Blog entry by Arif Khwaja
There is a great review of the Iranian model of living kidney transplantation by Mitra Mahdavi-Mazdeh in this months Kidney International. The process of unrelated transplantation is described in some detail but in essence involves a kind of regulated negotiation between donor and recipient at a patient 'kidney-foundation' clinic. Once a patient has been deemed suitable for a transplant the foundation provides a space for a negotiation between donor and recipient - this is a pure financial transaction and as in all such transactions there is hard negotiation over the price. Once the transplant goes ahead the government provides 1 years of medical insurance plus $900 USD to the donor. The recipient is covered for life for the cost of immunosuppressive drugs (a benefit not yet afforded to Medicare patients in the USA). There is no doubt that the donors were poorer and of lower socio-economic status than the recipients. Whilst many may feel uneasy about the ethics of the process its worth considering the following:
i) The program has delivered transplantation successfully to huge numbers of patients who previously would have been condemned to a life on dialysis. Without such a system patients would have quite simply died - there was no deceased donor program in Iran for many years. For those of us sitting in the luxury of our ivory towers its easy to get queasy about ethics.. for patients such transactions are quite literally a matter of life and death. The Iranian government is currently piloting a 'fixed-price' model which may perhaps remove some of the stress related to the transaction.
ii) the success of the live transplant program has been absolutely instrumental in developing a blossoming brain death donation (BDD) program - whilst change in legislation was the catalyst for the growth in the BDD program, without the development of a successful live program with associated clinical expertise and infrastructure it is unlikely that the political establishment would have supported the initiation of BDD program.
iii) Disappointingly the live-related transplantation rate has remained relatively low and static over the last 10 years - perhaps confirming the impression that wealthier families would rather buy kidneys form poorer donors rather than 'gift' a kidney to a family member
iv) the Iranian experience is not only important to Iran but crucially provides a template to develop an active, high quality program in other emerging countries as well as in Islamic societies where kidney transplantation rates are often disappointingly low. What works in the USA and Europe often doesn't work in Africa, Asia or the Middle East. What Professor Mahdavi-Mazdeh has shown is that countries need to think outside the 'western paradigm' of transplantation and develop their own 'local' solutions to transplantation.
v) Critical to the success of the Iranian program is the way clinical leaders engaged with politicians, religious organisations and wider society - irrespective of where we live this is something we can all learn from
vi) In an accompanying commentary, Francis Delmonico from Harvard University, Boston rightly points out that there is no long term outcome data on the donors from Iran. Furthermore Delmonico states that donors tend to be 'poor, hapless, jobless and largely destitute' and argues that 'the exploitation of the poor that has enabled most Iranian kidney transplantations'. For Delmonico the fundamental unethical aspect of the process is the 'victimisation of the poor'.
This may well be true and the concerns raised are valid but we need to remember that in many societies ESRD is an immediate death sentence. There is a more than a hint of 'academic imperialism' here - Delmonico does not have to look far to find evidence of 'victimisation of the poor' in healthcare - an astonishing 16% of Americans have no health insurance with catastrophic consequences - public health experts from Harvard estimating that this results in nearly 45,000 extra deaths per year. Now that really is 'fundamentally unethical'......