(Doctor's Office by Maggie Osterberg; some rights reserved.)

Long before the July arrest of Levy-Itzhak Rosenbaum, the alleged organ broker swept up in the bust that netted an array of New Jersey politicians and Syrian rabbis, the writer Amy Fox had envisioned a fictional version of him. And well before a Swedish newspaper published a spurious account of IDF soldiers harvesting organs from slain Palestinians, Fox—sensitively, soberly—imagined what it might be like for an American-Jewish family to acquire a black-market kidney from a (living) Palestinian child. In her novel in progress, Signs of Rejection—an early chapter of which is excerpted here—Fox, a playwright and professor at NYU’s Tisch School, examines the extraordinary financial and emotional costs a family is willing to bear in an effort to save a child’s life.

* * *

David knew where the phone number was, scratched quickly in blue pen on a 3-by-5 index card in the top right drawer of his office desk. He had never recopied the number, and it still said the words “broker” and Zvi. There was a file too, for the paperwork, although there had never been very much of that. It was a handshake kind of business. But David was the kind of person who opened files—a case never felt quite real until it had a manila folder of its own. So there was one for this too, but with no label, although he kept it alphabetized under “k,” for Kevin or kidney; he had never quite decided. He remembered the chain of events with terrifying clarity. The first thing had been the phone call from his sister Danielle, who had just moved to Jerusalem with her new husband.

“David, I’m telling you, people here don’t wait for their name to come up on some endless list. Everywhere I go it seems like somebody has bought one. Or at least knows somebody who has. It’s not some deep dark secret here, people are pretty matter-of-fact about it. You call a broker, they tell you what it costs, and they set it up. It’s all included in the price—the surgery, transportation, they do it all kinds of places. It actually sounds kind of easy. And compared to what you’ve been through … and Kevin.”

That was all she had to say, really. And Kevin. What kind of parent lets their 13-year-old son suffer when halfway across the world people are contacting brokers every day, setting it up? He had heard rumors before; there might have even been whispers or hints he could have followed up on, to find out how these illicit purchases came about. He had once browsed an eerily serene website which promised to link people up with kidney “donors” from all over the world in a matter of weeks. The website didn’t say anything about money, but it wouldn’t have. There was only a post office box to write to for more information. He had never done so, and he’d never visited the site again. But Danielle said she could give him phone numbers. Just say the word, she said, and I can get you two, maybe even three phone numbers, for brokers.

Brokers. He wrote the word down on the card because it sounded so ridiculous. He put an exclamation mark after it. Brokers! Later, he found that the man they used, Zvi, preferred to be called an international transplant coordinator. But David sometimes thought of that word—broker, picturing a man in a dark blue suit with a sleek briefcase crunching numbers far away from anything resembling a hospital.

He had gone home that night, gone home to their large brick box of a house, home to the endless thump of the basketball belonging to the neighbors’ unfailingly robust boys, home to Ellen and Lila and Kevin. And Kevin.

He was never able to tell anymore, day by day, how Kevin was doing. Does he look more tired? Ellen would ask, is his face a strange color, stranger even than yesterday? David would shrug, which upset Ellen, as if shrugging to say I don’t know was indistinguishable from I don’t care. But Kevin himself couldn’t always judge, and they all relied on tests in those days, numbers typed on lab reports, even the trusty scale at the doctor’s office to tell them how things were progressing.

* * *

Just after dinner Danielle called again, this time with a phone number. Just so you have it, she said. She could get others, she reiterated. But this guy had a really good reputation. David wondered if she wasn’t getting a little too drawn in by the element of shadowy drama, his sister the good girl, relishing the passing of illicit phone numbers. An hour later David and Ellen sat outside on the porch, the basketball steadily thumping in the background, their hands clapping half-heartedly at mosquitoes. Ellen listened intently, her forehead crinkling just slightly. We could call someone here or in Israel. But the surgery doesn’t usually happen in either place. There are countries where things are monitored less, where the government looks the other way.

“And the person who sells the kidney,” Ellen asked, “how do they find them?”

“I don’t know,” David said, “I guess it’s not that hard to find somebody. I mean they get a lot of money, lot for them anyway.”

