Wednesday, November 23, 2016

Paying Bone Marrow Donors

US law says that "organ" donors, like those donating a kidney or part of their liver, can't be legally paid. However, most of the US supply of blood plasma comes from paid donors; indeed, the US exports blood plasma to other countries. While the US supply of blood for transfusions primarily comes from unpaid donors, a number of other countries (for example, in Latin America) rely on paid blood donors. Donors of eggs and sperm, as well as surrogate mothers, can be legally paid. But is bone marrow an organ, or is it more similar to blood plasma?

The answer to the question is a matter of life and death. About 275 American die every year because they have a disease like leukemia or certain kinds of anemia that sharply reduces the ability of their bone marrow to generate red blood cells--and they can't get a transplant. Offering payment of perhaps $2,000 to donors could potentially save those lives. Samuel Hammond makes the case in "Bone Marrow Mismatch:How compensating bone marrow donors can end the transplant shortage and save lives," written as a discussion paper for the Niskanen Center (November 15, 2016).

Developments in medical technology have given the arguments over paying bone marrow donors an extra twist. It used to be that bone marrow was extracted from donors by inserting a needle into a large bone, which was apparently even more painful than it sounds. But it's now possible to collect the cells through a technique called "apheresis," in which the cells are taken out of blood. The donor takes a drug a few days beforehand to stimulate production of these cells. Then the donor is connected to a machine so that some of their blood passes through the machine, which extract the needed cells and then returns the rest of the blood to the person.

About 70% if donations of the needed cells for bone marrow transplants now happen through the apheresis method.  The cells that are extracted by this method are just as good for bone marrow transplants as those from the big-needle-extraction approach. For donors, a Mayo Clinic study found that the frequency of adverse reactions by donors is lower than it is for standard donations of whole blood.

Thus, a federal court in 2011 ruled that apheresis was more similar to blood plasma donation than to donating a kidney, and thus donors could be paid. However, the federal government, through the Health Resources and Services Administration (HRSA) is now proposing a rule that would treat all all hematopoietic (that is, blood forming) stem cells as "organs," regardless of whether they were extracted by needle or by apheresis.

Here's a figure from Hammond that illustrates the situation. Transplants of HSC cells (that is,m hematopoietic stem cells) have risen from almost zero in 1990 to more than 6,000 per year. Extraction of the cells from apheresis, or from umbilical cords, is providing the additional source of cells for these transplants.

Peripheral blood stem cells

Hammond's report cites statistics that each year, about "30,000 people in the U.S. are diagnosed with a life threatening blood diseases like leukemia, of whom only 30% find a match within their family. For the remaining 70% who must find an unrelated donor," Although 6,000 procedures are carried out each year, another 10,000 are on the waiting list for such proposals. Several hundred of these people are dying each year while waiting for a HSC cell transplant.

There's a considerable literature of arguments most focused on blood donors and kidney donors, on whether paying donors is a good idea. Hammond offers an overview of these arguments, and they have arisen in various earlier posts here concerning blood and plasma, kidneys, and human breast milk. Interested readers might consult:

I won't try to review the arguments here, but several points are especially salient to me in this case. First, pretty much everyone else involved in HSC cell procedures gets  paid--doctors, nurses, equipment-makers, administrators--while the actual donors get a congratulatory lecture about doing their civic duty and a hearty handshake. Second, the volunteer system for signing up donors for HSC cell donation isn't providing a sufficient supply, and people are dying while the government writes new regulations.