What is a kidney worth?

For someone who has been poor all his life, money is to be spent, not saved or budgeted. And spend it he does. In the first few months of 2003, Hernani pays $1,700 to replace the roof, the floor, the walls, the windows, and the wiring in his mother's house. He uses $1,600 to pay off her credit cards. Another $1,200 buys him a brand new Honda CG 125 motorcycle, which he insists the dealer deliver to his house so his neighbors can see. On New Year's Eve, he buys Daisy a new blouse and skirt. He figures that leaves him somewhere between $1,000 and $2,000 to spend on drink and other women. Life is good.

While Hernani is busy blowing through his money, in Israel Arie Pach is hoping to avoid a life tied to a dialysis machine. But he's running out of options. He's been ruminating over them since 1995 when doctors first detected a problem with his kidneys. He knows that patients who get kidneys tend to live longer than those on dialysis. So he considers turning to his wife or sons for a kidney. Since they come in pairs, a healthy person can live on just one. But his wife and oldest son have the wrong blood type. His youngest son is a match, but he has health problems similar to Arie's. So getting a kidney from a related donor is out.

Another possibility: Signing up for Israel's national waiting list, which already has more than 500 people on it. But the wait time can be as long as four years for someone of Arie's age - those under 18 get priority - which means most go onto dialysis. For religious reasons, Israel's cadaver donation rate is relatively low, although its rate of donation among living relatives is above average. And anyway, organs from live donors are more effective than cadaveric ones.

So Arie and Mary, his wife of 36 years, feel they have no other alternative. They're left to consider paying a healthy stranger for a kidney. Mary has been an operating-room nurse for more than 25 years. She encourages Arie to find a living donor. "If you go for a transplant at the very end, after years of dialysis, your body is all worn out," she says. "If you do it before you get to dialysis, you have a much better chance of the surgery being successful."

Buying a kidney in Israel is against Health Ministry regulations, but there's no penalty associated with the rule - yet. As in many countries, the legal ground is soft. Going abroad for a kidney operation is perfectly legitimate, and in such cases questions are rarely asked about how the organ was obtained. Even under a new proposal that would punish brokers, recipients would not be prosecuted because they're victims of failing health and opportunistic organ brokers, says Meir Broder, legal adviser to the Health Ministry.

For Arie, who has spent a lifetime practicing law, the ethics of a kidney purchase are still complicated. He doesn't want, for instance, to exploit a poor person who's just trying to feed a family. Yet he's torn.

"Everyone is the boss of his own body, and if someone healthy wants to give away one of his own kidneys, I can't see why it shouldn't be done," he says. "There has to be informed consent."

Then there's the religious element. Arie and Mary aren't particularly devout, but they discuss the guidance Judaism offers. Arie finally concludes, "There really is nothing holy except for God and human life," and since "donating an organ is saving a life," it's entirely ethical.

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