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Trade A Man's Body, A Man's Right by Bart Croughs Some people would
pay any price for the extra years a new kidney can provide. Too bad politicians
won't let them.
The problem of organ shortage for transplants is
well-known. In the United States alone, over 80,000 people are on the waiting
list for an organ transplant. Every year, thousands of patients die while waiting
for their transplant. What is the cause of this persistent shortage?
| | Bart
Croughs is a columnist for HP/De Tijd, living in The Netherlands.
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How many TV sets would reach the market if television manufacturers were not
allowed to ask for money for their product? One does not need to be an economist
to understand what the consequences of such a policy would be. Yet this is
exactly the policy that exists today with regard to organs: it is illegal to pay
or receive money for organs. Adam Smith wrote these famous words: "It is
not from the benevolence of the butcher, the brewer, or the baker that we expect
our dinner, but from their regard to their self-love." The politicians who have
prohibited organ trade and the opinion leaders who support this prohibition still
fail to grasp this point. This is not rocket science; the harmful
consequences of the introduction of a maximum price for goods and services is
part of Economics 101. The price mechanism sees to it that supply and demand are
in equilibrium. When there is a shortage of a certain product, the price will go
up; the higher price makes it more profitable to make the product, which will
increase the supply of the product. If the government prohibits the rise of the
price of a certain product, thus artificially keeping the price below the market
price, the incentive to increase production disappears, and a permanent shortage
of the product ensues. For organs a de facto maximum price of $0 has been
introduced, with predictable results. Politicians often come up with new
interventions, with no results to speak of. The only thing politicians do not
consider abolishing is the initial intervention which has caused all the
misery. Organ trade is illegal in most countries. India was a well-known
exception, where organs were openly traded on a large scale, until the practice
was prohibited in the mid-'90s. Organ trade in India was limited primarily to
live donors selling a kidney. In the early '90s, a donor received a sum of money
for his kidney equaling six times the average annual income in India. The extra
supply of kidneys was not only used for kidney patients in India; patients from
all over the world who had been put on waiting lists in their home country
flooded in. Why the prohibition of organ trade? Most who oppose
organ trade recognize that paying for organs will lead to more donor organs
becoming available, but object nonetheless, mainly out of ethical
considerations. One of the reasons to prohibit organ trade is, as
bioethicist and CNN's private philosopher Jeffrey Kahn puts it, that organ trade
"could exploit people who need money and wouldn't donate except for
payment."1
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| In the early '90s in
India, a donor received a sum of money for his kidney equaling six times the
average annual income there; patients from all over the world who had been put on
waiting lists in their home country flooded in. |
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The reasoning is that people should decide to donate voluntarily; when a poor
man proceeds to donate out of a desire to be better off financially, it is no
longer a matter of voluntariness but of coercion — the poor man is "forced
by poverty." The Bellagio Task Force, a collection of scientists who have taken a
stand against organ trade, put it as follows: the poverty and deprivation of
organ donors can be "so extreme, that the voluntary character of a sale of an
organ remains in doubt."2 This argument proves
far too much. If the poor should not be allowed to sell a kidney because
transactions that are motivated by poverty are a matter of "coercion," then they
should not be allowed to take a job at a factory either, or to shine shoes, etc.
The poor agree to do any of these only because they are "forced by poverty" to do
so. Why should someone be allowed to improve his financial position in one manner
but not in another? This question is not answered. Of course, there is a
substantial difference between factory work and the sale of one's organs: selling
an organ entails more risk than working at a factory or shining shoes. In the
words of the Bellagio Task Force, the removal of an organ poses a "threat to [the
donor's] physical health and bodily integrity."3 (They
also note that "the risk to health in selling one kidney is truly minimal . . .
