An ethically defensible market in organs
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7356.114 (Published 20 July 2002) Cite this as: BMJ 2002;325:114
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Harris and Erin suggest an ethically defensible market in live organs
– both from cadavers as well as from living donors (1).
However, in the case of living donors it can be assumed that the
majority of people who do not actually need the financial reward offered
would not choose to subject themselves to such an invasion of their bodily
integrity. The success of such a scheme would therefore depend on those
who seemingly do not have this choice and who for financial reasons are
compelled to sell an organ to raise money, this would not necessarily be
restricted to the socially disadvantaged but will be so in the main. This
line of thought strongly suggests that an element of coercion will be
involved and that these agents will not act autonomously since given the
choice they would not do so.
Although it could be argued that paid living donors will to some
extent be acting altruistically, perhaps not towards society in the wider
context but, for example, towards their own families, the scheme would
still be morally unacceptable because of a disparity in value in the cost-
benefit equation. In the original version of their proposal the authors
argue that ‘if we wish to show our concern for the poor, we should help
them by alleviating their poverty’(2). This would in their view be one of
the main reasons, besides the obvious benefit to the recipient, for making
the act of paid donation morally justifiable. It is however doubtful
whether this aim can be seriously and significantly achieved by such a
scheme. What the recipient is offered is something of infinite value, a
new lease of life not measurable in monetary terms.
Therefore, unless the
payment the donor will receive offers a realistic chance of improving
their position, and substantially reduces their poverty in the longer
term, the scheme will be inherently unjust and will amount to
exploitation. Anything less than this amount would hardly be acceptable:
it would not only leave the donor worse off but it would also not achieve
one the main justifications for this proposal. The amount proposed by AMA
(admittedly for cadaver donations, which I would class differently in this
context) will definitely not meet this target (3).
In addition, the argument that ‘justice demands no less’ than that
donors could in addition ‘benefit’ from priority organ allocation is also
questionable: the likelihood of such a need is probably small since it is
reasonable to assume that the scheme would be confined to healthy donors.
1. Harris J, Erin C. An ethically defensible market in organs. BMJ
2002;325:114-115
2. Erin CE, Harris J. A monopsonistic market. In: Robinson I. Ed. The
social consequences of life and death under high technology medicine.
Manchester: Manchester University Press, 1994:134-57
3. Josefson D. AMA considers whether to pay for donation of organs. BMJ
2002;324:1541
Competing interests: No competing interests
Sir,
The AMA may be eight years behind a proposal from Harris and Erin for
an ethically defensible market in organs, but they in turn were three
years behind a proposal of mine which you published in which I argued that
the NHS could become a monopoly purchaser of live donated kidneys.(1)
One serious potential problem with such a proposal, referred to by me
but not by them, is the impact it may have on the cadaveric donation of
organs other than kidneys (which cannot be the subject of live donation).
If the market in live kidneys lead to a collapse in organ donation, heart
and liver transplantation could be seriously damaged. I know of no way of
assessing how serious this danger is other than empirically.
The assertion (from Stephen Jan, Stephen Wigmore and Raj Mohindra)
that there would result a net flow of organs from the poor to the rich is
not a good argument against a market. Even though it is probably true,
the consequence would be a net flow of cash from the richer (via taxation
and the NHS budget) to the poorer, which is surely a good thing. How can
reducing the options open to poor people be to their benefit? It is
notable that those who argue that poor people should not be allowed to
sell organs are in general not poor themselves!
Jeremy Wight
Ref:
Wight J.P. Ethics, commerce and kidneys. British Medical Journal
1991:303;110.
Competing interests: No competing interests
The concept of a market in organs contains large risks and would not
appear to carry clear overall benefit to society. Firstly, it would
significantly erode the gift relationship that currently binds donor and
donee.1 This erosion of societal altruism would be a great loss,
particularly in the context of the values enshrined in the concept of the
NHS.
Secondly, the fact that a disinterested third party intervenes and
allocates the donations does not alter the fact that overall there would
result a net flow of organs from the poor to the rich. This is because
only someone for whom the present market rate for a given organ outweighs
the costs and risks of donation would offer the sale of their organs.
