The trouble with organ banking
Our system of donating body parts may be costing lives, says Northeastern’s Kara Swanson
After last year’s Boston Marathon bombings, many people rushed to donate blood—so much that the Red Cross, in a statement the next day, said it had more than it needed. An adequate blood supply is something most of us now take for granted: Thanks to altruistic donors, we assume that, if we end up in the hospital after a traffic accident or for open-heart surgery, the blood will be there.
This was not always the case. In the early years of blood transfusion, patients were often out of luck if they couldn’t find—or couldn’t afford—a paid blood donor. That began to change in the 1930s, when a Chicago hospital set up the first “blood bank,” a term that once really did run on the idea that blood could be repaid with blood, much as we might pay a cash loan back with money. Those who received blood were asked to come back to the hospital once they recovered (or send a relative in their place) to replenish the bank with a donation. Later, blood banks began to rely more and more on volunteer donors, who deposit the blood that hospitals store and patients rely on.
The enormous success of volunteer blood banking has shaped the way we now think about body products in general, writes Northeastern University law professor Kara Swanson in a new history, “Banking on the Body: The Market in Blood, Milk, and Sperm in Modern America” (Harvard University Press). Today, we divide body products into “commodities” and “gifts”—roughly speaking, options and necessities. Sperm and eggs are perfectly legal to sell and buy, while lifesaving products like bone marrow and organs follow the blood model, and are considered beyond the market.
But Swanson argues that for all the success of blood banking, the model can have deadly consequences when it comes to other body products. Thousands of people die each year waiting for organ transplants. The solution, Swanson says, might be to realize that this dichotomy is basically a quirk of history, and start paying kidney or bone marrow donors just as we do men who donate their sperm. She spoke with Ideas at a cafe near her home in Cambridge.
IDEAS: We’re familiar with the term “blood bank,” but you write that the first body product to be “banked” was actually breast milk, right here in Boston, after a pediatrician’s fruitless search for a wet nurse in 1908.
SWANSON: I love that image of Fritz Talbot. This was a Harvard-educated doctor. He’s got a sick patient. It’s harder to find wet nurses....He gets on the streetcars in Boston, and he starts going into the tenement districts and knocking on doors. This is not what he went to Harvard Medical School for....[Talbot] gets this idea, “If we could disembody the milk, then it’s in the bottle, and I can tell the mother to feed the baby this much at this time. The baby will do better. A woman who doesn’t want to be a wet nurse might be convinced to sell her milk.”
IDEAS: There was once a huge amount of anxiety surrounding the idea of transferring body products from one person to another.
SWANSON: When blood transfusion was being developed, we didn’t know about DNA, so blood was it. “It runs in that family.” Where does it run? It runs in the blood....Before people were transfusing blood, people were using wet nurses, and there was that same kind of socio-cultural anxiety. What might this woman who is different than myself and my family transmit to my baby? Personality traits? Religion? Preference for odd, spicy foods?...That tension was resolved in part because of the bank. If you have it sitting there in a fridge, lined up bottles of milk, bottles of blood, or vials of sperm, it doesn’t feel as personal.
IDEAS: In the early days of blood transfusions, in the 1920s and ’30s, there were “professional donors” who were portrayed as these strapping, heroic young men. You wrote about one man who had a supposedly superhuman blood supply.
SWANSON: Right, the newspapers reported that it was his eating of raw onions that made him able to give blood. They were super-masculine, super-robust, super-healthy....The medical community liked having paid donors. They were convenient. They were efficient. It was a way of controlling donors, because in exchange for paying them, they would submit to regular physical exams and to more intrusive physical exams than volunteer donors would do. Volunteer donors may be asked, “Have you ever had syphilis?” “No.” And that’s the end of it. Whereas if you were a paid donor, you had to strip down and show you didn’t.
IDEAS: Our entire supply of whole blood now comes from volunteer donors. What changed?
SWANSON: I think Richard Titmuss carries a lot of blame. He’s a terrific, admirable British sociologist who wrote this very influential book called “The Gift Relationship” [published in 1970]....It was very timely, and it spoke to a lot of the problems that were going on in the American blood supply. We had hepatitis in our blood supply, problems where parts of the country didn’t have enough blood, while in other parts, blood was being collected but not used. Titmuss [argued that it showed] the British National Health Service [which relied on volunteer donors] was better than American free-market medical care. He was effective in convincing Americans, who worried about these things, and American blood banks got together and said, “Before the feds do something, before there’s regulation, let’s just see if we can step away from the paid donor.”
IDEAS: Just as we learned to distrust paid blood, we’ve also come to think of organs as being beyond money. Was that influenced by how we handle blood?
SWANSON: The transplantation of organs sourced from nonrelatives came to be more successful around the same time that Americans were learning to fear the paid supplier—formerly respected as the “professional donor,” now characterized as a skid-row bum. When one doctor announced he was going to establish a supply of organs the same way his predecessors had established supplies of human milk, blood, and sperm—that is, by offering money—Congress and the medical profession moved quickly to outlaw such a practice [with the federal National Organ Transplant Act] in 1984. Harvesting kidneys from living donors is of course more risky to suppliers than selling renewable body products, which also played into the decision to ban sales.
IDEAS: How would you change the system we have now?
SWANSON: With respect to life-preserving body products—[the scarcity of] bone marrow is a great example—it’s completely unsatisfactory. Today, we have this association of paying suppliers with disease and fear, but if you step back and think about it, cash doesn’t cause disease. There are all kinds of people who get paid for doing things that we think are very honorable—like a transplant surgeon, for example....OK, we’re not comfortable having a free market in kidneys, but what if kidney suppliers were all paid $3,000? Or if the family of a deceased person, when they were asked, “Do you want to donate your loved one’s organs?” were told, “And a check for $5,000 will be coming to your family that you can put toward last medical expenses.”
IDEAS: Isn’t the fear of exploitation legitimate? Living organ donors are actually putting their lives at risk.
SWANSON: I’m not sure that it’s better or worse that they’re not getting paid. They’re doing it anyhow....I think we can look at those options without this dread that the minute we talk about paying a supplier we are starting down a path to things that we don’t like. I’m telling you, as a historian, we’ve been down that path and we were able to make it work.
IDEAS: Do we know paying organ donors would increase supply?
SWANSON: I’m a historian, not a fortune teller! What history has told us is that not paying organ donors has correlated with a situation of scarcity....History has also shown that Richard Titmuss’s theory that payment will diminish gifting also is not always borne out by the facts. It makes a great deal of difference how the act of supplying a body product is framed by all participants.