Science and Spirit

Reprinted with permission from Science & Spirit Magazine.

Weakened by cancer and then by a progressive kidney disease that left him dependent on dialysis, Bob Hickey felt his life slipping away. To clear the toxins from his system, he needed to ramp up his already painful treatment schedule to a five-hour ordeal that would take place every other day. Even that, his doctors admitted, might not entirely counteract his disease, but would certainly place extra stress on his body. After four years of waiting for a kidney from the national donor list, Hickey contacted a hospice and was mentally preparing to die.

Then he did something that might seem reckless to those of us who are not ill and frightened and desperate to be well again: He tried searching for an organ online. Hickey joined, a commercial Web site that functions like a dating service, but makes matches of organs like livers and kidneys rather than soul mates—at a cost of 295 dollars a month. For three months, the clinical psychologist living near Vail, Colorado, screened the 4,500 contacts he heard from through the Web site. First, he eliminated the women; at six feet five inches and a bloated 320 pounds, he needed a large kidney. After that, he interviewed eligible donors who matched his O-positive blood type. When finally, with the help of his transplant center’s medical testing staff, he had narrowed the field to three, he made his final choice.

"I picked the youngest one," Hickey says of Rob Smitty from Chattanooga, Tennessee. "I decided to swap my fifty-eight-year-old failing kidney for a thirty-two-year-old’s."

Hickey paid for all the travel and expenses, and what was only twelve months ago a very new and controversial transaction has today left Hickey a healthy man—and the first of sixteen people who have successfully received organs through

There’s nothing technically wrong with the path Hickey chose toward his new life; while it is currently illegal to sell an organ, it is perfectly legal to solicit one. Still, some medical ethicists say there’s something not quite right about the choice. They worry donations like the one Hickey received—donations of organs from living donors directed toward individual recipients—undermine the fairness of the existing system, which allocates organs from deceased donors to those who need them most according to an objective formula devised by the medical community. They worry that campaigning for an organ makes receiving one the result of a popularity contest and not the “gift of life” ideal of altruism that has forever been the foundation of organ donation. And they worry that when donors get to choose who receives their organs, they also are able to decide individually who “deserves” to live or die based on religion, race, or any other particular preference.

When people offer an organ to a stranger they meet on a Web site, they do so on the strength of the patient’s appeals: Maybe as fathers, they identify with a father of three who needs a new liver; maybe as daughters of mothers who spent years on dialysis, they want to ease that particular pain. Maybe they’re just moved by a compelling story. But those details about the patient aren’t medical; they’re personal, says Arthur Caplan, chairman of the medical ethics department and director of the Center for Bioethics at the University of Pennsylvania. Human as the human interest that drives such donations may be, Caplan doesn’t believe it should affect who gets to live or die. “Directed donation is not a place for the unattractive or those who have flaws,” he says. “The person’s story is part of the appeal. The person’s background is part of the appeal. Because it’s a gift framework, you’re stuck dealing with people’s desires and their feelings. But feelings aren’t always related to what’s fair.”

In one of the most recent and extreme examples of such bias, discussed at a public forum hosted by Harvard Medical School’s Division of Medical Ethics, a Jewish man in New York decided he would donate a kidney to a particular Jewish child in Los Angeles, based on his strong desire to help someone of his own faith. “Despite his discriminatory preference, one might view the donation as permissible, since at least some patients would benefit (the child would receive a kidney, and those below her on the waiting list would move up one notch) and no one would be harmed (those above the girl on the waiting list would not receive the kidney under any circumstances, because the man would not give it to them),” suggests Doctor Robert Truog, a professor of anesthesia and medical ethics at Harvard Medical School and a senior associate in critical care medicine at the Children’s Hospital Boston, in an article he wrote last summer for the New England Journal of Medicine.