The Global Organ Shortage: Economic Causes, Human Consequences, Policy Responses

By T. Randolph Beard, David L. Kaserman and Rigmar Osterkamp

Although organ transplants provide the best, and often the only, effective therapy for many otherwise fatal conditions, the great benefits of transplantation go largely unrealized because of failures in the organ acquisition process. In the United States, for instance, more than 10,000 people die every year either awaiting transplantation, or as a result of deteriorating health exacerbated by the shortage of organs.

Issues pertaining to organ donation and transplantation represent, perhaps, the most complex and morally controversial medical dilemmas aside from abortion and euthanasia. However, these quandaries are not unsolvable. This book proposes compensating organ donors within a publicly controlled monopsony. This proposal is quite similar to current practice in Spain, where compensation for cadaveric donation now occurs "in secret," as this text reveals.

To build their recommendations, the authors provide a medical history of transplantation, a history of the development of national laws and waiting lists, a careful examination of the social costs and benefits of transplantation, a discussion of the causes of organ shortages, an evaluation of "partial" reforms tried or proposed, an extensive ethical evaluation of the current system and its competitors.

• Language: English
• Publisher: Stanford Economics and Finance
• Release date: Jan 9, 2013
• ISBN: 9780804784641

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Library of Congress Cataloging-in-Publication Data

Beard, T. Randolph (Thomas Randolph), author.

The global organ shortage : economic causes, human consequences, policy responses / T. Randolph Beard, David Kaserman, and Rigmar Osterkamp ; with a foreword by Friedrich Breyer.

pages  cm

Includes bibliographical references and index.

ISBN 978-0-8047-8409-2 (cloth : alk. paper)

ISBN 978-0-8047-8464-1 (e-book)

1. Procurement of organs, tissues, etc.—Government policy.   2. Procurement of organs, tissues, etc.—Economic aspects.   3. Donation of organs, tissues, etc.—Government policy.   4. Donation of organs, tissues, etc.—Economic aspects.   I. Kaserman, David L., author.   II. Osterkamp, Rigmar, author.   III. Title.

RD129.5.B43 2012

362.17′83—dc23

Typeset by Newgen in 10.5/14 Bembo

The Global Organ Shortage

Economic Causes, Human Consequences, Policy Responses

T. Randolph Beard, David L. Kaserman, and Rigmar Osterkamp

With a Foreword by Friedrich Breyer

STANFORD ECONOMICS AND FINANCE

An Imprint of Stanford University Press

Stanford, California

In memory of David L. Kaserman (1947–2008)

Contents

List of Illustrations

Foreword Friedrich Breyer

Preface

Acknowledgments

1. Introduction

2. The Evolution of Organ Transplantation and Procurement Policy

3. Consequences of the Current Policy

4. Social Costs and Benefits of Transplants

5. Economic and Political Causes of the Shortage of Organs

6. Reforms Short of Open Donor Compensation

7. An Assessment of the Moral Basis of Alternative Organ Donation Rules

8. Compensation for Organ Donation and a Proposal for a Public Monopsony for Organ Acquisition

9. Conclusion

Notes

References

Index

Illustrations

Figures

Figure 3.1   Number of persons on organ waiting lists, United States, 1988–2009

Figure 3.2   Number of persons on kidney waiting lists, removals due to death and sickness, United States, 1995–2009

Figure 3.3   Number of patients on dialysis, United States, 1995–2006

Figure 3.4   Eurotransplant waiting lists, by organ, 2001–2009

Figure 3.5   Number of organ donors, by organ and donor type, United States, 1996–2008

Figure 3.6   Number of organ transplants in Eurotransplant countries, 2001–2009

Figure 3.7   Deceased kidney donor characteristics, United States, 1999–2008

Figure 3.8   Shortages promote black market sales

Figure 5.1   The organ market and the shortage, a conventional view

Figure 8.1   The organ market and the shortage, including living donors (after Becker and Elias)

Figure 8.2   Total organ supply—groups A and B exhibiting equal (absolute) supply elasticities

Figure 8.3   Total organ supply—group A’s supply elasticity is (absolutely) smaller than group B’s

Figure 8.4   Total organ supply—group A’s supply elasticity is (absolutely) larger than group B’s

Figure 8.5   Optimal organ procurement with positive prices for both sources (living and cadaveric)

Tables

Table 3.1a   Number of persons on organ waiting lists, Eurotransplant countries, by organ, 2009