Thirdly, the simple incentive to match supply and demand is not
reality. In the context of the NHS The supply of money comes from
taxpayers. Competing demands for cash, the political agenda and local
factors would all impact upon the market price, driving it down. The
effect of creating a monoply purchaser would grant that purchaser the
power to drive down the price.
Fourthly, creating a dynamic market would result in commodification
of organs. One danger is that a black market may develop as indeed may a
derivatives market. The latter arises where the rights in the organs can
be traded between parties that do not include the donor. A broker could
trade such rights and eventually foreclose or sell them on for someone
else to foreclose. Clearly a matched potential recipient would wish to
buy such rights and foreclose on a date and time of their choosing to
ensure the best chance for them to receive the organ. Making such markets
illegal would not prevent their existence.
Fifthly, legally there would be difficulties. How could an organ be
reduced to property? If so could it be held on trust for life? How could a
contract to donate be enforced? What if the money for the organ had
already been paid and a donor identified followed by a refusal to donate?
Would this mean a reduced priority for the receipt of future organs?
1. Titmuss RM. The gift relationship from human blood to social
policy. London: Allen & Unwin 1970
Competing interests: No competing interests
The buying and selling of organs would involve a devaluation of the
human body and thus of the human person. It would mean treating the body
as a commodity. And since our bodies are part of ourselves, if we treat
them as commodities or let others do so, we treat ourselves or let others
treat us as commodities. In other words, if we allow body parts to enter
the marketplace, we depersonalise and devaluate ourselves.
Organ donation is very different, it involves an act of self-giving.
and self-giving involves no delvauation of ourselves or of others. In the
case of organ donation, it means sharing with a neeedy neighbour.
Competing interests: No competing interests
Sir,
We welcome the continuation of the debate regarding the ethics of
buying and selling organs from living donors1. Unfortunately the statement
by Harris and Erin, with its strong advocacy of paid donation, misses some
important aspects touched upon in other well argued articles published
recently.
Harris and Erin propose that a market would be made ethically
defensible by being monopsonistic and having the NHS as sole purchaser
which avoids potential exploitation of the donor. It is important to note
that the NHS is an unusual healthcare delivery system, being "free at the
point of delivery". This argument must not be allowed to slide into
justification of such a market in a mixed healthcare system which is much
more common worldwide. Such a system, where private healthcare is taken up
by those who can afford it, continues the risk of exploitation of the
vulnerable donor.
Even if the monopsonistic broker is an NHS-like beast, there is no
guarantee that it would not still prey on the vulnerable, but at a state
rather than an individual level, since people in need of money are the
most likely volunteers to sell their organs. In addition, it has been
argued that a system similar to that described by Harris and Erin may be
controlled locally but lead to major problems if applied on a larger
scale2. Financial compensation for donors would probably be different
between countries with "transplant tourism" encouraged. At worst the poor
of the developing world could become a vast reservoir of organs for the
elderly with degenerative disease in the developed world organs for the
elderly with degenerative disease in the developed world3.
In writing about this issue it is important to acknowledge the harm
which may come to a donor. This serves to highlight the moral difference
between the sale of an organ and a voluntary donation. Many of the multi-
disciplinary teams looking after a donor may find it difficult to come to
terms with paid donation. This is because of the notion that bodily
integrity is highly valued and violation of this integrity is not well
compensated for other than by spiritual/philosophical gains such as acting
in an altruistic fashion4. The guidelines drawn up by the British
Transplantation Society and the Renal Association state that information
on the long term effects of living kidney donation is relatively poor5. It
is urged that donors should be followed up for life. Presumably the
monopsony would also provide for this aspect of care.
Fair distribution among recipients is an important principle of organ
allocation. Whilst nodding to this, Harris and Erin immediately break the
equity of access principle by suggesting a preference for living organ
donors who subsequently require transplantation. This argument slips
easily into preferential access for other groups, eg. children or those
most in need of transplantation (otherwise known as age bias or clinician
bias). This whole are needs to be thought through more carefully.
Transplantation in general and paid living donation in particular are
frequent subjects of philosophical and ethical debate. If society chooses
the road to paid organ donation, it is important that the debate
surrounding such action is transparent and complete. It is only in this
way that a decision can be soundly based.
1. Harris J, Erin C. An ethically defensible market in organs. BMJ
2002; 325: 114-115.
