The Ethics of Human Rights (25): Free Organ Trade and the Commodification of the Body

The case for allowing free organ trade seems like a no-brainer. Many countries, including the U.S., now forbid the sale and purchase of most organs, and, as a consequence, sick people die because of organ shortages, and poor people stay poor because they can’t “monetize” their organs. Poor people suffer a “double injustice”:

[We say] to a poor person: “You can’t have what most other people have and we are not going to let you do what you want to have those things”. (source, source)

However, when organs are freely tradable, many extremely poor people, especially those struggling to survive, will be tempted and even forced to sells parts of their bodies. Moreover, the rich will be able to benefit disproportionately from the market because prices will be high, given that demand will outstrip supply in an ageing society. The most obvious means to balance supply and demand, and to force down prices and allow the less than wealthy patients to participate in and benefit from the market, is to create a global market without trade restrictions, an organ-GATT if you want. This will bring in the masses of poor people from Africa and Asia, pushing up supply of organs and hence bringing down prices. This will supposedly benefit both the less than wealthy patients and the very poor donors. The latter will benefit even with prices for organs falling because of increased supply, because they start at extremely low levels of income. Even the sale of a cheap kidney can mean years of income for them.

The problem with this global market is that organ extraction will take place in sub-optimal medical conditions, creating risks for donors (if you can still call them that), also in the case of renewable tissue donation. Paradoxically, the poor are driven to risk their lives in the process of saving their lives. Even in the best healthcare systems in the world, organ extraction is often very risky. In the U.S., the extraction of a section of the liver, for example, carries a risk to the donor’s life of almost 1 percent (source). That’s not negligible. I doubt anyone would cross a street if that were the odds of getting hit by a car.

I’m convinced that an opt-out regulation for cadaveric donors (meaning that everyone’s a donor after death unless an explicit opt-out), combined with non-financial encouragement of voluntary pre-death donation, is the best way to solve the organ shortage problem. A free organ market will obviously also solve the organ shortage problem, but will create new problems instead.

The distinction between renewable tissue such as bone marrow, and non-renewable organs such as kidneys, eyes, etc. is a relevant one. If the donation of renewable tissue can take place in medically safe conditions, I can’t see a problem with being allowed to trade, on the condition that poor patients have the same opportunity and power to buy as rich ones (and that’s a pretty big “if”). The needs of the sick or disabled who risk dying or suffering because of a lack of available organ, clearly outweigh any remaining concerns.

One of those remaining concerns is the problem of the commodification of the body. Organ trade is obviously commodification, and commodification is dehumanization. I don’t want to imply that organ trade liberalization necessarily results in “organ farms”, dystopian places where people are “cultivated” solely for the harvesting of their organs – although the Chinese criminal justice and capital punishment system for instance comes awfully close. (I sometimes wonder if deterrent and punishment is the real goal of executions in China). But people can commodify and dehumanize themselves. And although we should normally respect people’s self-regarding choices, what looks like a choice may not always be a true choices.

The logic of economics tends to overtake all other domains of life, even those where it doesn’t belong and can do serious harm. Why is it so evident to so many that body parts are something that it supposed to be tradable? Even the most outspoken proponents of organ trade draw the line somewhere: they won’t allow people to sell parts of their brains, I guess, or their children and wives, or the parts of aborted fetuses (perhaps fetuses specially conceived and “harvested” for their parts), not even if this would fill a great social need. And yet they accept as natural that non-vital body parts should be tradable and seem to forget that irreplaceable body parts form our body and that we can hardly exist without our body. If we allow total freedom of organ trade, we will have to accept the case in which a poor father decides to sell off every single one of his organs for the survival of his family. After all, he is the master of his own body, he has a right to self-determination, and the government has no right to limit what masters of their own bodies should be allowed to do with it. If you don’t accept the legitimacy of this extreme case, you accept limitations on the freedom to trade organs. Since most opponents of organ trade also accept certain types of trade – e.g. renewable organs such as bone marrow and skin – the disagreement isn’t a principled one but one about degree.