Table 3.1b   Time spent on Eurotransplant kidney waiting list, 2003–2009 (percent of patients)

Table 3.2a   Number of persons on waiting lists, Scandiatransplant countries, by organ, 2004 and 2009

Table 3.2b   Kidney transplants, cadaver and live grafts, Scandiatransplant countries, 2007 and 2009

Table 3.2c   Persons on waiting list, death on waiting list, Scandiatransplant countries, 2007 and 2009, for kidney and liver

Table 3.3   Reliance on living kidney donation, 17 countries in 2004

Table 3.4   Living kidney graft rates, per 100,000 population, selected countries, 1995–2009

Table 3.5   Number of transplants in Eurotransplant region, by organ and donor type, 2001–2009

Table 3.6   Number of kidneys transplanted per deceased donor, United States, 1996–2008

Table 3.7   Countries of origin of kidney sellers, buyers, and transplant locations

Table 3.8   Costs of illegal kidney transplants, seller’s remuneration

Table 3.9   Number of wealthy adults in the world, 2000

Table 3.10   Replies of Council of Europe member states to a questionnaire on organ trafficking, 2004

Table 4.1   Estimated U.S. average first-year transplant costs

Table 4.2   Patients removed from waiting list in 2007, United States (in percent)

Table 5.1   Additional costs and cost savings after an increase of 1,000 postmortem organ donors, over 10 years, for the United States (in thousands of dollars)

Table 6.1   Alternative measures of the organ shortage, 2001

Table 8.1   Comparative statics results for optimal quantities

Table 8.2   Comparative statics results for optimal prices

Foreword

Every day, 30 U.S. citizens die from the failure of a vital organ while still waiting for a suitable transplant, and similar figures—relative to population size—are reported from all of the other developed countries. It is one of the few problems of modern health care that cannot be solved by pouring more money into the existing system. The reason is that the rate of organ donations is simply not sufficient. Another tragic fact is that hundreds of thousands of people with end-stage renal disease (ESRD) can be kept alive only by renal dialysis. They have to be treated three times a week, at high costs and greatly reduced quality of life, while most of them would be much better off after receiving a transplant. At the same time, hundreds of millions of people have two healthy kidneys, and many of them would be willing to part with one of them if only they were adequately compensated for the (small) risk attached to the surgery and any possible pain and discomfort. That society in principle accepts this additional risk for living donors is obvious because living kidney donation is a very common procedure among relatives.

These facts describe a severe shortage of human transplants. Economics tells us that shortages can be alleviated by acting either on the demand or on the supply side. In the particular case of human organs, the demand is more or less fixed by medical need (e.g., reducing the rate of kidney failure by persuading people to eat less and exercise more is an extremely slow process). The supply, however, can be and is in fact influenced by policy measures and regulations. The most important feature in this respect is the universally established rule that all organ donations must be altruistic and no compensation may be paid to the donor. And it is this very rule that the authors of this book—three economists who have studied the problem for decades—hold accountable for the lack of adequate supply and thus for the enormous pain and suffering caused by the shortage of organ transplants.

This book is provocative in the best sense of the word: its purpose is to provoke a new discussion not only on how to increase the procurement of organ transplants, but on the very nature of health care policy in the United States, in Europe, and in many other developed countries. Is it better to prevent unnecessary pain, suffering, and early death, or is it more important to comply with certain widely held normative convictions such as no commodification of the human body?

The authors must be congratulated for providing a comprehensive overview of the severity of the problem, the reasons for the failure of existing institutions, and the potential of alternative proposals to solve the problem. Of course, at the heart of this book is their own proposal to create a system of donor compensation that meets ethical criteria. The authors argue their case very carefully and forcefully, but they may not be able to convince all those readers who are skeptical of using monetary incentives in matters of life and death. (On the other hand, why does no one object to paying doctors and nurses for their services?) At the very least, however, the book should spur a discussion of what we all can do to solve one of the most pressing health care problems of our time.

Friedrich Breyer

Preface

The extent of the global organ shortage is horrifying. Tens of thousands of patients die every year around the world due to the shortage of organs. Even the lucky ones may languish on waiting lists for years until an organ is made available to them. Moreover, due to the shortage, a global black market for organs—mainly kidneys—has developed, and it has been rightly criticized for unfairness and even exploitation. In the course of our work, we have arrived at the conviction that the dire situation that patients in need of an organ are facing is—not exclusively but overwhelmingly—the consequence of the primary element of organ procurement systems implemented practically all over the world: exclusive reliance on uncompensated donation. Our main motivation in writing this book is to contribute to a change in the current organ procurement policy.