2. Schlitt, HJ. Paid non-related living donation: Horn of Plenty or
Pandora's box? Lancet 2002, 359: 906-7.
3. Plant WD, Akyol MA, Rudge CJ. The ethical dimension to organ
transplantation. In Transplantation Surgery: Current Dilemmas, Ed Forsythe
JLR, WB Saunders Co Ltd, London 2001, 1-24.
4. Wilkinson S, Garrard E. Bodily integrity and the sale of human
organs. J Med Ethics, 1996, 22: 334-9.
5. United Kingdom Guidelines for living donor kidney transplantation.
British Transplantation Society and Renal Association. 2000.
Stephen J Wigmore, Senior Lecturer, Wellcome Fellow and Hon
Consultant Transplant Surgeon,
Jen A Lumsdaine, Living Donor Kidney Transplantation Co-ordinator,
John LR Forsythe, Consultant Surgeon and Director Living Kidney
Transplantation Programme
All work in the Transplant Unit, Royal Infirmary of Edinburgh,
Edinburgh EH3 9YW.
Email s.wigmore@ed.ac.uk
Competing interests: No competing interests
In the July 20th 2002 of the BMJ, J Harris and C Erin present a model
for a live organ market. 1 As they claim, their proposal may be ethically
acceptable. However, as a transplant surgeon who has been directly
involved with living donors and the relatives of brain-dead donors for
many years, I am afraid that their scheme is pure theory and close to
utopia. Contrary to the American suggestions of Delmonico et al, 2 those
of Harris and Erin are alternatives rather than incentives to altruistic
donation. Altruism has its own limitations indeed, as demonstrated by the
current organ shortage, but it has also been the cornerstone of most
achievements in transplantation medicine. In donation matters, emotion is
a key factor that is completely ignored by Harris and Erin. Live tissues
and organs are not plain goods like drugs or pieces of equipment. If they
became regarded as such, the authors' contention that altruistic donation
would not be affected may turn bitterly wrong. In addition, their
statement that all would "stand an equal chance of benefiting" sounds like
wishful thinking: is it reasonable to believe that the rich will sell
their own body parts as often as the poor? Finally, in an era of cost
containment, is it realistic to promote an international bureaucracy
supposed to control the market place and prevent malpractice?
Solutions to the organ shortage must be searched and investigated but
the achievements of altruism must not be underestimated. Once again, let
us not throw the baby away with the bath water!
References
1. Harris J, Erin C. An ethically defensible market in organs. A single
buyer like the NHS is an answer. BMJ 2002; 325: 114-5.
2. Delmonico FL, Arnold R, Sheper-Hughes N, Siminoff LA, Kahn J, Youngner
SJ. Ethical incentives - not payment - for organ donation. N Engl J Med
2002; 346: 2002-5.
Competing interests: No competing interests
There is an ideational agnosia by those at the AMA, an inability to
see that their narrow money oriented viewpoint shows contempt for the
ordinary opinions of ordinary people outside of academia.<P>The idea
that people who are not willing to donate organs out of love would be
willing to sell the organs of their loved ones (for a nominal fee) implies
that money is the highest value in life, and that poor people are dimwits
who would do anything if the money was good enough. <P>Reality,
however, shows that the poorest (especially minorities) are more unwilling
to donate because of an innate distrust of the medical system than lack of
altruism. This distrust (the suspicion that a person would be left to die
so that their organs could be harvested) has it's roots in the Tuskeegee
experiments. Paying for organs will exacerbate, not improve the
problem.<P>Finally, a loved one's body is more than a piece of meat
to be sold to the highest bidder. Most people feel a reverence toward the
body as a symbol of the deceased, and there is a feeling that seeking a
good rest for the body is a way to honor the loved one. <P>This is
why the Marines promise never to let any of their own behind, and why
firefighters at the world trade center kept watch for months to discover
and recover their deceased relatives and friends.<P>Until the AMA
rediscovers the ancient virtue of reverence, it will continue to state
policies that make no sense to the average person.
Competing interests: No competing interests
It was not clear in your recent editorial whether the proposed market
in human organs would involve the sale of rights to organs which are
subsequently exercised by the purchaser upon death of the vendor or
alternatively, the sale of organs from live donors. This clearly is a very
important distinction with major economic and ethical consequences and
thus should have been addressed explicitly. The former involves the
transfer of organs only once they no longer have use value to the donor.
