Issue 6 / 24 February 2014

IF someone living in desperate poverty wants to sell a kidney, do we have the right to tell them they can’t?

Expatriate Australian ethicist Professor Julian Savalescu has defended people’s right to sell their body parts:

“If we should be allowed to sell our labour, why not sell the means to that labour? If we should be allowed to risk damaging our body for pleasure (by smoking or skiing), why not for money which we will use to realise other goods in life? … To prevent [people] making these decisions is to judge that they are unable to make a decision about what is best for their own lives. It is paternalism in its worst form.”

A debate in the March issue of the Journal of Medical Ethics centres on whether bans on the organ trade are inherently paternalistic.

Oxford University ethicist Professor Janet Radcliffe-Richards is one who believes they are, pointing out the bans have been imposed “by the people with least temptation to engage in the practice (the rich and healthy) on those with the most”.

When the trade in organs was first exposed, governments and professional bodies rushed to put in place prohibitions “as a direct response to feelings of moral outrage”, she writes, only later seeking “a justification for the original intuition that organ selling must be wrong”.

On the other hand, a colleague at Oxford, Dr Simon Rippon, argues bans on the organ trade are not necessarily paternalistic.

Although an individual might see selling an organ as their best available option, that same individual might have been better off if the option had not been there in the first place, he argues.

“… because people in poverty often find themselves either indebted or in need of cash to meet their own basic needs and those of their families, they would predictably find themselves faced with social or legal pressure to pay their bills by selling their organs, if selling organs were permitted”, he writes.

“So we would harm people in poverty by introducing a legal market that would subject them to such pressures.”

That’s not to say this isn’t already happening as a result of the black market in organs that flourishes in India and elsewhere.

For example, Dr Rippon cites anthropological work suggesting debt collectors may be more aggressive in pursuing creditors in those regions of India that have become “kidney zones”.

A survey involving 305 people in Chennai who had sold a kidney found 96% of them did so to pay off debt, receiving an average payment of just over US$1000 (A$1117) in return.

Sadly, there was little evidence of long-term benefit for these people. Average family incomes declined by one-third after nephrectomy, about 86% of participants reported a deterioration in health and three-quarters were still in debt at follow-up (on average, 6 years later).

Almost 80% of these participants said they would not recommend selling a kidney to anybody else, but does that mean they should have been prevented from doing it?

One argument not canvassed in the Journal of Medical Ethics articles might relate to harm minimisation.

If organs could be legally bought and sold, perhaps the poor of Chennai would undergo the procedure in safer conditions and receive a more ample payment for their sacrifice.

We make such arguments in relation to other activities that may cause harm, such as prostitution or drug use. Perhaps we could make it here too.

But that “original intuition” that organ selling must be wrong is a powerful one, which I struggle to dismiss.

Legalising a global trade in organs would, in effect, signal an acceptance that some people’s circumstances are so dire they have little option but to sell a kidney.

I’d rather see us doing something about the poverty that drives people to such desperate options in the first place, but I guess that’s a pipe dream.

Jane McCredie is a Sydney-based science and medicine writer.

3 thoughts on “Jane McCredie: Organs for sale

  1. Ian Hargreaves says:

    We have few ethical qualms about a parent donating a kidney or half a liver to a child in an altruistic act, although  such a donation carries no health benefit to the donor, combined with definite detriment and significant risk. The intangible benefit of improving or saving your child’s life is considered sufficient compensation for the physical damage the donor suffers.

    Australia has the distinction of performing perhaps the world’s first employee-to-employer kidney transplant, where the friendship between Kerry Packer and his helicopter pilot was judged sufficient grounds for an unrelated live donor to be used.

    For those patients who lack a compatible relative or a devoted staff member, the future is bleak unless the current fashion for bicycling brings a new supply of post-mortem donors. We cannot expect the poor of India to donate organs altruistically to rich Australians, so the question is whether the greater harm is to allow the Indians to die of poverty and the Australians of organ failure, rather than for the rich recipient to pay an equitable amount to the poor donor for his organ. Clearly, $1000 is too low by at least one or two orders of magnitude.

    Rippon’s article makes the unsubstantiated assumption that the psychic stress of feeling pressured to sell an organ is intrinsically worse than the stress of watching your children die of starvation, or untreated infections, when you cannot afford food or antibiotics. We know that parents in the Old and New world are willing to give up their organs to save their children – it is paternalistic in the worst sense to deny parents in the Third world that option.

  2. Martin Knapp says:

    This debate should be cultivated despite the view of many organisations that represent transplant surgeons and physicians. In a society in which several high risk activities for financial return, eg motor racing, are allowed (without censure)  it would not seem unreasonable that organ donation of a paired organ for financial return is sanctioned,  but only when there is top level care for the donor and appropriate renumeration for the donor.

     Paid organ donations have been unregulated – because they were not sanctioned by many and were not legal in many developed countries, with poor outcomes for donor and recipient.  On the balance of harm and good it may well be, however,  that there will be better outcomes for donors (and patients) if  paid donations are permitted conditional but with regulations that protect the rights of the donor and place an obligation on there being appropriate care for both donor and recipient and on the renumeration being appropriate. The current interpretation of what is unethical and what is ethical has been reponsible for the development of transplant “tourism” and poor outcomes for both donor and recepient – because of the inability to regulate the clinical care of both donor and recipient and to prevent the explotation of donors.

    I hope this article fuels further discussion on the topic in Australia and elsewhere and also stimulates more individuals to consider altruistic organ donation ie. donation by non-relatives without payment  – when there should be payment of all expenses, including loss of earnings, and this is considered to be ethical.

  3. Simon Rippon says:

    Thanks for the write-up, Jane McCredie! I’d say Ian Hargreaves is making an unsubstantiated and false assumption of his own when he comments:

    Rippon’s article makes the unsubstantiated assumption that the psychic stress of feeling pressured to sell an organ is intrinsically worse than the stress of watching your children die of starvation, or untreated infections, when you cannot afford food or antibiotics.

    I neither say nor assume any such thing. What I do say is that the harm of pressure to sell an organ would not only accrue to those who sell (and therefore to the beneficiaries of selling Ian imagines, including some – presumably very rare – beneficiaries whose children would be saved just as a result of selling, and would otherwise die of starvation or untreated infection). I also say in the article:

    Such social and legal pressures do not merely impose psychic costs … It is in view of the harms imposed by pressures like these that we think it necessary to enact … laws for … minimum wages, minimum vacation days, parental and sick leave, and workplace safety standards, which cannot be contracted out of … [and] laws against prostitution or against selling our children (even into the most loving homes).

    Would advocates of organ markets have us abolish all such restrictions on markets on similar grounds, then? On the other hand, I think Jane McCredie’s harm reduction argument has potential and is worth investigating (for all the above kinds of restriction too). And by the way, I’m all for letting people in poverty vote on whether they want these restrictions or not!

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