We have, however, a private motive, and, to us, it is ultimately the most compelling. David Kaserman, one of the authors, responded to the profound challenge that his congenital kidney disease presented in a manner that many would be unable to imitate: he applied his training as an economist to his predicament as an organ transplant patient, and he concluded that the medical misery in which he found himself had an economic cause. David Kaserman made several significant contributions to economics, especially in the areas of vertical integration, competitive market analysis, and regulation, but he felt more engaged by his work on the organ shortage than on any other topic. As his health deteriorated (partially as a consequence of the long-term use of drugs designed to block rejection of his transplant), his focus on the organ shortage became stronger, and he was actively engaged in work on this book at the time of his death. Our decision to complete this project is our way of honoring his memory.

T. Randolph Beard

Rigmar Osterkamp

Acknowledgments

This book is the outcome of a four-year intense collaboration among three economists, two Americans and a German. It was one of the American authors, David Kaserman of Auburn University, who encouraged the other to take the global organ shortage problem more seriously. He was the guiding light for this book. We say was because David died in January 2008 in the renal intensive care unit of the University of Alabama at Birmingham Hospital. He designed the outline of the whole book and wrote drafts or outlines for most of the chapters. David deserves the most credit for the success of this book.

We were fortunate to be able to present seminars in Munich and elsewhere, where we received many valuable criticisms. We are very much indebted to the contributions made by Professor Friedrich Breyer, University of Konstanz; Dr. Detlef Bösebeck, regional chair of the German organ procurement network DSO; Michael Horvath of the Technical University of Munich; Professor Clifton Perry Esq., Auburn University Department of Political Science; Professor Thomas Gutmann of the University of Münster Faculty of Law; Dr. Charles Diskin; John Covell of MIT; theologian Andreas Peltzer of Windhoek, Namibia; and Auburn economists Bob Ekelund, Mike Stern, Richard Saba, Hyeongwoo Kim, Mark Thornton, and John Jackson. All of these individuals provided suggestions, criticisms, and support, although none of them should be blamed, in any way, for any errors, nor for our conclusions. If nothing else, in this process of writing this book, we learned that compensation for organ donors is a topic that generates very strong opinions on all sides.

Finally, we would like to express our gratitude for the patience and support we received and the stimulating discussions we had with our and David’s loved ones: Lois Kaserman, Leslie Beard, Erna Sutter, and Judith Osterkamp.

T. Randolph Beard, Auburn

David L. Kaserman (1947–2008)

Rigmar Osterkamp, Munich

January 2012

1

Introduction

Do not go gentle into that good night. . . . Rage, rage against the dying of the light.

Dylan Thomas

The organ transplantation policies adopted by the vast majority of the world’s nations have failed. Although transplantation provides the best, and often the only, effective therapy for many otherwise fatal conditions, the great benefits transplantation could provide go largely unrealized because of failures in the organ acquisition process. In the United States, for example, more than 10,000 persons die every year either awaiting transplantation or as a result of deteriorating health exacerbated by the shortage of organs. More than 350,000 kidney patients receive dialysis treatment at an average annual cost of over $75,000. Similar statistics can be observed in many other wealthy countries. In poor countries, the problems are often masked by inadequate public health resources: countries in which dialysis is generally unavailable do not exhibit waiting lists because their end-stage renal disease patients die quickly. Patients needing transplants of organs other than kidneys receive less attention due to their smaller numbers, but in such cases no therapeutic alternative to transplantation, such as dialysis, exists. These patients usually die quickly, and thus receive less attention than those on dialysis.

Organ transplantation, especially in the cases of kidneys and livers, has shown itself to be by far the best medical response to a variety of life-threatening conditions. Further, numerous studies have established the large financial savings many transplants provide, even in less-than-ideal patient populations. Patients receiving successful transplants often enjoy substantial improvements in the qualities of their lives, including being able to work, care for family members, and so on. As a result, it is nearly universally agreed that a large expansion in transplantation activity, at least for kidneys and livers, is unambiguously desirable from virtually any point of view. Further, it is nearly universally agreed that, on purely medical grounds, there exist sufficient, or more than sufficient, numbers of suitable organs, currently unutilized, which could in principle be used to support a large increase in transplant operations. Such an expansion would save many tens of thousands of lives annually and would reduce the burden on public health insurance funds by many billions of dollars or euros. Lives saved, pain eliminated, costs reduced—what could be more worthwhile? And yet, despite these essentially undisputed facts, the deaths, suffering, and costs continue, year after year, all over the world. How can this be?