And Ellen nodded slightly, her expression thoughtful. The information was not new exactly; she too had checked out the suspicious website. But new for them, new as something they might actually consider. Looking back, David is surprised to realize that early on there was never a moment of conscious moral shifting. They did not change from people who would not participate in something like this to people who would. They simply transitioned from people who didn’t have the right phone number to people who did. Later there would be passionate debates over ethics. But in the beginning, it was simply a new possibility, something to be looked into. What he didn’t understand was how quickly things would unfold once they called that number, how he would feel even more urgently that this was his responsibility now, as a parent, to make this possibility real for his son.

Ellen wanted to ask Kevin what he thought, but David said it was a lot of weight to drop on a 13-year-old. Let’s just get some more information, he argued. There’s a lot we don’t know about it yet. But the truth was, David wasn’t sure he wanted a lot of information. The issue would come to seem complex and murky, and he wanted it to remain very simple. Kevin. The eerily pale boy who was right now watching a Yankee game on TV, getting popcorn all over the couch and hugging a fat cushion like it was the pet rabbit he was always begging for. That boy. That’s how clear it should remain.

* * *

The guy had a slight Israeli accent.

“I have done this many times for many people,” he reassured David. “Not to worry.”

David remembered an Israeli tour guide who had always used this expression. Half the group was lost and hadn’t been heard from? Not to worry. Somebody’s camera was missing? The cave entrance looked too small for a fat tourist to crawl through? At the end of the trip, somebody had T-shirts printed with NOT TO WORRY printed in block letters.

“It’s very easy,” the guy said. The broker. “Really what we need money. After that it’s very easy.”

David wanted to correct him. What you need is money, what I need is an organ.

“But what about finding a match?”

“I will find you a perfect match. Better than his own brother, this match. There will be no problems. Not to worry. I’m giving you the name of a doctor in New York. This man is a nephrologist, very good, the best. You will go to him, get the tests, we find a match. It is not difficult.”

The fee was $130,000, cash, paid in advance. David asked how much the donor would get, immediately recognizing that he was using the wrong word.

“The seller, he is paid well. Not to worry about him. But most of the money, much of the money goes to the surgeons. This is a risky business for them; we have to pay them well. I take a modest fee. It is risky for me as well. But the surgeons, they could lose their license.”

* * *

David and Ellen began a nightly ritual of unspoken dialogue. During dinner, while he was forking a stubborn potato, or she was cutting meat off the bone, their eyes would meet, a gaze held steady with mute question and answer. Will we or won’t we. It seemed any question they actually verbalized would seem disloyal to Kevin somehow. As if there was anything—money or law—that they valued more than their child.

It became a mundane matter of making a doctor’s appointment. No different from any of the thousands of doctors’ appointments they had made over the years. David simply picked up the phone and committed to Monday at 3 o’clock. He marked the date in his calendar with the strangely deliberate handwriting he had written down what Danielle and Zvi had told him. He didn’t say who had referred them, and the pleasant receptionist didn’t ask.

They decided to talk to Kevin on Sunday night. Ellen sat on his bed, playing with the tassels of a brown afghan. David leaned against the closet door. Kevin was at his desk—he never went near his bed when he was feeling well.

“You guys are creeping me out,” Kevin said after a weighty silence.

David looked at Ellen. She was braiding the yarn now, with steady fingers.

“Your mother and I have been looking into some new possibilities,” David began. “In terms of getting you a transplant. And it looks like there may be a way to make that happen sooner rather than later.” He couldn’t look at Ellen now. He knew his words were clunky and imprecise.

Kevin was blinking his blue eyes at him.

“We may have to travel somewhere, for the operation.”

As if that were the biggest obstacle. An airplane flight.

“What about the list? Am I moving up?”

“This is different from the list. It turns out there are some other ways to do this.”

“It turns out,” Ellen abruptly echoed, almost mocking him.

He stared at her hard. He needed her loyalty on this; they needed to erase each other’s doubts.

“But what about the list?” Kevin asked again, faintly this time, as if he was beginning to understand.

“It turns out,” Ellen said, her voice strained, “that you can make a lot of things possible, if you are willing to pay for them.”

David was about to interject, but Kevin nodded as if her words made perfect sense. This was terrifying. There was no semblance of innocence these days, no childhood protected from awareness of money and power.

“You’re bribing someone?” Kevin asked.

“Well something like that,” David admitted, “but it’s totally separate from the waiting list. Basically, what it is is—”

Ellen was shaking her head as if she was truly disgusted with his inability to explain the situation in plain words. He took a deep breath, determined to prove his words could land squarely on the ground.