at least in developed countries.") The risk is greater that one will come to
regret the donation; because of that, the poor should be protected from
themselves, to prevent them from making the wrong decision. But the
argument that the removal of an organ is not without risk also applies to organ
donations motivated by altruism — they have exactly the same risks. There is
no reason to assume that the risk of regretting an organ donation is greater when
you are left with a large sum of money after the transaction, than when you are
left with nothing except the satisfaction of having helped someone. (The opposite
is more likely: there is a real possibility that the transplanted kidney will be
rejected. The person who only donated out of altruism has lost his kidney for
nothing; this is not the case for the person who gave up his kidney for financial
gain.) Nonetheless, there is a widespread assumption that the poor person
who decides to go through life with one kidney in exchange for a large sum of
money makes the wrong decision. For example, in 1998 Atul Gawande, writing for
the online magazine Slate, argued that the sale of an organ "would be right for
so few, if any, that permitting the option makes no sense at
all."4 But on what basis Gawande drew this conclusion
remains a mystery. By what magical means can an outsider, who knows nothing of
the specific circumstances and preferences of the potential seller, be a better
judge of which decision is the right one than the organ seller himself? The
probable cause of the popularity of this view is that the relatively prosperous
intellectuals and politicians who occupy themselves with these issues would not
easily sell a kidney for money themselves, and therefore conclude that people for
whom selling a kidney can mean the difference between poverty and relative wealth
should not do so either — an understandable error. In fact, the
"forced by poverty" argument can be reversed: the more someone is "forced by
poverty" to sell a kidney, the more important it is that organ trade is not
prohibited. In the most extreme poverty, when the choice is between selling a
kidney and starving to death, it is most in the interest of the poor that organ
trade is legal. The whole idea that actions that are risky should be
forbidden is ridiculous anyway. It would mean that working as a taxi driver in
New York should be prohibited, just like Formula 1 racing, taming lions, having
sex without a condom with homosexual junkies, etc.
| If the poor should not
be allowed to sell a kidney because transactions that are motivated by poverty
are a matter of "coercion," then they should not be allowed to take a job at a
factory either. |
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Another argument from the "exploitation" category is put forward by
anthropologist Nancy Scheper-Hughes, the driving force behind anti-organ-trade
organization Organs Watch. She laments the fact that donor organs move "from
South to North, from Third to First World, from poor to rich, from black and
brown to white and from female to male."5 That may seem
unfair, until you realize that there is also a movement in the other direction:
namely, a flow of money from the rich to the poor, from the First World to the
Third World, etc. And that flow of money is exactly the reason that the poor are
prepared to give up their organs! Moreover, the supply of organs is hardly
the only service in which the provider of the service is generally poorer than
the one who receives it. According to the reasoning above, the profession of
housekeeper, for instance, should be prohibited — what great injustice that
the flow of household work goes from the rich to the poor! Yet another
typical objection to organ trade is that inequality between poor and rich could
result if people would have to pay for organs. As Jeffrey Kahn phrased it: "it
could give rich people the chance to get available organs
first."6 That possibility cannot be excluded,
but at this moment, too, there is inequality: that between the patients who are
on the waiting list and die before an organ has become available, and the
patients who are lucky enough to make it to the operation. The main thing that
legalization of organ sales will do is make more organs available, and therefore
fewer people will be part of the unlucky group. Apparently, those who use
this argument do not consider inequality based on luck unjust, but they do
consider inequality based on income unjust. But why? When you realize how the
current, luck-based system of inequality works, the opposite conclusion makes
more sense. Patients who have the money to buy an organ are not allowed to do so;
many are therefore prematurely regulated into their graves by the government. How
this is just is not evident. At the same time, these unfortunate patients are
forced to pay for the operations of those who are lucky enough to survive the
waiting list. The fairness of that, too, is questionable at best. People who have
the money to buy an organ do not cause other patients not to have that money, and
neither are they the cause of those patients' illnesses; it is therefore unclear
why it is just to make them financially liable for the cost of other people's
organ operations. This is a violation of the elementary legal principle according
to which people can only be held liable for the damage they cause.
| In the most extreme
poverty, when the choice is between selling a kidney and starving to death, it is
most in the interest of the poor that organ trade is legal.
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The whole idea that inequality in health care on the basis of income is unjust
and should therefore be prohibited is sanctimonious nonsense that few people
really take seriously. Western countries have access to health care that is far
better than that of the average inhabitant of the Third World, purely on the
basis of higher incomes here. Why should this outrageous inequality continue to
exist? Why not lower the level of Western health care to Third World level, and
donate the money that is thus saved to the Third World to improve health care
over there? The reason why abolishing inequality within a country is so much more
popular than abolishing inequality between countries is simple: the desire to
collect other people's hard-earned money with impunity is much better developed
than the desire to lose your own hard-earned money to others. Considerations of
"social justice" and "solidarity" are little more than sorry excuses for the
desire to live at the expense of other people. Another objection against
organ trade that is often heard is that giving up organs should be done out of
altruism and not out of pursuit of profit. As Jeffrey Kahn puts it: "the risk we
run is that society comes to share the view that organ donation is no longer
about altruism but about less virtuous
motives."7 In this view, thinking of one's own
interests is so reprehensible that it should be prohibited. This argument is
diametrically opposed to the previous argument: this time, the donor should not
be prevented from entering into an agreement that would harm him, but he should
be prevented from entering into one that would benefit him. It's amusing that
both arguments are typically used by the same people. But even if we
assume that the desire to benefit financially from a transaction should be
prohibited, the problem remains that far too much is proven with this argument.
