This article was downloaded by: [University of Connecticut] On: 12 October 2014, At: 09:47 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Organ Markets: Problems Beyond Harms to Vendors a
b
Alexander M. Capron , Gabriel M. Danovitch & Francis L. Delmonico a
University of Southern California
b
University of California, Los Angeles
c
c
The Transplantation Society and Massachusetts General Hospital Published online: 17 Sep 2014.
To cite this article: Alexander M. Capron, Gabriel M. Danovitch & Francis L. Delmonico (2014) Organ Markets: Problems Beyond Harms to Vendors, The American Journal of Bioethics, 14:10, 23-25, DOI: 10.1080/15265161.2014.947048 To link to this article: http://dx.doi.org/10.1080/15265161.2014.947048
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Kidney Vendors in Regulated Organ Markets
Organ Markets: Problems Beyond Harms to Vendors
Downloaded by [University of Connecticut] at 09:47 12 October 2014
Alexander M. Capron, University of Southern California Gabriel M. Danovitch, University of California, Los Angeles Francis L. Delmonico, The Transplantation Society and Massachusetts General Hospital For more than a quarter century, the World Health Organization (WHO) has encouraged nations to ban the purchase or sale of human organs for transplantation from living or deceased donors (WHO 2010). Most countries now impose criminal penalties on organ commercialism, and the Council of Europe Convention against Trafficking in Human Organs, which received final approval by the Committee of Ministers on July 9, 2014, extends the offense of organ trafficking to include the actions of brokers in advertising for and recruiting organ vendors, as well as physicians who knowingly transplant a vended organ (L opez-Fraga et al. 2014). In the past decade, professional bodies such as the Declaration of Istanbul Custodian Group have actively promoted the adoption and implementation of laws to halt organ commercialism and transplant tourism (Danovitch et al. 2013). Nonetheless, as Julian Koplin (2014) describes, a vocal group of liberal philosophers and free-market advocates has argued that the shortfall in the supply of organs (particularly kidneys) for transplantation could be overcome through a “regulated market” (Matas, Hippen, and Satel 2008). The market proponents portray the tradeoff in terms of principles, between promoting liberty and extending human lives, on the one hand, and protecting human dignity and preventing commodification of the human body, on the other. They confidently predict that paying for organs would achieve the former, while loss of the latter would not prove harmful to society or individuals. But proposals to establish a regulated market in organs can also be viewed in consequentialist terms. Indeed, Koplin provides strong evidence that regulated markets will not in fact safeguard kidney vendors from physical, psychological, social, and financial harms—in other words, that they pose real threats to people, not solely to principles. Beyond those strong reasons for rejecting proposals to repeal the prohibitions on organ purchases, three objections that Koplin notes merely in passing deserve further exploration. First, regulated organ markets would be very expensive and complex to administer and risk creating real or perceived unfairness. Second, ample evidence exists that the form of regulated organ purchases being proposed would not increase the net supply of organs for transplantation. Finally, regulated markets contain the
seeds of their own undoing and would soon devolve into unregulated markets.
“REGULATED MARKETS” FOR ORGANS WOULD BE VERY EXPENSIVE AND COMPLEX TO ADMINISTER Some proponents of using payments to increase the supply of organs have actually accepted the conclusion of the Declaration of Istanbul that in the resource-poor countries where organ commercialism has been concentrated, buyers have targeted “impoverished and otherwise vulnerable donors,” which has led “inexorably to inequity and injustice” (Declaration of Istanbul 2008). Yet, they contend, such problems would not arise in wealthier countries where the financial incentives offered to organ vendors—principally to living persons who are selling one kidney, but also to the next of kin of deceased persons who permit removal of any transplantable organs—could be chosen so as not to appeal to the very poor, who want immediate cash. This is the heart of “regulating” the market in organs, namely, that payments would be in a deferred form, such as a deposit into a retirement or college account for future use, and that the amount would be set at a level appropriate to the risk and inconvenience involved—calculated at $15,000 by Gary Becker, the late Nobel laureate in economics—rather than an amount generated through the interplay of demand and supply. Beyond the expense that such a payment would add to the total cost of transplantation (namely, $1,500,000,000 more to clear the U.S. kidney transplant waiting list), the first objection to a fixed price is that it would not appeal equally to all groups in society. In order to offer a financial incentive that would be as attractive to high-income as to middle- or low-income people, the amount paid would have to vary according to each person’s income (or wealth). This would require potential organ sellers to disclose private financial information and administrators to investigate these submissions. To induce donation, advertisements would have to promise “You’ll get your fair reward,” rather than offering a set incentive to everyone.