“Basically it’s buying the organ. Somebody decides to sell their kidney, and then we have the option to purchase one.”

“Why would someone do that? Kevin asked, and then the glimpse of naiveté was gone. “For the money.”

“Basically,” David said.

“It’s a decision we have to make,” Ellen said. “All of us. We’re not asking you to make the decision, but we won’t make it without you.”

Now it was her words that threatened to float away, abstract and full of breezy contradiction.

“The first step is,” David said, “for you to see this doctor. He’s a nephrologist in the city. He’ll help us find a match.”

“So we’re doing this?”

“It’s a decision we have to make,” Ellen said again. There were six tight braids of brown yarn now, twisted by her fingers.

“Do you want to ask us anything?”

Kevin shrugged, a troubled expression in his eyes.

“It’s weird,” he said, “it sounds kind of screwed up.”

* * *

The doctor didn’t operate out of a dark alley. His office was on a quiet street of brownstones on the Upper West Side, his name typed in thin black letters on a copper plate. There was an orange haired receptionist who signed them in without any unusual scrutiny. There were the same magazines in the waiting room—Kidney Forecast as well as Good Housekeeping and Men’s Health. There was an old man with startling white hair waiting near the water cooler, and a heavy woman in purple paisley. David found himself staring. Were these people also purchasing? Or did Dr. Chen have two kinds of clients. Did the receptionist know the difference?

In the car, Kevin had asked why they couldn’t go back to his regular doctor.

“Not every doctor does this kind of thing,” David explained patiently.

He could feel Ellen next to him, simmering like a pot about to boil. She pursed her lips. David shook his head, but it was too late.

“It’s illegal”, she said


David saw years of careful parenting flushed down the gutter. Right and wrong, society’s code, all these concepts painstakingly explained to a child.

“Like we could, go to jail?” Kevin asked

“No, no—the laws aren’t usually enforced. Can you imagine—the cops spending their precious time arresting sick kids? The most it would be is a fine.”

“But couldn’t you be disbarred?”

Ellen was watching him. This was one of the silent questions they had been asking themselves. He tried to laugh it off.

“Kevin, I could be disbarred for lighting firecrackers.”

“I doubt it.”

“There’s always a risk. Okay? But I don’t want you to worry about that. That’s my decision.”

“Why is it illegal?”

“Because the government doesn’t want people getting money for giving up a part of their body. They’re worried about exploitation.”

“You know what exploitation is?” Ellen asked

Kevin and David both gave the same snort of irritation. Of course he knew. He was not, exactly, a child.

* * *

Dr. Chen was a thin Chinese man with long fingers and a soft voice. He sounded like a man who repeats things often and with great patience.
“You’ve had most of these tests before, I know, and I’m sorry to do them again. But we want to get you the right match.”

Kevin nodded.

“How much does he get?”

David was shaking his head, but Dr. Chen looked unperturbed.

“I’m just here on the medical side of things. To make sure you’re in good shape for your transplant. That’s my responsibility here.”

Kevin nodded again. He got it. He held out his arm.

“Luckily I’ve got great veins.”

Luckily. Some gene in there actually came through. David watched the familiar rush of blood into clear tubing. The same deep red as his own. David wanted to see the toxins, wanted to understand how contaminated blood could look so normal. He looked down at his own veins. Mr. Haven, his third grade science teacher, had wowed them all by announcing that blood is blue until it hits oxygen. David and the other boys spent recess pricking their fingers with safety pins, trying to catch a glimpse of blue, to witness the instant of transformation. But the droplets were red, red, red; the body held fast to its mysteries.

“I’m AB,” Kevin was telling Dr. Chen, a trace of pride in his voice. He knew the ramifications of this, how difficult it was to find compatibility, but he spoke as if it were an asset. David’s own blood type was compatible, but not his tissue type. And Ellen, Lila, how was it possible that not a single one of them could give Kevin what he needed? And yet, somewhere out there was some distant person from who knew where, the perfect match.

“Don’t worry,” Dr. Chen said, “we’ll find somebody.”

Somebody. Somebody AB, with the right markers on their white blood cells, tissue type DR, and what—the right level of desperation?

“We will actually be mixing your blood with the blood of the potential match to check for a reaction,” Dr. Chen explained.

David could see it. The two test tubes spilling together, red blood with red blood, indistinguishable to the eye. But somehow Kevin’s blood holding its own chemical legacy, its own toxins, its own memory of having flowed blue.