Underlying the argument in favor of organ trade is the fiction of a market populated by free, equal and self-determining individuals who make free and rational economic decisions and agreements on what to sell and buy, free from government interference. The reality is of course that organ trade isn’t an expression of self-determination or autonomy but rather of the absence of it. And that organ trade, just like a lot of other trade, is radically asymmetrical: some are forced to sell in order to survive, especially if the price and hence the reward is very high, as it will be relatively speaking for the poor. And others will sell without rationally examining the benefits for or risks to their interests (absence of informed consent). It’s beyond my powers of comprehension that all this can be denied:

It’s true that I don’t find any of the arguments about the coercive effects of money on peoples’ decisions particularly compelling.  Megan McArdle (source)

Any potential paid organ donor is always free to decline the transaction, and is left no worse off than before. What next, will you tell me that I “coerced” Apple into sending me a Macbook? (source)

This seems to me to be more correct, or at least less outrageous:

Talk of individual rights and autonomy is hollow if those with no options must “choose” to sell their organs to purchase life’s basic necessities. … Choice requires information, options and some degree of freedom. (source)

Of course, some would say: if someone is forced by poverty to sell her organs, would you stop her and make her worse off by imposing legal restrictions on her autonomy and “reducing her resources”? That’s again the myth that markets always make things better. What if she does get some money, has a better life in the short run, but gets sick because of the operation (or do we also assume the myth of perfect healthcare for the world’s poor?) or because of the lack of an organ? Who would make her worse off? The one allowing her to sell, or the one stopping her? And anyway, there are better ways to protect the poor than to allow them to harvest their organs.

So, if we’re afraid that free organ trade might be exploitative for the poor, why not allow free trade but exclude the poor from selling? Because the poor will be, in general, the only ones tempted to sell. A wealthy person has no incentive to sell organs. Hence a free trade system restricted in this way will not solve the shortage problem, the main concern of proponents of free trade.

I’ve stated before that government interference can promote rather than restrict freedom. In the case of organ trade and donation, two specific types of interference can help:

  • Restricting the freedom to trade non-renewable organs, as well as renewable organs in circumstances in which extraction poses a health risk to donors, will protect the freedom of the poor. Not their freedom to sell organs obviously – which isn’t freedom for them anyway but compulsion – but the freedom to live a healthy live.
  • Imposing default cadaveric donation with an opt-out clause will protect the freedom to live a healthy live of patients in need of replacement organs. Of course, if it’s the case that for some organs cadaveric donation isn’t possible medically, I’m willing to accept an exception.

How about allowing people to sell their organs after death? This would evidently remove the health risks for donors. It could be considered a kind of life insurance for the deceased’s family. That would indeed remove all the concerns from the donor side. (The counter-argument that such a system would encourage families to kill their members for the “insurance money” seems a bit weak, and just as weak as the similar counter-argument against generalized organ trade liberalization, namely that people would murder in order to sell organs; I guess they already do).

But assume that we would allow free post-mortem trade: what would happen with the organs? They would be sold of course, but to whom? The most wealthy first, and hence we still have our problem on the beneficiary side: wealth yields better health. Of course, that’s already the case in healthcare in general: rich people also have better dental care etc. But do we want to add to the existing injustice by allowing wealth to determine who gets an organ?

If we allow limited organ trade of deceased’s organs, we’ll have to do something on the beneficiary side in order to neutralize the effects of wealth. A lottery system could be an option. Or subsidies for the poor, or price caps etc.

14 thoughts on “The Ethics of Human Rights (25): Free Organ Trade and the Commodification of the Body”

  1. I beg to differ. Rationalizing needless deaths each year on the basis that markets are evil simply won’t cut it. You’ve essentially said wealthy people should die precisely because they’re wealthy. Since they’re wealthier and will be disproportionately able to pay for organs, that’s unfair and it’s fairer to let them die! Hogwash, I say.

    The idea that altruism will solve all of our ills hasn’t panned out. Supply has not yet met demand (nor will it ever, under current conditions). So unless you support needless deaths, then it’s basically agreed something ought to be done. Opt-out “donation,” besides being grossly unethical, doesn’t come close to solving the problem.