Although some of the issues of quality (organ) and the crowding out of
altruism that concerned Titmuss a number of years ago in relation to
payment for blood donation may also be relevant here, 1 it nonetheless
avoids the serious ethical problem outlined below.
In the latter, a transfer of a healthy organ occurs from individual A to
individual B based on A’s willingness to accept a specified payment for
that product. Given that the poor will inevitably have a lower minimum
willingness to accept threshold, the proposal will in essence promote a
general redistribution of healthy organs from the poor to non-poor. This
would occur despite, as stated by the authors, ‘no direct purchasing’ by
B, because ultimately the organs will tend to be sourced from the poor.
Furthermore, the incentives created by such markets along with weak
regulation, as seen in some developing countries, can potentially
undermine safety and create conditions for the exploitation of those in
greatest economic need.
1. Titmuss RM. The gift relationship from human blood to social
policy. London: Allen & Unwin 1970
Competing interests: No competing interests
I seriously hope that the article ' An ethically defensible
market in organs' was a satyrical response to the
concept of financial incentives for organ donation. The
authors have taken pains to address all possible
issues for the smooth and legal management of such
a market; even as far as suggesting that the legislation
excludes the possible view that poor individuals by
having potentially marketable organs could be
considered as having capital and consequently not be
entitled to welfare! The whole article conjures the
image of a futuristic Sci-fi society ruled by criminals.
It would never be possible to rule out coercion behind
any financially rewarded organ donation especially in
this materialistic age. Suggesting that a financially
rewarded organ donation could be altruistic is a
contradiction in terms.
A realistic incentive to increasing organ donation would
be to reward individuals who have committed
themselves/thier organs to a donor list to financial
rewards such as tax cuts.
Competing interests: No competing interests
Market of organs: unethical under any circumstances
We read with interest the editorial by Harris and Erin entitled “An
ethically defensible market of organs” [1] published in British Medical
Journal 2002; 325: 114-115. While we admire the authors’ commitment to
solve the dilemmas posed by organ shortage, we strongly disagree not only
with their conclusions, but also with their assumption, i.e. the idea of
giving ethical grounds to the selling and buying of human organs.
Harris and Erin harness their theory to the laudable commitment to
raise donation rates but get to the definition of an “ethical market” by
promoting a system that seems to depend only on a restricted group of
citizens –those possibly appealed by the monetary incentives proposed.
Firstly, the integrity of the human body should never be subject of trade.
Can we in earnest define this system as “ethical” only because the selling
and buying of organs is administered by the state? Secondly, how can a
system be called “ethical” when it implicitly penalizes the weakest ones
and exacerbates a discrimination based on census? Will a healthy well-off
citizen ever decide to give away part of his/her body for monetary
incentives? Donation rates might be boosted but while both the rich and
the poor will continue benefiting from transplantation indiscriminately,
organ procurement will be increased only by contributions by the poor.
Any commitment towards raising donation rates can be better channeled
using targeted investments, as shown by our experience at the Istituto
Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT),
a transplant program recently established in a geographic area with
significant cadaveric organ shortage. At ISMETT, from the inception of
activity in July 1999, living donation was vigorously pursued: out of 120
transplants performed to date (livers and kidneys), 33% were from living
donors –all family related. At the same time, though, considerable
energies have been invested to promote cadaveric donation. Those efforts
have been rewarded by a 314% increase in the donation rate (from 2.8
donors per million in 1999 to 8.9 in 2001).
Any financial incentive to organ procurement, even though
governmentally regulated, must be avoided, as it dangerously undermines
human dignity by promoting the gloomy overlapping of human being and
marketing. We recently expressed our preoccupation about the suggestion of
the American Medical Association to explore monetary incentives for organ
donation [2] and we are frightened by its enthusiastic support by such
notable experts as Harris and Erin.
REFERENCES:
1) Harris J, Erin C. An ethically defensible market in organs. BMJ 2002;
325: 114-115.
2) Marino IR, Cattoi A, Cirillo C. Health at any price. Italianieuropei
2002; (3): 170-180.
Competing interests: No competing interests