The problems of organ transplantation and the shortages of organs represent perhaps the most complex and morally controversial medical issue aside from abortion and euthanasia. In the organ problem, one comes face to face with such topics as the meaning of personhood, the proper treatment of the bodies of deceased persons, the ethics of rationing a life-saving yet extremely finite resource, the meaning and definition of death, the problems attendant on the mechanical maintenance of human life beyond its natural limits, black markets, and so on. Add to these very difficult questions the often conflicting religious and cultural traditions, and toss in many billions of dollars of public expenditure and powerful special interest groups, and one has a perfect recipe for conflict, controversy, and public policy gridlock.

Yet, it is the contention of this book that the problems of organ transplantation, and the shortages of organs for that purpose, are in no sense unsolvable. Although one may hope, and perhaps reasonably expect, that scientific advances such as cloning will one day allow transplant patients to receive tailor-made organs grown from their own cells, it is both unnecessary and irresponsible to fail to act now just because ultimately the problem may be resolved by technical means. Rather, we have the means now to resolve the shortage over a reasonable period if we choose to do so. The primary problems are not technological but are instead political and moral. Establishing this thesis is a primary purpose of this book.

As economists, we must confess to the typical economist’s bias toward cynical, financially based explanations for human behavior. However, any prospect for true reform, which we feel must include meaningful donor compensation, is dependent on taking the opposing arguments seriously and vanquishing them on their own terms. Hence, we cannot avoid entering the moral arena and battling the moral objections using the tools of ethics and philosophy. This book, therefore, is not solely composed of economic analyses and financial calculations.

Our conclusions are relatively simple: any practical solution to the organ shortages under current technological means must involve paying meaningful compensation to donors for their willingness to donate. All available evidence, fairly evaluated, suggests that compensation will be effective in greatly increasing the availability of organs for transplant. Compensation may be paid both to the families of deceased donors and to living donors (in the case of kidneys). We propose the establishment of public monopsony buyers for organs and argue that such a system may be adequately managed to produce greatly improved patient outcomes while saving money and avoiding serious moral failings. The distribution of organs will be handled on purely medical grounds, presumably within the existing national and international organ procurement systems. The probable levels of compensation necessary to secure substantially increased organ supplies are likely to be modest in comparison to the cost savings arising from expansion of transplantation, at least for kidneys and livers. In the case of kidneys, the costs of dialysis, its medical side effects, and the sizes of end-stage renal disease populations suggest that huge savings in both lives and medical expenditures are readily available. It is true that it will be more difficult to make such claims in the case of certain other transplants, such as lungs or hearts, and the resolution of such problems is important. However, the case for greatly expanded renal transplantation therapy is incontrovertible.

The proposal to compensate donors is, of course, an old one. Indeed, it is quite difficult to think of any other system where begging is the sole legal means of obtaining a supply of goods. From the perspective of the economist, price controls are the fundamental cause of the observed shortages, and very little convincing is necessary. For many physicians, medical societies, and sociologists, however, this linkage is not compelling. Many doctors, for example, argue that compensation would result in fewer organs or organs of poorer quality, undermining the entire transplantation system. Others suggest that any increase in the numbers of organs available would result in increased enrollment on transplant waiting lists. Still others suggest that many of those on renal transplant waiting lists are not legitimate candidates for transplants, so the extent of the alleged shortage is overblown. Some medical ethicists, while perhaps accepting the potential of compensation to increase organ supply, reject the entire notion on moral grounds, often predicated on Kantian ideas of the objectification of the human body/human person. Others confuse the notion of compensating donors within a regulated, transparent public system with a Dickensian, free-for-all organ bazaar, in which poor citizens of Third World nations are duped into selling parts of their bodies for the benefit of the undeserving wealthy. (Somewhat ironically, this is precisely the case today with the black market, a consequence of the current system.) These are deep waters, emotionally speaking—so deep that they have been sufficient to maintain the current procurement system despite its unsatisfactory performance. Our task in this book is to address each of these lines of argument with an effective refutation, and, because these are not entirely economic challenges, we cannot hope to vanquish them solely using economic arguments. But economics will be our primary tool, and for that we cannot apologize.