    The argument of protecting the poor is emotionally appealing, but it neglects to mention the sober reality. The reality of the matter is that “donations” already occur in undesirable conditions precisely because it’s illegal. (The same is true when abortion is criminalized.) The underlying argument being made is that poor people are irrational, that they must be protected from themselves, that the government knows what is better for them than they themselves do. The rational question is, how does disallowing poor people from selling their organs “improve the welfare of poor persons?” It doesn’t, of course.

    Organ transplants, while risky (like all surgery), is not nearly as dangerous as it’s painted. Modern medicine has come a long way. A living donor is now able to remove just a portion of their liver, which will regenerate and approach full functionality within weeks (the same is true of the recipient). Death rates for this procedure are low: 0% in Japan and less than 0.5% in the U.S. These rates will continue to decline as advances in medicine continue and as surgeons progress along the learning curve. Kidney transplantation is even safer. Remember, it was Joseph Murray who won the Nobel Prize in medicine for completing the first kidney allograft in 1954. The patient in that case is still alive.

    If risk is reasonably low for live patients, it’s zero for dead bodies. There’s no rational argument to disallow poor families to receive money for a zero-risk procedure. If distribution of organs is most equitable through lottery, then make it a lottery. Just don’t deny people the right to seek a better life. The sale of organs is an obvious extension to one’s right to life, if that right has any meaning anymore.

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    1. I didn’t say markets are evil. That would be a stupid thing to say and I generally try not to be stupid. What I did say is that market aren’t always symmetrical, meaning that they do not always conform to the ideal image (many would say real image) of voluntary transactions between two parties who benefit equally from the transaction. Often they do conform to this image of course: when I change my money for a meal, I benefit and the restaurant benefits, and everything is equally voluntary. I argue that the same isn’t true for organ trade.

      If I read you correctly, you admit that wealthy people benefit disproportionally from organ trade, as they do from trade in most “goods”. I didn’t argue that this unfairness – if it is one – is a sufficient reason to let them die. I argued that it’s a sufficient reason to limit organ trade (as you can read I don’t want to ban it altogether). And that’s not the same thing, since trade isn’t the only way to make organs available. I refer of course to opt-out donation, which you call unethical without any argument in favor of this proposition (perhaps because there are none). I frankly can’t see what’s unethical about it. It’s also successful. It’s practiced in many countries, for example my own country (which is Belgium, for the moment), with great success and with the added benefit that pressures to legalize trade are completely absent. So supply can meet demand without legalizing trade.

      I accept that trade already goes on, in circumstances that make it very dangerous. Legalizing trade would indeed solve that problem, like it did with abortion. But only if you take a narrow national view. Organ sellers in the US would benefit from legalization because of the quality of healthcare in the US, but not sellers from poor countries. And because of the price mechanism of the market, trade would move to low income countries, and those are countries where sellers wouldn’t benefit much from legalization because of the lack of quality of healthcare in their countries. Your characterization of the risks of organ transplants isn’t realistic beyond the borders of the west.

      But perhaps you are willing to accept the risk that some sellers die in the process if only enough buyers benefit to a larger extent. But then we’ll have a discussion on the unacceptability of utilitarian morals.

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  2. These arguments are the same that could be said of any good in the marketplace. The rich can disproportionately afford luxury vehicles, so perhaps we shouldn’t allow luxury vehicles to be sold on the market? It doesn’t make sense. I’ve heard of similar arguments against blood. I mean, how can we stoop so low as human beings to commodify blood, an essential part of the human body? That’s “dehumanizing” after all. Well, as it turns out, the legalization of selling blood has resulted in countless lives being saved. So, on the one hand you have “dehumanization” (if you accept that), and on the other, people’s right to live actually being respected. I think the choice is a clear one. In fact, I can’t really think of anything more dehumanizing than simply letting someone die (which is precisely what you’re doing when you outlaw the sale of blood, organs, bone marrow, etc.).

    “We’re not really letting people die because we have an opt-out system.” Really? First, the opt-out system isn’t based at all altruism, but rather laziness. The hope is the people are too lazy or too ignorant to opt-out (otherwise it would be opt-in). The assumptions being made, of course, is that the state owns your body. The state owns you by assumption, i.e. when there is no consent. If you want to call that ethical, fine. You and I have different definitions for the term.

