Battling over bone marrow

Federal law prohibits payment to people who donate organs, such as kidneys, other than to compensate them for travel and other related expenses. But it is perfectly legal to pay people for their plasma, sperm and ova. As for blood donors, they may be paid, but no major organization does so. In other words, a complicated set of rules and ethical considerations determines whether people are paid to give up a part of their bodies.

The law places bone marrow in the same category as kidneys. But a court case advanced by the Institute for Justice, a libertarian law firm, argues that marrow, which can save the lives of people with leukemia and other life-threatening illnesses, was wrongly included. The suit raises some valid arguments in favor of the societal good that might come from paying marrow donors (the amount suggested by the institute is $3,000, paid through an independent nonprofit agency), but those are outweighed by various ethical and practical considerations.

Congress banned payments on various organs out of concern that poor people would be motivated to undergo dangerous procedures and give up vital organs in return for money. There also was an equity issue: If rich people who were ill were allowed to pay for organs, then they might receive life-saving donations ahead of people in greater need.

But bone-marrow transplants differ from other procedures involving donated organs or tissue. Our bodies can’t make new kidneys or other solid organs once we donate them, but we regenerate marrow as we do blood. The newest procedure for donating marrow, now the more common one, is much safer than organ donation; it’s also safer and far less uncomfortable than the older method of puncturing a person’s hipbone with a big needle. In fact, it’s not much tougher than giving blood. Yet, unlike blood transfusion, bone-marrow transplant requires a close genetic match between donor and recipient. And that means that of the 14,000 or so people each year who need bone marrow for treatment of a life-threatening disease, about 1,000 will not find a match either in their family or in international registries of 16.5 million potential donors, 9 million of them in the United States registry. So there is a real, pressing need for more donors.

Maybe a financial lure would persuade more people to join the registry, increasing a patient’s chances of finding a match. That’s an especially important consideration for Latino, Asian and African American patients, whose chances of finding an unrelated donor range from 66% to 73%; for white people, the chances are more than 90%. (About 30% of patients receive marrow from a relative.)

But potential donors would have to be advised that their chances of actually collecting money were remote. Donating bone marrow isn’t like selling plasma. Volunteers undergo an easy cheek swab to have their DNA tested — a procedure that they might or might not have to pay about $100 for — and then are entered in the registry. They will only be called on to donate (and receive money) if they are found to match someone who needs their marrow. The probability is extremely small and, if it happens at all, would probably occur years afterward.

According to the National Marrow Donor Program, which opposes financial incentives, a dearth of suitable donors isn’t the main reason many patients who could benefit from a transplant don’t get one. It’s more likely that they lack access to sophisticated medical facilities, or that they lack health coverage to pay for the procedure, or that their condition worsens too quickly to make them a candidate for transplant.

Meanwhile, a money-for-marrow program could backfire. One reason that the American Red Cross and other major blood-collection organizations will not pay for blood is that money motivates some donors to hide troubling medical conditions or troubling health histories, endangering recipients and even themselves. Blood and bone marrow are both tested extensively, but the tests, though highly effective, are not perfect. Three years ago, a Colorado man was infected with HIV after receiving blood from a donor who lied about his sexual history. The donor was not paid for his blood, and studies find that most unpaid donors tell the truth — but the valid concern is that such scenarios would become more commonplace if a financial incentive were involved. Paid plasma donation is different because plasma goes through long-term testing, rechecking and processing; unlike whole blood and other tissues, it also can be sterilized.

In addition, experts say, public perceptions of a donation program change if donors can receive money. When altruistic donors see that others are paid for their tissue, they tend to think the problem is being taken care of and that their participation is no longer needed. The marrow registry might therefore gain some donors but lose others.

No other country that participates in the international donation of bone marrow allows payment, according to the National Marrow Donor Program. Allowing financial rewards would violate the standards set by the World Marrow Donor Assn. That in turn might lead to loss of international accreditation for marrow programs here, and to nations refusing to cooperate either by accepting marrow from or donating it to people in the United States.

There may come a day when factors would weigh in favor of compensating marrow donors. Technology is likely to bring about faster and more accurate screening tests. Registries could conduct studies to see how they might add paid donors without alienating altruistic ones. And at that point, it might be worthwhile to start an international discussion about whether more lives could be saved, without jeopardizing medical ethics, by paying marrow donors.

At this point, though, financial reward carries too many risks with little certainty of real benefits. For now, there are more effective ways to help patients get needed marrow donations: Outreach in minority communities to encourage more people to join the registry. Better health insurance coverage so that patients aren’t denied a transplant for financial reasons. And above all, a campaign to let the public know that bone-marrow transplant doesn’t have to be a painful procedure that necessitates a hospital visit. Through a process called peripheral blood stem-cell donation, the donor is given a drug to move more blood-forming cells from the marrow to the bloodstream; the cells are then filtered through a machine in a procedure very similar to plasma donation. Saving a life was never easier.