Address correspondence to Alexander M. Capron, University of Southern California, USC Gould School of Law, Los Angeles, CA 900890071, USA. E-mail: [email protected]
October, Volume 14, Number 10, 2014
ajob 23
American Journal of Bioethics
Moreover, it would likely be widely objectionable if a wealthy person were offered $200,000 for his kidney on the ground that this would be equivalent to the $15,000 that would persuade a manual laborer to part with her kidney.
Downloaded by [University of Connecticut] at 09:47 12 October 2014
THE PROPOSED SYSTEM OF REGULATED PAYMENTS WON’T INCREASE THE SUPPLY OF ORGANS There are several reasons why a regulated market will not increase the net supply of organs. First, experience shows that paid donation does not add to the organ supply but merely replaces unpaid donation; conversely, prohibiting payment actually increases the supply. For instance, several years ago, after Israel stopped paying for its citizens to go to countries where they could get transplants with purchased kidneys, the numbers of both deceased and living related donors rose dramatically (Lavee et al. 2013). The phenomenon of “crowding out” occurs for two reasons. Psychic and reputational benefits to donors—both living individuals and the families of deceased patients— disappear when organ donation is no longer associated with altruism but with payment. Furthermore, potential recipients are reluctant to enter into the complex “gift relationship” that arises when a relative or friend donates an organ if instead they can obtain a kidney from a stranger in an arm’s-length commercial transaction (Ghods, Savaj, and Khosravani 2000). Likewise, potential related donors no longer feel obligated; recently, when the U.S. rules for allocating deceased donor kidneys were changed to give children on the waiting list greater access to deceased adult donors’ kidneys, parental donations fell by a larger amount, so that overall fewer pediatric kidney transplants are being done while some potential adult recipients have been deprived of a kidney that went to a child instead. Further, in all settings where kidneys have been market commodities, the act of selling a kidney is seen as debasing, something that a person would do only if he or she had no other means of survival. A regulated market won’t change that. Indeed, it is likely that means would arise to circumvent the intended limitations on the incentives, such as financial entrepreneurs arranging for poor kidney sellers to obtain a lesser sum in cash in exchange for the money deposited into a retirement account for them. From the viewpoint of transplant programs, this would have the advantage of producing more kidneys (since in all societies the poor are the readiest source of organs), but very unjustly and by making a mockery of the notion of a “regulated” market.
