Transplantation at Any Price?

In the face of the lethal gap between supply and demand, some experts (1Wight JP Ethics, commerce and kidneys.BMJ. 1991; 303: 110Crossref PubMed Scopus (9) Google Scholar, 2Radcliffe-Richards J Daar AS Guttmann RD et al.The case for allowing kidney sales.Lancet. 1998; 351: 1950-1952Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar, 3Harris J Erin C An ethically defensible market in organs.BMJ. 2002; 325: 114-115Crossref PubMed Scopus (84) Google Scholar) including Arthur Matas (4Matas AJ The case for kidney sales: rationale, objections and concerns.Am J Transplant. 2004; 4: 2007-2014Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar), have concluded that the fastest way to increase the supply of kidneys is to permit living persons to sell one of theirs. Matas argues that, at least with respect to the developed or what he terms ‘Western world’ a ‘regulated vendor system’ would •increase the supply of kidneys,•not violate any key ethical norms and•have a reasonable chance of implementation and success. Does he make a convincing case? What does the evidence about existing commercial markets involving living persons reveal? Nothing that supports Dr. Matas' case or other proponents of kidney sales. There is ample evidence that existing markets in nations such as India, have failed dismally (5Rothman DJ Rose E Awaya T et al.The Bellagio Task Force report on transplantation, bodily integrity and the international traffic in organs.Transplant Proc. 1997; 29: 2739-2745Crossref PubMed Scopus (72) Google Scholar). They have not produced a large number of successful kidney transplants due to the high failure rate associated with bought kidneys (6Goyal M Mehta RL Schneiderman LJ Sehgal AR Economic and health consequences of selling a kidney in India.JAMA. 2002; 288 (1589–93)Crossref PubMed Scopus (292) Google Scholar). There is overwhelming evidence that kidney sales have resulted in diminished health and emotional disappointment among the desperate, and often frail sellers of kidneys (5Rothman DJ Rose E Awaya T et al.The Bellagio Task Force report on transplantation, bodily integrity and the international traffic in organs.Transplant Proc. 1997; 29: 2739-2745Crossref PubMed Scopus (72) Google Scholar, 6Goyal M Mehta RL Schneiderman LJ Sehgal AR Economic and health consequences of selling a kidney in India.JAMA. 2002; 288 (1589–93)Crossref PubMed Scopus (292) Google Scholar, 7Ram V International traffic in human organs.Frontline. 2002; 19: 6-10Google Scholar, 8Wilkinson S Bodies for sale: ethics and exploitation in the human body trade. Routledge, London2003Google Scholar). Matas attempts to avoid the implications of this hard evidence that markets do not work by restricting his case for sales to the developed world. But, would such a market really be independent of the problems that have plagued the poorer parts of the globe? The current flow of illegal immigrants into North America and Europe make it highly unlikely that adequate controls could be put in place to prevent those in the underdeveloped world from selling their organs in the markets of the developed world. Matas focuses his ethical analysis of kidney markets on the claim that sellers will be exploited. He rejects this argument noting that the poor are capable of rationality when it comes to sales and the inequity he sees when only those who supply parts among all involved with transplants are asked to go without compensation. On ethical grounds, however, his argument is wanting. The issue is not the rational capacity of the seller, but the likely absence of real alternatives. It is hard to imagine that there will be numerous persons in wealthy Western nations eager to sell a kidney unless their compensation were significant. That has been the experience with markets in egg sales and paid surrogacy in the United States (9Harris J, Holm S. (eds). The future of human reproduction. UK : Oxford 2000.Google Scholar, 10Macklin R Is there anything wrong with surrogate motherhood?.in: Gostin L. Surrogate motherhood. Indiana University Press, Bloomington ; Indiana1990: 136-151Google Scholar). Choice is imperiled by high compensation, not because the sellers are rendered irrational by the prospect of money, but for those in need of money certain offers, no matter how degrading, are irresistible (10Macklin R Is there anything wrong with surrogate motherhood?.in: Gostin L. Surrogate motherhood. Indiana University Press, Bloomington ; Indiana1990: 136-151Google Scholar, 11Lyons D Welcome threats and coercive offers..Philosophy. 