The format of the book reflects, to some degree, the evolution of the organ shortage problem itself. We begin in Chapter 2 with a history of transplantation medicine, highlighting those developments that made the miracle of human solid organ transplants possible. Our current system of unpaid donation evolved in an environment in which transplants from strangers were technically infeasible. When the family unit was itself the sole organ procurement organization, the prohibition of compensation had no practical effect. The discovery of cyclosporin and similar drugs, however, pushed the state of the science well beyond the boundaries drawn by public policy. With the widespread public funding of hemodialysis therapy came the kidney transplant waiting list, now a baleful constant of modern life in industrialized countries.

Chapter 3 evaluates the consequences of this altruistic donation system. Several hundred thousand people have died awaiting transplants (primarily for kidneys) since 1980. Waiting lists are long in many (though not all) industrialized countries, especially for kidneys and livers. Severe shortages of organs have led to steadily decreasing standards for deceased donors, and despite continuous improvement in antirejection therapy and organ handling protocols, medical outcomes with substandard organs are generally worse. The proliferation of living-donor transplants stands as a testimony to the inability of many national authorities to increase postmortem sources to meet demands. Black or gray market transplant activities and so-called transplant tourism have become widespread.

Chapter 4 makes the medical and financial case for large increases in transplant activity. We review studies that examine in detail the social costs and benefits of various transplants, and we find, consistent with overwhelming medical opinion, that transplantation is the best and most cost-effective treatment for a number of serious disorders. In the case of kidney transplants and end-stage renal disease, one can justify paying very large compensation to donors (or their families) based solely on savings to public health funds. Many billions of dollars or euros are lost every year through continued reliance on the current system of organ procurement. In contrast, it is more difficult to rationalize large increases in certain other transplant procedures purely based on direct medical cost effects. It is unlikely, given current technological constraints and life expectancies, that large expansions in heart-lung transplants will pay for themselves in this sense.

Chapter 5 considers the sources of the current crisis, with special emphasis on the role of the price control imposed by bans on donor compensation. We lay the blame for the shortage primarily on this aspect of the current system. However, it is not accurate to say that this prohibition is the only example of defective incentives in the organ procurement effort. The widespread use of monopsony structures in organ procurement, characterized by geographic exclusivity in donor recruitment, may also be problematic, as are other moral hazards endemic to the ways in which transplant centers and others are compensated. Public responses to the organ shortage, manifested in steadily rising rates of living-donor transplants, also present an obstacle, and we document a pattern of intertemporal substitution between deceased and living-donor organs. In particular, increases in deceased-donor organ supplies reduce future living-donor supplies to some degree, potentially undermining efforts to expand transplants through deceased-donor recruitment. A defective incentive to organ donation is also created by the rule that nondonors are treated the same as willing donors if they should ever need an organ. Finally, we examine the political economy of the shortage system and identify potential conflicts of interest among interested parties. Because organs are jointly supplied by deceased donors, increases in the numbers of deceased donors may also increase pressure to perform more transplants of other solid organs, increasing total medical costs. This fact may be relevant in explaining the public positions of some insurance funds in the compensation debate, at least in Europe. This effect should not apply to efforts to increase living-donor kidney supplies through compensation.

The poor performance of the organ procurement mechanism has given rise to many proposals for reform that fall short of donor compensation. Chapter 6 reviews what one might term piecemeal reform proposals, both implemented and hypothetical. Many such efforts have not been very useful, but several, such as presumed consent, pairwise exchanges, and best practice efforts (such as the Organ Donor Breakthrough Collaborative, or ODBC, in the United States), have measurable benefits. Some possible innovations, such as donation to a waiting list, have yet to be evaluated in practice.

Chapter 7 addresses the moral and ethical issues surrounding the compensation proposal. As is clear from the preceding discussion, we cannot find these arguments persuasive. Human life is a very great value indeed, and it is surely incumbent on anyone arguing against donor compensation to make an extremely compelling case. As economists, we are admittedly consequentialists in these matters. In fact, we find the arguments presented by opponents of compensation to be very weak. It appears that much of the informed opposition may actually represent a deep and understandable aversion to the prospect of poor donors selling their organs for the benefit of wealthy patients, albeit this aversion is couched in an ethical language.