If giving up organs for financial gain should be prohibited because giving organs
away for free is so much more noble and generous, then it is hard to see why, for
instance, baking bread for financial gain is acceptable; the logical conclusion
of such reasoning is that not only should people give up organs altruistically
and non-commercially, but also bake bread, make clothes, build houses, etc. In
other words: why only sacrifice the well-being and the life of the people who
need organs? If it is so morally superior to sacrifice people on the altar of
altruism, why not be consistent and let everyone suffer? Say of the communists
what you want, at least they were consistent. Another argument against
organ trade that is often used is that it is reprehensible to "commodify" parts
of the human body — i.e., to use them as objects. Nancy Scheper-Hughes
denounces the markets: "By their very nature markets are indiscriminate,
promiscuous and inclined to reduce everything — including human beings,
their labor and even their reproductive capacity — to the status of
commodities. . . . [and] nowhere is this more dramatically illustrated than in
the booming market in human organs from both living and dead
donors."8 First of all, it is not markets that
tend to reduce organs to the status of objects, but people. The reason for that
is simple: both buyer and seller expect to gain and there is no third party
involved. So what is the problem? This seems to be a primitive way of thinking:
organs are (unconsciously) considered as beings who can think and feel, and
should therefore be treated "with respect." But even if you assume that
"commodification" of organs is wrong, it is still unclear why this objection
should only apply to organ trade and not to organ donations. Why is an organ that
is sold being "treated as an object" and an organ that is given as a present not?
Objects such as chairs and tables can both be traded and be given as presents;
their status as "object" does not depend on whether anything is exchanged for
them. It is hard to see why, when it concerns organs, their status as "objects"
should suddenly be dependent on whether money is asked in return. In short, if
organ trade should be prohibited because "commodification" of organs is
reprehensible, then organ donations should be prohibited as well.
| The main thing that
legalization of organ sales will do is make more organs available.
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Another practical objection that is often used, as pointed out by the Bellagio
Task Force: there are allegations of "babies and children kidnapped and murdered
for their organs. Many journalists as well as individuals are convinced that the
ready market for organs has stimulated these
abuses."9 There is not much reason to assume
that the risk of organ theft will increase when organ trade is legalized. The
present shortage of organs for transplant is the product, at least in part, of
the prohibition of organ trade; the supply of organs is low, so the price of an
organ is high when a black market develops. When organ trade is legalized, the
supply of organs will increase, which will make the price of organs drop. That
will make stealing organs less profitable, so criminals will have fewer reasons
to do so. And, of course, it's easier for organ traders to defraud organ donors
(accepting the organs, but not paying the price that was agreed upon) when organ
trade is prohibited. When selling organs is illegal, the victims of fraud are
less inclined to go to the police. So rather than an argument against legalizing
organ trade, the risk of people being robbed or defrauded of their organs is
really an argument in favor of legalizing organ trade. Even if it were
true that the risk of crime would increase if organ trade were legalized, there
would still be no reason to prohibit organ trade. People are killed to collect
their life insurance; should life insurance therefore be prohibited? People are
killed so others can quickly receive their inheritance; should the laws of
inheritance therefore be abolished? The objections against organ trade do
not make sense; the result of the prohibition of organ trade is that numerous
patients are sentenced to death each year for no good reason, while at the same
time numerous poor people are deprived of the chance to improve their standard of
living. Finally, this is also a matter of principle. To whom do my organs
belong: me or the state? A man's body, a man's right!
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| Endnotes | An earlier version of this article appeared
in HP/De Tijd. It was translated into English by René van Wissen.
1.
http://www.cnn.com/HEALTH/bioethics/9905/organ.donate/template.html
2.
http://www.icrc.org/Web/eng/siteeng0.nsf/iwpList302/87DC95FCA3C3D63EC1256B66005B3F6C
3.
http://www.icrc.org/Web/Eng/siteeng0.nsf/iwpList302/87DC95FCA3C3D63EC1256B66005B3F6C
4. http://slate.msn.com/id/2676
5. http://www.freeindiamedia.com/health/8_july_health.htm
6. http://www.cnn.com/HEALTH/bioethics/9905/organ.donate/template.html
7. http://www.newint.org/issue300/trade.html
8. http://www.cnn.com/HEALTH/bioethics/9905/organ.donate/template.html
9.
http://www.icrc.org/Web/eng/siteeng0.nsf/iwpList302/87DC95FCA3C3D63EC1256B66005B3F6C |
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