1975; 50: 23-32Crossref Scopus (29) Google Scholar, 12Macklin R Due and undue inducements: on paying money to research subjects.IRB. 1981; 3: 1-6Crossref PubMed Google Scholar). Those who are in need of money might rationally decide to sell their children, but the sale of babies is not permitted because this is seen as a gross exploitation of the poor if they have no options but to resort to child sales. It is precisely for this reason that severe restrictions are in place on what can be paid to subjects who ‘volunteer’ themselves or their children for medical experiments and toxicity testing (12Macklin R Due and undue inducements: on paying money to research subjects.IRB. 1981; 3: 1-6Crossref PubMed Google Scholar). The possibility of making a lot of money relative to one's means also creates enormous pressure from third parties on the prospective seller to ‘choose’ to sell. Those in severe debt with no alternatives cannot truly be said to choose to become organ vendors if those to whom they are in debt force them into sales. Choices require options as well as the ability to reason about them. Matas has not, however, grasped the real ethical nettle with his focus on exploitation. The debate about whether exploitation is inevitable in markets in rich or poor countries misses the two most important reasons why allowing the sale of kidneys is unethical. Participation in sales, even in a tightly regulated market, violates the ethics of medicine. And markets will prove next to impossible to implement in North America and Europe on ethical grounds. Medicine has long held that the core ethical norm of the profession is the principle ‘Do no Harm’. Taking organs from living persons is in direct violation of this moral norm. The only way in which it seems morally defensible to remove an organ from someone is on the grounds that the donor chooses to undergo the harm solely to help another and that there is sufficient medical benefit to the recipient. The creation of a market puts medicine in the position of removing body parts from persons solely to abet their interest in securing compensation for themselves. Is this a role that medicine can ethically countenance? What would such a role do to public trust in physicians? The goal of medicine is the alleviation of illness, disability and suffering not finding ways to permit persons to make a profit for themselves by interventions that cause them permanent and significant harm. A key moral problem with markets in kidneys and other body parts is what it does to the ethics of the medical profession. In a market, even a regulated one, doctors use their skills to help people harm themselves for money and solely for money. Even if it is possible to get past the facts that there is no data that existing markets in organs have done much to increase the supply, that there is exploitation associated with such markets and that a market using living sources severely compromises the ethics of the medical profession, is there any real chance of shifting public policy toward a market? What little data exist show health-care providers opposed to markets (13Jasper JD Nickerson CAE Ubel PA Asch DA Altruism, incentives and organ donation.Med Care. 2000; 42: 378-386Crossref Scopus (26) Google Scholar). If they are not willing to support them then they simply will not be implemented. Major religions in the developed world will not countenance a market in living body parts (14Stempsey WE Organ markets and human dignity: on selling your body and soul.Christ Bioeth. 2000; 6: 195-204Crossref PubMed Google Scholar, 15Goodenough P. Pope nixes embryonic cloning, okays organ donation, 2000; Available at http://www.christianity.com/partner/Article_Display_Page/0,PTID5339%7CCHID24%7CCIID139361,00.htmlGoogle Scholar). The Pope, for example, has made himself quite clear about the Catholic church's aversion to markets in organs. Anglo-American law, ever since the days in which markets in body parts resulted in graveyards being stripped to supply medical schools with teaching materials, has not recognized any property interest in the human body and its organs (16Meyers DW The human body and the law. Stanford University Press, Stanford1990Google Scholar). Alienating religions and cultures, which do not view the body as property, would have a devastating impact on the supply of organs available. Indeed, some sub-populations in the United States are as likely to be turned off by the institution of a market in body parts due to their historical experiences with slavery and a keen distrust of medicine as they are to be motivated to become sellers to the rich (17Minniefield WJ Yang J Muti P Differences in attitudes toward organ donation among African Americans and whites in the United States.J Natl Med Assoc. 2001; 93: 372-379PubMed Google Scholar, 18Siminoff LA Saunders Sturm CM African-American reluctance to donate: beliefs and attitudes about organ donation and implications for policy.Kennedy Inst Ethics J. 2000; 10: 59-74PubMed Google Scholar). The argument that increasing the supply of organs through sales will be implemented because it is cost effective is not persuasive. It will take real resources to try to regulate and police a market in organs. The rates of compensation required will likely consume any money saved by reducing the reliance on dialysis to treat patients. And the amounts of savings involved are not likely to be such as to overcome long-standing cultural resistance to permitting trade in body parts (16Meyers DW The human body and the law. Stanford University Press, Stanford1990Google Scholar, 19Scott R The body as property. Viking, New York1981Google Scholar, 20Fox RC Swazey JP Spare parts. Oxford University Press, New York1992Google Scholar). The case for kidney sales is not persuasive. Existing experience with markets has been dismal. Attempts to restrict markets to wealthy nations create onerous problems. The devastating moral cost to medicine of engaging in organ brokering is far to great a price to pay for the meager benefit that might be had by those in need of transplants.