In Chapter 8 we come to the specifics of our proposal. We describe institutional arrangements for the introduction of compensation. We provide a simple mathematical analysis of the likely appearance of a socially directed monopsony procurement organization and establish several propositions regarding the forms compensation might take. We suggest that, in general, both living and deceased-donor kidneys would be rewarded by such an entity, and at differing levels, at least in the early stages and in countries with severe shortages. We review the limited empirical evidence relevant to the question of organ compensation rates, and we argue that payments are likely to be well below those levels at which cost savings are consumed in acquisition expenses. On the contrary, it is quite likely that organ acquisition will be cheaper under a compensation program. We review the performances of legal markets for other body parts, such as those for blood products and sperm, and find no inherent and obvious difficulty with a regulated compensation scheme. We also address the issue of the effect of offering compensation on altruistic donation levels. Criteria for organ recipients, as well as donor evaluation and enrollment, are also reviewed. We argue that the introduction of compensation for organ donation, for both deceased donors (all organs) and living donors (kidneys), could be implemented quickly in many countries. Trials are an obvious first step.

Chapter 9 summarizes our recommendations. On balance, we think it is fair to say that the existing system is unacceptable. Current procurement efforts do not utilize the strongest and most efficient means of obtaining additional organs for transplantation. Compensation will increase the number of organs available with no reduction in their quality. Huge amounts of money, and many thousands of lives, could be saved by this reform. No person needs to be unfairly exploited to accomplish this. Indeed, it is the current system, with its unnecessary deaths, thriving black markets, and astronomical public costs, which represents exploitation in its most unjust sense. Of course, if everyone agreed with these opinions and with the evidence presented to support them, it would be difficult to see how the current system could have survived to the present day. That it has survived, however, is obvious. Explaining how we got to this point and, more importantly, how we can get away from it is our purpose. If this effort hastens the demise of the present system for obtaining organs for transplantation, then we shall be very glad indeed.

2

The Evolution of Organ Transplantation and Procurement Policy

Introduction

Before we can successfully diagnose the underlying causes of the organ shortage and prescribe an effective remedy, it is useful to examine the origins of the current system of organ procurement and transplantation. Accordingly, in this chapter we describe the historical paths that have led to modern transplantation technology and the organ procurement policy that supports it.

We acquaint the reader with the genesis, advances, and constraints of organ transplant technology—and we hope to instill some appreciation for this rather amazing medical achievement. We continue with a description of the important aspects of an organ transplant process. We list the types of transplants and sources of organs, and we examine the patients’ perspective. The focus of a later section of this chapter is the existing procurement system, established practically worldwide, and its philosophical-ideological base: altruistic donation. The chapter ends with a summary of these discussions.

In the Beginning:

The Technological Challenges and Advancements

Early History and Advances

The familiarity and almost routine nature of modern organ transplantation mask the incredible achievements that have led to this important tool of modern medicine. Indeed, the first reported transplant that most people remember was the one performed by the Saints Cosmas and Damian. The miracle reportedly occurred in the late second century CE, and it is still commemorated in the Liturgy of the Mass of the Roman Catholic Church.¹ As portrayed by many pious artists over the centuries, the physicians Cosmas and Damian grafted the leg of a deceased Ethiopian onto the body of a patient whose own leg was diseased. This act, of course, was regarded as miraculous, and by means of such wonders Cosmas and Damian converted many pagans to Christianity, an achievement for which they were later martyred.

The apparently miraculous character of transplants between persons would persist for a very long time. From a technological standpoint there were two major hindrances. First, the surgical techniques that would allow for the attachment (or reattachment) of living tissue would not be discovered until the early 1900s, when future Nobel laureate Dr. Alexis Carrel published his findings on vascular anastomotic techniques, first in France and later in the United States.² Dr. Carrel pioneered techniques that made it possible to graft together veins and arteries, establishing sufficient blood flow to support organ survival. He worked for a time in Chicago with surgeon Dr. Charles Guthrie, and the pair performed several important transplantation experiments on animals. These techniques, which are among the most important discoveries in medical history, led to Carrel’s Nobel Prize in Physiology in 1912.

A second difficulty, however, undermined the early optimism that attended Dr. Carrel’s discoveries. Although blood typing was discovered by Karl Landsteiner as early as 1901, it would not be until many years later that the mystery of why some blood transfusions worked and others caused the patient to die would be resolved. Carrel himself was able to transplant animal kidneys to different locations in the donor’s own body with great success, but he found that transplants between different animals—even of the same species—generally quickly failed. Dr. Reuben Ottenberg performed the first blood transfusion utilizing blood typing in 1907, but many attempts at solid organ transplants were unsuccessful. It was observed that the patient would first develop a fever, and then the organ would fail within a relatively short time unless the donor was either the patient himself (termed an autograft) or the patient’s identical twin (termed an isograft). Transplants between people who were less closely related,