The Ethics of Free-Market Kidneys, Part 1

February 4, 2014

In some countries selling one's organs is perfectly legal. In the United States, it is against the law, although many people have suggested that legalizing the trade would save lives and offer real social benefits. Others find it an ethically dubious proposition.

Discover magazine noted that the need is dire, and that "those needing a kidney vastly exceed the number of kidneys available from deceased donors. In the United States, some 88,000 individuals were on the waiting list as of early 2010, with 34,000 names typically added every year. The wait averages five years" (Bhattacharjee 2010).

Though organ transplants have been done for decades (with varying degrees of success, depending on many conditions including the type of organ and the compatibility of the donor and recipient), it wasn't until the early 1980s that the picture changed. That was when an immunosuppressant called cyclosporin was created, which dramatically reduced the problem of organ rejection from unrelated donors. It quickly became possible to transplant kidneys from outside the immediate family, which made stranger organ donations (and sales) possible, and "The first reports of kidney selling began to surface in India around 1985" (Bhattacharjee 2010, 67).

Despite rumors and urban legends about kidney theft, the fact is that for practical purposes kidneys cannot be stolen. Willing donors are required, and many are available. Lawrence Cohen, a researcher at the University of California-Berkeley, "has worked in cities and towns in India, and reports that the idea of trading ‘a kidney for a dowry' has become a fairly common strategy for poor parents trying to arrange a comfortable marriage for an ‘extra' daughter: in other words, a spare kidney for a spare daughter" (Scheper-Hughes 1998).

The cost for a kidney depends on demand, the country where the organ is procured, and other factors; according to a recent estimate (Tsai 2007), a kidney can cost $25,000 in Russia; $80,000 in Colombia; $20,000 in Iraq; $120,000 in South Africa; and $145,000 in Turkey. With such disparity in pricing, it is inevitable that kidneys-like any other commodity subject to free market pressures-will be taken from where they are cheapest: typically poorer countries.

In response to growing concern over the organ trade, several governments took steps to address the issue. In 1994 the Indian legislature passed the Human Organs Act, which banned the practice of buying and selling organs (though a loophole in the law allows people who are related to the recipient only by "ties of affection" to donate organs under some circumstances). A decade later in England the Human Tissue Act was passed, which allowed for anonymous organ donation and required that the wishes of the dead donor take priority over any relative's wishes. As noted, the United States also banned organ sales.

Legalizing Organ Sales?

New York Times columnist Nicholas Kristoff noted that the current ban on any payment for organs "costs up to 6,000 American lives a year, far more than will die in Iraq. A furious debate erupted in the medical community this year on this issue, and by the time the policy is overturned-as it will be-it'll have killed more Americans than the entire Vietnam War." The solution is simple: legalizing kidney sales. "Nobody is talking about payments to live donors," Kristoff notes, "only to the estates of the dead. One proposal is to offer $2,000 or so of the funeral costs of anyone who has contributed organs."

Professor David Kaserman (2002), author of The U.S. Organ Procurement System: A Prescription for Reform, points out that because kidney dialysis is much more expensive over the long term than a transplant operation, it would be cost-effective to legalize organ trade: "We're losing 6,000 lives a year, more than twice the number killed in the 9/11 attacks. And if we were paying for the organs, federal expenditures would go down. So we're actually spending money to kill people."

Of course kidneys are not the only body parts subjected to commerce: women sell their eggs, men sell their sperm, and so on. In their analysis of the economics of organ trade, Gary Becker and Julio Jorge Elías (2007) note that "Proposals to pay for organs, even from cadavers, have been sharply criticized on several grounds. One of the most common is that payment is ‘immoral' because it involves the ‘commodification' of body parts. Individuals who make this argument deny that people have the right to control the use of their bodies. If women can get paid to host the eggs of other women and bear their children-as they can in the United States-why cannot men and women get paid for selling their organs to save the lives of others? Surely, the moral considerations involved in allowing pay for organs that save lives are no weaker, and for many persons would be stronger, than those involved in allowing pay for the use of wombs to create lives" (Becker & Elías 2007).

Indeed, college newspapers across America often contain advertisements offering money for students' blood; the ad placement is not a coincidence. Students are typically young and poor, and the extra cash comes in handy. Few people see an ethical problem with this situation, but on a basic level there seems little difference between that and kidney selling. In both cases needy and underprivileged people offer important, medically useful parts of their bodies to others in exchange for money.

"Free trade proponents argue that donors would fare much better under a government-regulated program, which could provide incentives such as lifelong health insurance or college tuition for the donor's children" (Bhattacharjee 2010, 76). It's hard to argue with this; many parents-especially in impoverished countries-spend many years trying to provide for their families and children. If a man or woman can provide an education for their child by choosing to donate a kidney instead of working for a decade sweeping streets, picking crops, or breaking ships, why shouldn't they be given that opportunity?

Indeed, that argument is advanced by Tarif Bakdash, an Assistant Professor in Bioethics at Damascus University, who writes "that the sale of organs should be legalized and regulated" (Bakdash & Scheper-Hughes 2006). Becker and Elias (2007) point out that "the most egregious effect of the organ shortage on those people who wait is the suffering and the deterioration in the quality of life while waiting for an organ. For example, most people waiting for transplant are unable to work." Furthermore, the authors "show that monetary incentives would increase the supply of organs for transplant sufficiently to eliminate the very large queues in organ markets, and the suffering and deaths of many of those waiting," with minimal increase in cost.

Even when no money changes hands, there can be other, more subtle pressures.
Time magazine writer Christine Gorman (2000) noted that "It is no longer unusual for a spouse or relative to donate a kidney to a loved one," though often times these close ties can complicate the process because of strong unspoken pressure on healthy people to donate an organ. "'There's often the feeling that you're not a good friend, father, mother if you don't do this,' says Arthur Caplan, director of the University of Pennsylvania's Center for Bioethics. Some transplant centers will invent a ‘medical problem' on behalf of those who are reluctant to donate but feel they can't say no.'" This raises a further ethical quandary, since one cannot legislate against such familial pressures.

 


Part 2 will appear next week

 


References


Bakdash, T., Scheper-Hughes, N. (2006). Is It Ethical for Patients with Renal Disease to Purchase Kidneys from the World's Poor? PLoS Med 3(10): e349. doi:10.1371/journal.pmed.0030349

Becker, G. & J. Elías. (2007). Introducing incentives in the market for live and cadaveric organ donations. Available at
http://graphics8.nytimes.com/images/blogs/freakonomics/pdf/BeckerEliasOrgans(5-06).pdf

Bhattacharjee, Y. (2010). The organ dealer. Discover, April, 65-96.

Gorman, C. (2000). Spare a kidney? Time. March 13, 98.

Human Rights Watch/Asia. (1994). Organ procurement and judicial execution in China. Human Rights Watch report, August, Vol. 6, No. 9. Retrieved from
http://www.hrw.org/legacy/reports/1994/china1/china_948.htm.

Kaserman, D. (2002). The U.S. Organ Procurement System: A Prescription for Reform. New York: Aei Press.

Kristoff, N. (2002). Psst! Sell your kidney? The New York Times, November 12. Available at http://www.nytimes.com/2002/11/12/opinion/psst-sell-your-kidney.html.

Radford, B. (2008, February 19). The truth about sensational kidney thefts. LiveScience.com, available at http://www.livescience.com/4826-truth-sensational-kidney-thefts.html.

Scheper-Hughes, N. (1998). Truth and rumor on the organ trail. Natural History 107(8), 48-56.

Tsai, M. (2007). Organs for sale. Wired, April, p. 48.

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