prove ineffectual and short-lived. In regulated markets, payments to organ vendors are supposed to be provided by the entity running the organ allocation system, not by individual organ recipients. Yet it is not surprising that in Iran, the only country with a formal program to pay living kidney donors, the state tolerates side payments by organ recipients (Ghods 2014). Such payments produce more donors than would the official price alone. And once payments are legally acceptable, the policing of additional payments ceases being a high priority, particularly since such payments are difficult to discover and violators are unlikely to be harshly punished if prosecuted, given that the state has established that nothing is inherently wrong with exchanging a kidney for a financial benefit. Once it becomes apparent that a regulated market cannot solve the organ shortage, two responses are theoretically possible: restore the old system, or change the rules of the market. Yet the former would be extremely difficult: Having established that it is all right within a society to buy organs, there really is no way to reestablish a system in which people are supposed to truly donate their organs because it would be wrong to pay them. So the other option presents the only realistic policy: Drop whatever restrictions on the type or amount of payment stand in the way of persuading more people to part with a kidney or more families to give permission for organs to be obtained from their dead relative. Thus, replacing our long-standing ban on organ purchases with a regulated market today means accepting organs as market commodities a few years hence, as the philosopher who is the strongest advocate for a market in organs freely acknowledges. “If it is presumptively bad to prevent sales altogether because lives will be lost and adults deprived of an option some would choose if they could, it is for the same reason presumptively bad to restrict the selling of organs” (Radcliffe Richards 2003, 140). That’s the future once “regulated markets” are allowed; if we cross that Rubicon, there will be no turning back. “Pilot studies” aren’t needed since a wide range of natural experiments demonstrates that treating human organs as market commodities simply substitutes paid for unpaid donors who come disproportionately from the poorest strata of every society and from the poorest countries. &
REFERENCES Danovitch, G. M., J. Chapman, A. M. Capron, et al. 2013. Organ trafficking and transplant tourism: The role of global professional ethical standards—The 2008 Declaration of Istanbul. Transplantation 95:1306–1312.
THE LIMITATIONS ON PAYMENTS WON’T BE OBEYED AND WON’T SURVIVE
Declaration of Istanbul on Organ Trafficking and Transplant Tourism. 2008. Available at: http://multivu.prnewswire.com/ mnr/transplantationsociety/33914/docs/33914-Declaration_of_ Istanbul-Lancet.pdf
This end run around the means intended to prevent exploitation of poor and marginalized groups is merely the first way in which the purported limitations would
Ghods, A. J. 2014. The history of organ donation and transplantation in Iran. Experimental and Clinical Transplantation 12(Suppl. 1): 38–41.
24 ajob
October, Volume 14, Number 10, 2014
Kidney Vendors in Regulated Organ Markets
Ghods, A., S. Savaj, and P. Khosravani. 2000. Adverse effects of a controlled living-unrelated donor renal transplant program on living-related and cadaveric kidney donation. Transplantation Proceedings 32:541. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18.
Downloaded by [University of Connecticut] at 09:47 12 October 2014
Lavee J., T. Ashkenazi, A. Stoler, J. Cohen, and R. Beyar. 2013. Preliminary marked increase in the national organ donation rate in Israel following implementation of a new organ transplantation law. American Journal of Transplantation 13: 780–785.
L opez-Fraga M., B. Domınguez-Gil, A. M. Capron, et al. 2014. A needed convention against trafficking in human organs. Lancet 383:2187–2189. Matas, A. J., B. Hippen, and S. Satel. 2008. In defense of a regulated system of compensation for living donation. Current Opinion in Organ Transplantation 13(4): 379–385. Radcliffe Richards, J. 2003. Commentary: An ethical market in human organs. Journal of Medical Ethics 29:139–140. World Health Organization. (2010). Sixty-Third World Health Assembly, Human organ and tissue transplantation. WHA63.22 (21 May). Available at http://apps.who.int/gb/ebwha/pdf_ files/WHA63/A63_R22-en.pdf
Harms to Vendors: We Should Discourage, Not Prohibit Organ Sales Alberto Giubilini, Centre for Applied Philosophy and Public Ethics, Charles Sturt University Selling a kidney is probably a poor decision. Julian Koplin’s (2014) review of the medical and anthropological literature indicates that “vendors will usually experience a range of significant harms that ultimately leave them worse off than before the sale” (14) in terms of physical, psychological, social, and financial consequences. Besides, circumstances related to the poor socioeconomic status of likely vendors would make them extremely vulnerable even if a legal market replaced the currently widespread black markets. For example, often poor vendors would not return to transplant centers for follow-up care because they are reluctant to disclose that they have sold a kidney, which might reduce their chances of employment. Here I want to answer two questions that Koplin’s analysis raises. The first question is whether the likelihood of extremely poor outcomes, by itself, makes the decision to sell an organ irrational. I answer in the negative. The second is whether such likely poor outcomes represent a reason against the legalization of organ sales. The answer depends on the type of promarket argument we endorse. However, I also want to stress the importance of studies like the one conducted by Koplin for debates about legal markets in organs. Koplin says that “harms to vendors have no bearing on promarket arguments rooted primarily in the value of personal autonomy” (15). While it is true that harms to vendors do not provide a reason against liberal promarket arguments, Koplin’s very exhaustive review is relevant indeed for designing and implementing public policies within a liberal framework. Although his
