the money … it’s just an arrangement that we’ve worked on.

Well, who’s going to take my heart? Obviously it has to be a hospital. They’d look at me like I was crazy, they wouldn’t do a thing. So there’s just a limit to what two people can arrange. Because there are these mediating institutions that, that have their standards and their responsibilities and they wouldn’t engage.

HEFFNER: You don’t see this as part and parcel of the whole notion of surrogate activities?

SATEL: Well, here again, remember … the whole goal is to get more organs. It’s not to, it’s not to … it’s not to have an arrangement that … it’s not just to make a donor richer.

HEFFNER: I understand.

SATEL: And so …

HEFFNER: But you would be the first person, I would think … who would talk about the social, psychological consequences, the relationship between the culture at large and the activity you’re talking about.

SATEL: I think if anything, it would reflect a culture that has grappled … you know, if we did … and we’re talking now, again, about pilot studies. That a culture that has responded to a tragic medical situation. This isn’t stem cells, which I’m in favor of stem cell … funding for stem cell research. But the benefits from that are almost abstract at this point … they’re so far down the line.

Again, with the organ problem, there are people we can save tomorrow. The therapies are established and I would consider that actually a benign and very humane social response.

HEFFNER: Dr. Satel, I appreciate so much your willingness to discuss this at length, in terms of your own experience and I’m so glad to have you here on The Open Mind.

SATEL: Thank you.

HEFFNER: Thanks. And thanks, too, to you in the audience. I hope you join us again next time. For a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.