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.
EXIT WOUND:Hernani shows the scar where his kidney was removed in November 2002 in South Africa. ANDREW DOWNIE
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.
Religious beliefs often figure in decisions about organ trading. They're invoked both to encourage and discourage it. The Old Testament story of Hagar bearing a child for Abraham (because his wife, Sarah, is "barren"), is often cited as the first case of surrogate motherhood. Some people use this scripture to justify paying someone to be a surrogate for an organ, says Dr. Scheper-Hughes of Organs Watch. Or as one Israeli doctor said to her, "God performed the first transplant" when he took a rib out of Adam and created Eve. In many Christian circles, too, there's the belief that "your body is a gift from God," says Scheper-Hughes, "or that you have use-rights over your body, but that it belongs to God."
Yet one reason Israelis rarely donate organs after death is that many Jews believe the body is sacred, and should be whole at the time of burial. Orthodox Jews believe that the deceased should be intact for the Resurrection they believe will follow the coming of the Messiah. But views are shifting.
"If someone needs to save his life and the only way to motivate someone to help him do that is by financial incentive, then I don't think they should prevent people from doing that in order to save lives," says Robert Berman, the founder of the New York-based Halachic Organ Donor Society, which has enlisted prominent rabbis to encourage donation.
"The fact is that people are dying and that there are not enough organs going around to save their lives," he says. "There's a widespread misperception that organ donation is categorically prohibited by Jewish law. It is not. Jewish law supports saving lives."
Meanwhile, after many conversations, Arie and Mary agree they're making the right choice. "This decision," says Mary, "completely changes the course of your life."
* * *
Arie soon discovers buying a kidney is a pretty easy path to take in Israel. In dialysis units, in doctors' offices, even in newspaper classified ads, the names of organ brokers - people who arrange kidney trades - are an open secret. For $60,000 to $150,000, a new kidney can be purchased.
Arie starts surfing the Web, looking at clinics in the United States that do transplant surgery. A friend suggests a medical-advice hotline run by an aide to an influential rabbi. "People call him and say, 'I need an operation' and 'Who's good?' " says Arie. He tries it and gets the name of a doctor in Tel Aviv. Soon, he's put in touch with a broker who tells him a transplant, done in South Africa, will cost $100,000, with 10 percent paid up front.
It's a lot of money, but Arie figures he can at least manage the down payment from his retirement fund.
Many Israelis, even those without great wealth or savings, find ways to cover the cost. Israel's health-insurance funds reimburse patients as much as $70,000 for any medical procedure done abroad. Technically they're not supposed to pay for illegal operations, but if it's done outside Israel, it's off their radar screen. Critics say the health-care companies are turning a blind eye to an international racket. Government and health officials say there's no way to control what a patient does outside Israeli territory.
Click on a country to see how its government has dealt with legal issues surrounding organ trade.
BRAZIL: A 1997 law makes it illegal to sell organs and tissue and forbids anyone from soliciting them. Punishment includes three to eight years in prison and a fine equal to as much as 360 days of minimum wage. In 1998, Brazil passed a law making every Brazilian adult an organ donor at death, except in case of special exemption. But "presumed consent" was decried by critics and was subsequently amended a year later to require the consent of relatives. In the 1990s, Brazilian newspapers reported that prisoners were granted furloughs to donate their organs.
SOUTH AFRICA: The Human Tissue Act of 1983 says that no one can receive payment for the transfer of any tissue, including flesh, bone, organ, or body fluid. Violators are subject to a maximum fine of $300 or imprisonment of no more than one year. But a loophole grants a hospital's medical director and pathologist the right to remove tissues and organs without consent, when the identity of the deceased person is initially unknown and relatives have not come forward to claim the body within the period when organ retrieval is medically feasible.
ISRAEL: While it is now against health ministry regulations to buy and sell organs, one bill pending in the Knesset would make it a felony. If it passes, brokers could be fined and receive up to three years in prison, though recipients and donors would not be prosecuted. Another proposal would make it legal to reimburse a kidney donor for healthcare costs.
UNITED STATES: President Bush signed the Organ Donation and Recovery Improvement Act on April 5. While it is still illegal to sell or pay for organs, the act authorizes the federal government to reimburse living donors for expenses and to offer project grants aimed at increasing donations and improving organ preservation and compatibility. And this year, Wisconsin became the first state to give living donors a tax deduction of up to $10,000 for medical costs, travel, and lost salary.
IRAN: Kidney sales are legal and regulated. The trade is organized and controlled by two nongovernmental organizations – the Charity Association for the Support of Kidney Patients (CASKP) and the Charity Foundation for Special Diseases (CFSD) – both endorsed by the government. The CASKP connects potential recipients and donors, and organizes tests to ensure compatibility. Recipients often offer donors employment or extra money after the transplant.