review does not provide strong enough reasons against the legalization of organ sales, it suggests that organ sales should be discouraged, in the same way as hazardous— but legal—activities like smoking, drinking, and gambling are discouraged. IS THE DECISION TO SELL AN ORGAN IRRATIONAL? The high risk of extremely poor health and financial outcomes of organ sales does not, by itself, make the decision to sell an organ irrational. Circumstances might be so desperate, or prospects so extremely poor anyway, that the positive value of the immediate financial gains might outweigh the negative value of the (probable) poor long-term outcomes. Likelihood of such outcomes is just one of the factors to be considered when assessing the rationality of the choice. Other factors include, at the very least, personal circumstances of the willing vendors, their personal ranking of values, and the alternatives available. Ultimately, the rationality of the choice needs to be assessed on a caseby-case basis. In 1989 the UK public was outraged over a Turkish man’s decision to sell one of his kidneys at a London clinic to pay for urgently needed care for his leukemic daughter (Brecher 1990; New York Times 1989). But whether on that occasion the choice to sell a kidney was irrational depends on how much he valued the life of his daughter and the prospect of having his daughter with him for some more years, compared to the negative value of the hardships he
Address correspondence to Alberto Giubilini, Centre for Applied Philosophy and Public Ethics, Charles Sturt University, Canberra, Australia. E-mail: [email protected]
October, Volume 14, Number 10, 2014
ajob 25
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Organ Markets: Problems Beyond Harms to Vendors a
b
Alexander M. Capron , Gabriel M. Danovitch & Francis L. Delmonico a
University of Southern California
b
University of California, Los Angeles
c
c
The Transplantation Society and Massachusetts General Hospital Published online: 17 Sep 2014.
To cite this article: Alexander M. Capron, Gabriel M. Danovitch & Francis L. Delmonico (2014) Organ Markets: Problems Beyond Harms to Vendors, The American Journal of Bioethics, 14:10, 23-25, DOI: 10.1080/15265161.2014.947048 To link to this article: http://dx.doi.org/10.1080/15265161.2014.947048
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Kidney Vendors in Regulated Organ Markets
Organ Markets: Problems Beyond Harms to Vendors
Downloaded by [University of Connecticut] at 09:47 12 October 2014
Alexander M. Capron, University of Southern California Gabriel M. Danovitch, University of California, Los Angeles Francis L. Delmonico, The Transplantation Society and Massachusetts General Hospital For more than a quarter century, the World Health Organization (WHO) has encouraged nations to ban the purchase or sale of human organs for transplantation from living or deceased donors (WHO 2010). Most countries now impose criminal penalties on organ commercialism, and the Council of Europe Convention against Trafficking in Human Organs, which received final approval by the Committee of Ministers on July 9, 2014, extends the offense of organ trafficking to include the actions of brokers in advertising for and recruiting organ vendors, as well as physicians who knowingly transplant a vended organ (L opez-Fraga et al. 2014). In the past decade, professional bodies such as the Declaration of Istanbul Custodian Group have actively promoted the adoption and implementation of laws to halt organ commercialism and transplant tourism (Danovitch et al. 2013). Nonetheless, as Julian Koplin (2014) describes, a vocal group of liberal philosophers and free-market advocates has argued that the shortfall in the supply of organs (particularly kidneys) for transplantation could be overcome through a “regulated market” (Matas, Hippen, and Satel 2008). The market proponents portray the tradeoff in terms of principles, between promoting liberty and extending human lives, on the one hand, and protecting human dignity and preventing commodification of the human body, on the other. They confidently predict that paying for organs would achieve the former, while loss of the latter would not prove harmful to society or individuals. But proposals to establish a regulated market in organs can also be viewed in consequentialist terms. Indeed, Koplin provides strong evidence that regulated markets will not in fact safeguard kidney vendors from physical, psychological, social, and financial harms—in other words, that they pose real threats to people, not solely to principles. Beyond those strong reasons for rejecting proposals to repeal the prohibitions on organ purchases, three objections that Koplin notes merely in passing deserve further exploration. First, regulated organ markets would be very expensive and complex to administer and risk creating real or perceived unfairness. Second, ample evidence exists that the form of regulated organ purchases being proposed would not increase the net supply of organs for transplantation. Finally, regulated markets contain the
seeds of their own undoing and would soon devolve into unregulated markets.
