Thursday, November 6, 2008

Dying for a donation

The most outstanding feature of organ markets is that most people hate the idea. This is a curiosity deserving a second glance. There are organ shortages almost everywhere, with people dying on waiting lists hourly. To sentence them to death based on a cursory throb of disgust is not just uncivilised but murderous.

First I should get some technical details out of the way. An organ market can involve buying from living donors, or selling rights to organs after death, or both. Organs needn’t go to the rich preferentially; like any treatment, that depends on the healthcare system. The supply of organs available won’t decrease – if free donations dropped as a result of sales, the price would rise until either enough people sold organs or relatives and friends felt morally obliged to donate them anyway. A regulated market needn’t lead to an increase in stolen Chinese organ imports. It would lower the price here, making smuggling less worthwhile, while stopping Australians going on desperate holidays to seek organs in the under-regulated Third World.

That they ‘commodify the human body’ is the main objection to organ markets. They certainly do that, but why is commodification terrible? Well, a commodity is generally an object subordinated to the goal of making money. Treating other humans in that way leads to abominable actions. Slavery and organ theft are examples of human commodification that rightly repulse us. This doesn’t generalise however. The horror in these examples is that people are being made miserable because they don’t want to be sold. This is a completely different scenario to people voluntarily commodifying themselves.

After all, if commodifying people is inherently wrong, why allow paid labour? Renting out a portion of your time, mind and body to a company or government is surely commodification in the same vein. Or is selling body parts just too much commodification? It doesn’t seem so to me – you can lose more of your most personal possession, your limited lifespan, working than you would selling a kidney. Regardless of how we personally answer that question, there is no reason for the public to decide where the line on commodification should be drawn rather than the people choosing to be involved.

Perhaps anyone who wants to commodify themselves must necessarily be insane and unable to make good choices. To decide that somebody with an alternative idea must not be of sound mind is a big step. The fact that someone disagrees with your opinions, especially ones without arguments behind them, hardly proves they are insane. To all of those who use their gut reaction of disgust to produce policy, Alex Tabarrok asks, “Is it not repugnant that some people are willing to let others die so that their stomachs won’t become queasy at the thought that someone, somewhere is selling a kidney?”

But can people in desperate poverty be considered to be making free choices? Many say no. So, is the choice between starving and selling one’s kidney really a choice? Yes; an easy one. One of the options is awful. To forbid organ selling is to take away the better choice. If we choose to provide an even better option to the person that would be great – but it is no solution to the problem of poverty to take away what choices the poor do have absent outside help.

A related argument is that even with better choices, poor people will be so desperate as to be irrational. However even if we accept that poor people are irrational, for anyone desperate enough to become irrational, selling an organ is probably a great idea. Given the ubiquitous human aversion to being cut up, poor people are more likely to underestimate the merit of that cash source. Should we intervene there?

Another argument regarding poverty is that organ markets are highly unegalitarian; they’re another way to exploit the poor. However, there are two inequalities involved in this market. People have differing amounts of money, and people have differing numbers of functioning organs. Which of these inequalities is worse for those with less? The most pressing egalitarian action would be to redistribute the organs more fairly. By happy coincidence the most effective way to do this is to simultaneously redistribute wealth as well. If poor people sell organs, all the better; the money is redistributed to them as organs are also redistributed to those with least.

The alternative to a market is ‘altruism’. If a brother needs an organ to live, how can you refuse? Unlike the disconnected poor person who benefits from an extra option, this family member loses their previous option of keeping both their organs and their family relationships. The latter are effectively held to ransom. This system leaves the patient with the stress of traipsing around making such awkward requests. Instead of loving support, they get to watch the family politics as everyone tries not to be left with the responsibility, everyone hiding their relief when their blood type is incompatible. Often people offer an organ, then ask the transplant team to judge them a poor match. This gets them off the hook, but leaves the ill person in a cruel cycle of hope and despair. It’s analogous to telling cancer patients ‘come for chemo on Tuesday’, then refusing them any every week till they die. If the patient is fortunate enough to find a donor, there is potentially the stifling lifelong obligation to them. People have refused organs over this. The troubling emotional dynamics surrounding ‘donation’ led Thomas. E Starzl, a great transplant surgeon, to stop doing live transplants.

