Infographic on kidney crisis courtesy of Living Kidney Donation, UK

The above infographic is a great illustration of the huge gap between supply and demand for organs for transplant.  Last week I wrote about how this gap creates desperation.  I wrote about how journalistic stories often oversimplify the issues and contribute to alarmism about organ trafficking.

To be clear, I am in no way advocating illegal trafficking of human organs.  However, I would like to go beyond a surface discussion and consider bioethical, economic and legal issues.  My hope is to encourage deeper thought and discussion about this serious problem.   The lives of both those needing transplant and living donors (God forbid against their will) are at stake.

Today I’m writing about the bioethical debate.  The treatment of human organs as commodities and whether or not they should be bought and sold in a market is a highly emotional issue.  The polarization of viewpoints generally tends to prevent discussion that contributes to finding a way through the issues to solutions.  For the most part, the debate centers on whether or not impoverished donors are coerced due to their dire economic circumstances and whether or not they receive proper medical treatment.

Poverty as socially structured coercion.  This argument states those most likely to sell a kidney are compelled to do so because of their circumstances and therefore are not responsible for their decision to sell a kidney.  To some ethicists, people free from poverty cannot understand the coercion of poverty.  Individuals not in poverty do not have to face choices between letting their children starve or doing anything to prevent that (such as selling their body parts).

In other words, poverty is socially structured coercion.  Coercion is implicit in situations where people are forced to consider selling their organs and is therefore morally condemnable.  Miran Epstein further argues that the bioethical debate inherently helps to conceal this type of structured coercion.  This school of thought believes that putting a price tag on a human organ causes individuals who would not otherwise consider living organ donation for free; therefore coercion in the decision is inherent.

Individuals are fully autonomous in decision making.  The flip side of the argument is even individuals under duress can still be fully autonomous in their decisions provided that the subjection to duress was not imposed by others with the aim of making them choose the course of action.   Stated more plainly, unless the coercion is specific to the action, then the individual’s decision is autonomous.  Society allows payment for other risky, altruistic behaviors (which often disproportionately attract the poor) such as soldiers, fire-fighters and oil rig workers.  Pattinson that merely offering financial incentives for risky activities does not constitute coercion unless all such activities are deemed impermissible.  The coercion argument has also been used to argue against the use of lotteries by states arguing that lotteries are essentially a regressive tax unduly taking advantage of the poor.

I personally wonder the limit is of arguing that poverty inherently coerces the poor.  Are impoverished individuals always absolved of all personal responsibility for their decisions and related consequences because they are poor?

Are human organs commodities?  A second ethical argument regarding organ markets centers on whether human organs should be considered commodities.  This argument pits the philosophy of “human solidarity” against “commoditization”.  The side against the selling of human organs argues that altruistic giving is the best expression of human solidarity.  Only altruistic donation prevents human organs from becoming commodities.   The gift of a human organ is a gift of the highest magnitude and a heroic act.  This viewpoint generally does not trust that living unrelated organ donation would be done for purely altruistic reasons. Personally, this strikes me as ironic since there are clearly examples of altruistic living donation on the rise.  The counterpoint for this viewpoint is that other human parts are already treated as commodities.  Examples include sperm and eggs.

Mark Cherry, a bio-ethicist at St. Edwards University in Austin, makes one of the more coherent arguments regarding medicine as a commodity.  He argues commoditization is already fact:

“its [medicine’s] goods and services are bought and sold, valued over against other goods and services, are the subject of economic choices and are given a monetary equivalence.  Physicians and hospitals demand payment for services rendered.”

If medical goods and services are already given monetary value, including human parts such as sperm, eggs and blood, then a monetary value on an organ is different in only one way, that the donation act carries more risk for the donor than does the act of donating sperm, eggs and blood.  This risk is the important point to those arguing against financial pricing of organs.  Putting humans at risk when the surgery is not required for the patient is the issue.  Davis and Crowe argue  that the donor could become “little or nothing more than a means — that he or she will come to have a purely instrumental value for achieving the end of healing for the recipient.” Performing surgery on donors and putting them unnecessarily at risk (which can be considered the case when donation is unrelated to the recipient and for monetary gain only) is contradictory to the philosophy of medicine.  My personal thoughts are that there are people who are willing to do sacrificial giving, which I have written about before.

Next time:  legal issues.

References

Cherry, M.J. (2009). Why Should We Compensate Organ Donors When We Can Continue to Take Organs for Free? A Response to Some of My Critics. The Journal of Medicine and Philosophy, 34, 649-673.

Davis, F.D. and Crowe, S. J. (2009). Organ Markets and the Ends of Medicine. The Journal of Medicine and Philosophy, 34(6), 586 – 605.

Epstein, M. (2007). The ethics of poverty and the poverty of ethics: The case of Palestinian prisoners in Israel seeking to sell their kidneys in order to feed their children. Journal of Medical Ethics, 33(8), 473-474.

Epstein, M., and Danovitch, G. (2009). Is altruistic-directed living unrelated organ donation a legal fiction? (2008). Nephrology Dialysis Transplant Journal, 24, 357-360.

Pattinson, S. D. (2008). Organ trading, tourism, and trafficking within Europe. Medicine and Law, 27(1), 191-201.

Taylor, J.S. (2009). Autonomy and Organ Sales, Revisited. The Journal of Medicine and Philosophy, 34, 632-648.