“REGULATED MARKETS” FOR ORGANS WOULD BE VERY EXPENSIVE AND COMPLEX TO ADMINISTER Some proponents of using payments to increase the supply of organs have actually accepted the conclusion of the Declaration of Istanbul that in the resource-poor countries where organ commercialism has been concentrated, buyers have targeted “impoverished and otherwise vulnerable donors,” which has led “inexorably to inequity and injustice” (Declaration of Istanbul 2008). Yet, they contend, such problems would not arise in wealthier countries where the financial incentives offered to organ vendors—principally to living persons who are selling one kidney, but also to the next of kin of deceased persons who permit removal of any transplantable organs—could be chosen so as not to appeal to the very poor, who want immediate cash. This is the heart of “regulating” the market in organs, namely, that payments would be in a deferred form, such as a deposit into a retirement or college account for future use, and that the amount would be set at a level appropriate to the risk and inconvenience involved—calculated at $15,000 by Gary Becker, the late Nobel laureate in economics—rather than an amount generated through the interplay of demand and supply. Beyond the expense that such a payment would add to the total cost of transplantation (namely, $1,500,000,000 more to clear the U.S. kidney transplant waiting list), the first objection to a fixed price is that it would not appeal equally to all groups in society. In order to offer a financial incentive that would be as attractive to high-income as to middle- or low-income people, the amount paid would have to vary according to each person’s income (or wealth). This would require potential organ sellers to disclose private financial information and administrators to investigate these submissions. To induce donation, advertisements would have to promise “You’ll get your fair reward,” rather than offering a set incentive to everyone.
Address correspondence to Alexander M. Capron, University of Southern California, USC Gould School of Law, Los Angeles, CA 900890071, USA. E-mail: [email protected]
October, Volume 14, Number 10, 2014
ajob 23
American Journal of Bioethics
Moreover, it would likely be widely objectionable if a wealthy person were offered $200,000 for his kidney on the ground that this would be equivalent to the $15,000 that would persuade a manual laborer to part with her kidney.