My favourite argument against organ markets is ‘it will create a distopic world where an underclass exists to replace body parts of the rich’. This is flawed in a multitude of ways. Most people would be in neither category. It would create as much of a split as ‘people who make donuts’ vs. ‘people who eat donuts’. The exchange of money makes the parties more equal in the transaction than if one is the unfortunate victim of a request they cannot refuse. Individual people can’t be used as organ factories. Number of organs is a hopeless basis for discrimination, due to the effort involved in actually finding out which organs somebody has.

‘Altruistic giving’ is more coercive than a market, unnecessarily cruel to the patient, the donor and their family and friends, and leaves thousands to die on waiting lists. Organ markets can save lives without us having to sacrifice morality and should join the ranks of life insurance and money lending; markets we once thought unthinkable.

Originally published in Woroni. 

10 comments:

denis bider said...

I totally agree.

Interesting remarks about Dr. Starzl, and about people who offer organs but ask the transplant team to judge them a poor match. Can you relate the source? Perhaps The Puzzle People, Dr. Starzl's book?

One aspect you have not mentioned is that a minor but significant percentage of people who have given up on their lives, and who value their lives and health very low. They don't care whether they live or die, and might actively pursue risks that may end in them getting disease or dying.

But such people still have things they do care about, be it pleasure or specific other people. When they need money for something they do care about, these people will be willing to sell their kidney much faster and for much less than you and I would.

I might sell my kidney to Bill Gates for 10% of his current net worth. But these people will sell their kidney for a few thousand dollars. And these people will be the most frequent sellers; so the market price for a kidney will be a few thousand dollars.

This, I think, is where people's morality hackles are raised. I think most people would support a decision whereby person X sells his kidney to Bill Gates for billions of dollars. They would support that because they can see themselves doing it too. But they can't see themselves selling a kidney for $500, and cannot comprehend someone's decision to do so. Therefore it must be exploitation. If I wouldn't agree to it, but someone else does, then he must be taken advantage of.

You can see the same "logic" in people's complaints that third world workers are being exploited, etc. People can't see themselves working 12-hour days for a fistful of dollars. Therefore, anyone who agrees to it is being exploited. Never mind that it's the best option available to them.

Cristy aka Conspicuous Chick said...

"After all, if commodifying people is inherently wrong, why allow paid labour?"

That's a terribly incorrect analogy and the two are completely different. Labor is a verb; you are being compensated for behavior and perhaps time. An organ is not 'renting'; it is the removal of a vital part of the body through major surgery, in which myriad things can go wrong, resulting in the maiming or death of the donor (regardless of how safe it is).

Where will this money for organs derive? If not from intended recipients and their families, which will guarantee organs going to the highest bidder, then who - the insurance companies, the government? Either option means the consumer/tax payer will ultimately be footing the bill, and frankly, we have a big enough burden without ponying out cash for random kidneys and liver lobes.

www.livingdonor101.com

Katja Grace said...

Sorry for slow reply - I've had lots of exams.

Denis,
The bits about Starzl I read in this article: http://www.nytimes.com/2007/12/16/magazine/16kidney-t.html?pagewanted=1&_r=3

I'm not sure how many people there would be who value their life so little - not enough to fill demand I think, so the price would go up anyway. I think you're right that the idea of selling cheaply is what scares people particularly. Probably that fear is mostly due to sales in the third world where getting a few hundred dollars doesn't demonstrate not valuing life though.

Cristy,
An analogy requires that the compared are not identical. My point is that the differences are not relevant. Both can be converted to effect on our experienced life. I would say our organs are precious because they support our life, not because they are a hunk of flesh that we are fond of. Thus I would be more worried about selling years of my life than an unneeded support structure for it.

"An organ is not 'renting'; it is the removal of a vital part of the body through major surgery, in which myriad things can go wrong, resulting in the maiming or death of the donor"

If it were vital it wouldn't be being removed. This doesn't separate it from labour either, where maiming or death happens, depending on the job.

As far as I know getting an organ is cheaper than being on dialysis for ages. I could be wrong. If you don't think the public should pay for it (of all the greater medical expenses and less useful procedures) why shouldn't other consumers be allowed to pay for it if they want an organ? This argument seems absurd to me.

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