CHINA: It's illegal to buy or sell organs in China. But a 1984 law allows organs to be transplanted from an executed prisoner if family members don't claim the body right away. Amnesty International says Chinese media reported 1,060 judicial executions in 2002. But it says the actual figure may be as high as 15,000. Most harvested prisoner organs are sold to medical "visitors" from Hong Kong, Taiwan, or Singapore.
INDIA: The Indian government tried to stop illegal organ transplants with a 1994 law that criminalizes organ sales but allows for "unrelated kidney sales," a loophole that has led to corruption. Nonprofit organizations in the area claim the trade is rising now that it has gone underground.
BRITAIN: A British woman may be the first citizen to face prosecution under the country's Human Organ Transplants Act of 1989, which prohibits the sale or solicitation of any organ within the country. Last month, to pay off her legal debts, the woman closed a deal over the Internet to sell her kidney for $50,000 to an American.
There is an attractive economic component to this setup. Paying $70,000 for one kidney transplant is far cheaper than $50,000 a year for life in dialysis bills. But it's more than money. The transplant recipient is healthier, and has a better quality of life than a dialysis patient.
Some argue that since the trade is already flourishing, and is difficult to stop, the best way to protect sellers is to decriminalize it and create a regulated market. Michael Friedlaender is one of Arie's doctors after the operation and heads the kidney-transplant follow-up unit at Hadassah University Hospital in Jerusalem. He once opposed organ sales. Now he advocates a legal market.
Under the current system, he says, if something goes wrong during surgery, or if the financial transaction turns out to be a scam, neither the donor nor the recipient has any legal recourse. A regulated system, he says, would change that, and allow for things like malpractice suits, which help safeguard the process.
In a free market, Dr. Friedlaender argues, it's unethical
not to pay for an organ.
"Someone's saving your life," he says, "and you're not going to reward him? We pay for every other service in the world." Donating an organ is one of the most valuable services, "because it saves a life."
* * *
Only a few weeks after making contact with the broker, Arie gets the call. "We have a donor for you in South Africa," the broker says. Then things move fast. Plane tickets are delivered. He gives the broker a $10,000 downpayment, with the rest payable when he's admitted to the hospital for surgery. Suddenly he and Mary are on their way to South Africa.
On April 8, 2003, they arrive at St. Augustine's. With its warm yellow walls, highly polished floors, and views of the ocean, the transplant ward is one of the most luxurious in the country. They're struck by the professionalism of the staff.
But they hit a snag.
It turns out that Arie's donor has high blood pressure and is rejected by the syndicate. This comforts Arie and Mary, and persuades them that the doctors and brokers aren't just trying to scam them or the Brazilians. But the first donor isn't the only Brazilian there. Arie and Mary often hear Brazilian music wafting through the hospital hall, and the TVs are tuned to soccer. After several days of more tests, a suitable donor is found.
Arie soon meets the young man (Arie won't reveal his name) who's going to change his life. He's tall, thin, and youthful. He grins constantly. Through a translator he says he doesn't smoke or drink. He just wants to improve his life by getting married and going to college to become an architect.
As they talk, Arie keeps trying to remember how to say "thank you" in Portuguese.
"Ob..., Ob...," he stutters.
"Obrigado," Mary chimes in.
Through his interpreter, he asks the Brazilianif he really consents wholehearteldy to giving his kidney. The young man smiles, and says, "Yes." He offers his hand to Arie, and the two men shake as they are wheeled into the operating room.
Surgery falls on the eve of Passover, the Jewish holiday that celebrates the Children of Israel's passage from slavery into the freedom of the Promised Land. As he's lying on the gurney, being wheeled into the operating room, he whispers, "Shma Yisrael," a Jewish prayer that affirms God's oneness and the commandment to love God with all one's heart, soul, and mind.
That evening, back at the hotel, Mary feels lonely and apprehensive. Some local Jewish families have invited her to celebrate Passover with them, but she doesn't feel like being cheery and social. In her room, she lights some candles and reads the Passover story. Perhaps the surgery will finally let her husband find a new freedom of his own.
Michael Friedlaender
heads the kidney-transplant follow-up unit at Hadassah University Hospital in Jerusalem.
Nancy Scheper-Hughes
is a professor of medical anthropology at the University of California, Berkeley, and director of Organs Watch.
The next day she sees him, and he doesn't look well. He's pale gray and connected to machines she's seen all her professional life, but it's different when it's her husband. To her relief, the doctors say the surgery was a success.
In the following days, Arie meets his donor again. They pose for photographs. The Brazilian wraps an arm around Arie, flashes a thumbs up sign, and beams. In his bright red shirt, he looks like a fan whose team has just won the championship.
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