Downloaded by [University of Connecticut] at 09:47 12 October 2014
THE PROPOSED SYSTEM OF REGULATED PAYMENTS WON’T INCREASE THE SUPPLY OF ORGANS There are several reasons why a regulated market will not increase the net supply of organs. First, experience shows that paid donation does not add to the organ supply but merely replaces unpaid donation; conversely, prohibiting payment actually increases the supply. For instance, several years ago, after Israel stopped paying for its citizens to go to countries where they could get transplants with purchased kidneys, the numbers of both deceased and living related donors rose dramatically (Lavee et al. 2013). The phenomenon of “crowding out” occurs for two reasons. Psychic and reputational benefits to donors—both living individuals and the families of deceased patients— disappear when organ donation is no longer associated with altruism but with payment. Furthermore, potential recipients are reluctant to enter into the complex “gift relationship” that arises when a relative or friend donates an organ if instead they can obtain a kidney from a stranger in an arm’s-length commercial transaction (Ghods, Savaj, and Khosravani 2000). Likewise, potential related donors no longer feel obligated; recently, when the U.S. rules for allocating deceased donor kidneys were changed to give children on the waiting list greater access to deceased adult donors’ kidneys, parental donations fell by a larger amount, so that overall fewer pediatric kidney transplants are being done while some potential adult recipients have been deprived of a kidney that went to a child instead. Further, in all settings where kidneys have been market commodities, the act of selling a kidney is seen as debasing, something that a person would do only if he or she had no other means of survival. A regulated market won’t change that. Indeed, it is likely that means would arise to circumvent the intended limitations on the incentives, such as financial entrepreneurs arranging for poor kidney sellers to obtain a lesser sum in cash in exchange for the money deposited into a retirement account for them. From the viewpoint of transplant programs, this would have the advantage of producing more kidneys (since in all societies the poor are the readiest source of organs), but very unjustly and by making a mockery of the notion of a “regulated” market.
prove ineffectual and short-lived. In regulated markets, payments to organ vendors are supposed to be provided by the entity running the organ allocation system, not by individual organ recipients. Yet it is not surprising that in Iran, the only country with a formal program to pay living kidney donors, the state tolerates side payments by organ recipients (Ghods 2014). Such payments produce more donors than would the official price alone. And once payments are legally acceptable, the policing of additional payments ceases being a high priority, particularly since such payments are difficult to discover and violators are unlikely to be harshly punished if prosecuted, given that the state has established that nothing is inherently wrong with exchanging a kidney for a financial benefit. Once it becomes apparent that a regulated market cannot solve the organ shortage, two responses are theoretically possible: restore the old system, or change the rules of the market. Yet the former would be extremely difficult: Having established that it is all right within a society to buy organs, there really is no way to reestablish a system in which people are supposed to truly donate their organs because it would be wrong to pay them. So the other option presents the only realistic policy: Drop whatever restrictions on the type or amount of payment stand in the way of persuading more people to part with a kidney or more families to give permission for organs to be obtained from their dead relative. Thus, replacing our long-standing ban on organ purchases with a regulated market today means accepting organs as market commodities a few years hence, as the philosopher who is the strongest advocate for a market in organs freely acknowledges. “If it is presumptively bad to prevent sales altogether because lives will be lost and adults deprived of an option some would choose if they could, it is for the same reason presumptively bad to restrict the selling of organs” (Radcliffe Richards 2003, 140). That’s the future once “regulated markets” are allowed; if we cross that Rubicon, there will be no turning back. “Pilot studies” aren’t needed since a wide range of natural experiments demonstrates that treating human organs as market commodities simply substitutes paid for unpaid donors who come disproportionately from the poorest strata of every society and from the poorest countries. &
REFERENCES Danovitch, G. M., J. Chapman, A. M. Capron, et al. 2013. Organ trafficking and transplant tourism: The role of global professional ethical standards—The 2008 Declaration of Istanbul. Transplantation 95:1306–1312.
THE LIMITATIONS ON PAYMENTS WON’T BE OBEYED AND WON’T SURVIVE
Declaration of Istanbul on Organ Trafficking and Transplant Tourism. 2008. Available at: http://multivu.prnewswire.com/ mnr/transplantationsociety/33914/docs/33914-Declaration_of_ Istanbul-Lancet.pdf
This end run around the means intended to prevent exploitation of poor and marginalized groups is merely the first way in which the purported limitations would
Ghods, A. J. 2014. The history of organ donation and transplantation in Iran. Experimental and Clinical Transplantation 12(Suppl. 1): 38–41.
24 ajob
October, Volume 14, Number 10, 2014
Kidney Vendors in Regulated Organ Markets
Ghods, A., S. Savaj, and P. Khosravani. 2000. Adverse effects of a controlled living-unrelated donor renal transplant program on living-related and cadaveric kidney donation. Transplantation Proceedings 32:541. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18.
Downloaded by [University of Connecticut] at 09:47 12 October 2014
Lavee J., T. Ashkenazi, A. Stoler, J. Cohen, and R. Beyar. 2013. Preliminary marked increase in the national organ donation rate in Israel following implementation of a new organ transplantation law. American Journal of Transplantation 13: 780–785.
L opez-Fraga M., B. Domınguez-Gil, A. M. Capron, et al. 2014. A needed convention against trafficking in human organs. Lancet 383:2187–2189. Matas, A. J., B. Hippen, and S. Satel. 2008. In defense of a regulated system of compensation for living donation. Current Opinion in Organ Transplantation 13(4): 379–385. Radcliffe Richards, J. 2003. Commentary: An ethical market in human organs. Journal of Medical Ethics 29:139–140. World Health Organization. (2010). Sixty-Third World Health Assembly, Human organ and tissue transplantation. WHA63.22 (21 May). Available at http://apps.who.int/gb/ebwha/pdf_ files/WHA63/A63_R22-en.pdf
Harms to Vendors: We Should Discourage, Not Prohibit Organ Sales Alberto Giubilini, Centre for Applied Philosophy and Public Ethics, Charles Sturt University Selling a kidney is probably a poor decision. Julian Koplin’s (2014) review of the medical and anthropological literature indicates that “vendors will usually experience a range of significant harms that ultimately leave them worse off than before the sale” (14) in terms of physical, psychological, social, and financial consequences. Besides, circumstances related to the poor socioeconomic status of likely vendors would make them extremely vulnerable even if a legal market replaced the currently widespread black markets. For example, often poor vendors would not return to transplant centers for follow-up care because they are reluctant to disclose that they have sold a kidney, which might reduce their chances of employment. Here I want to answer two questions that Koplin’s analysis raises. The first question is whether the likelihood of extremely poor outcomes, by itself, makes the decision to sell an organ irrational. I answer in the negative. The second is whether such likely poor outcomes represent a reason against the legalization of organ sales. The answer depends on the type of promarket argument we endorse. However, I also want to stress the importance of studies like the one conducted by Koplin for debates about legal markets in organs. Koplin says that “harms to vendors have no bearing on promarket arguments rooted primarily in the value of personal autonomy” (15). While it is true that harms to vendors do not provide a reason against liberal promarket arguments, Koplin’s very exhaustive review is relevant indeed for designing and implementing public policies within a liberal framework. Although his
review does not provide strong enough reasons against the legalization of organ sales, it suggests that organ sales should be discouraged, in the same way as hazardous— but legal—activities like smoking, drinking, and gambling are discouraged. IS THE DECISION TO SELL AN ORGAN IRRATIONAL? The high risk of extremely poor health and financial outcomes of organ sales does not, by itself, make the decision to sell an organ irrational. Circumstances might be so desperate, or prospects so extremely poor anyway, that the positive value of the immediate financial gains might outweigh the negative value of the (probable) poor long-term outcomes. Likelihood of such outcomes is just one of the factors to be considered when assessing the rationality of the choice. Other factors include, at the very least, personal circumstances of the willing vendors, their personal ranking of values, and the alternatives available. Ultimately, the rationality of the choice needs to be assessed on a caseby-case basis. In 1989 the UK public was outraged over a Turkish man’s decision to sell one of his kidneys at a London clinic to pay for urgently needed care for his leukemic daughter (Brecher 1990; New York Times 1989). But whether on that occasion the choice to sell a kidney was irrational depends on how much he valued the life of his daughter and the prospect of having his daughter with him for some more years, compared to the negative value of the hardships he
Address correspondence to Alberto Giubilini, Centre for Applied Philosophy and Public Ethics, Charles Sturt University, Canberra, Australia. E-mail: [email protected]
October, Volume 14, Number 10, 2014
ajob 25