    What about actual results? Maybe it’s true, as some studies indicate, that opt-out yields slightly more donations than opt-in (because some people are lazy or ignorant). (There are also procedural problems, like opt-out being rarely enforced and family decisions being the final decision.) But that doesn’t cover the demand for organs. There’s no academic study that I have ever found that indicates opt-out donations supplies the necessary organs to meet the demand for them. If you find one, show me it. Because what I see is tens of thousands of needlessly suffering people waiting on lists because altruism isn’t cutting. What I see is thousands of people (and not only rich people, mind you) dieing because they can’t buy organs that would save their lives. If opt-out works, why are these people dieing? How anyone can call the current situation morally right is beyond me. If poor people will be unable to afford organs in free market for organs, then it’s necessarily the case that they’re even more disadvantaged when there is no market for them. You simply are not helping the poor by denying their right to their body.

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    1. What a silly comparison. Luxury goods aren’t bought from poor people who see no other solution to their predicament than cutting pieces from their body. I don’t see how this comparison can work for you.

      And regarding blood, I won’t repeat what I said in the post, apart from the fact that it’s quite a different matter. You’re making a caricature of my position by lumping together organs and renewable organs. I explicitly separated the two.

      Arguing against the opt out by saying that it means that the state owns your body by default is just libertarian hyperbole to me. Such talk is only useful to undermine public support for an opt out system. It seems you have a conception of “ethical” that involves evil with no harm: you believe it’s unethical for others to use your body after you died, even if that use can’t possibly harm you (since you’re dead). Indeed, we have different definitions of the term ethical. (Of course, this won’t cut if you believe in an afterlife and physical resurrection, in which case you need your body after death. I don’t know you well enough to know if that’s the case for you).

      You see thousands of people suffering and dying because of a lack of organs (true), and why would they diey if the opt out works? The problem is precisely that most countries don’t have an opt out system! You’re blaming an non-existing opt-out system for a lack of organs. Where it does exist, it works. Take a look here: http://en.scientificcommons.org/43810025 or here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1296026/pdf/jrsocmed00048-0009.pdf or here: http://surj.stanford.edu/2004/pdfs/gundle.pdf

      Not all problems are solved with opt-out systems, but they do help and increase organ availability dramatically. I know you’re really concerned about organ availability, and I also think you’re sensitive to the problem of poverty and the dramatic choice this imposes on people. I suggest you take the opt out system seriously, look at the evidence I gave you, and direct your efforts towards public acceptance of it, rather than the promotion of organ trade.

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  3. As the death toll from the organ shortage mounts, public opinion will eventually support an organ market. Changes in public policy will then follow.

    In the mean time, there is an already-legal way to put a big dent in the organ shortage — allocate donated organs first to people who have agreed to donate their own organs when they die. UNOS, which manages the national organ allocation system, has the power to make this simple policy change. No legislative action is required.

    Americans who want to donate their organs to other registered organ donors don’t have to wait for UNOS to act. They can join LifeSharers, a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at http://www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

    Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. Non-donors should go to the back of the waiting list as long as there is a shortage of organs.

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  4. The comparison to luxury goods isn’t necessary. The same comparison can be made of necessary goods (i.e. necessities). Food, medicine, organs, it’s all the same. The rich will be disproportionately able to afford them. That fact doesn’t mean we don’t allow a market for them. That’s a terrible argument against markets. There are people so desperate who see no other option than to sell their labor at a marginal rate and in abject conditions. The solution isn’t to outlaw selling one’s labor (unless you’re a syndicalist) but to better regulate it to ensure exploitation doesn’t occur. That’s the solution.

    The sale of blood, bone marrow (which is illegal, by the way), organs, etc. is not so different. The arguments given against their sale is the same. It’s dehumanizing, it’s commodification of the body, it’s unequal, and so on and so forth. Ignored is the fact that it saves the lives of real people. Nothing is more dehumanizing than simply letting someone die unnecessarily. The argument that blood is renewable while organs are not does not work. As I’ve already explained above, live donations of liver use a portion of the donors liver, which regenerates and returns to full functionality. People who donate their kidney are also very healthy individuals. In fact, they outlive their non-donor counterparts. The people who are arguing against transplantation of organs are simply not doing so on scientific or medical grounds. That much is clear.

    My ethics stem from the moral philosophies that rely on principles. The underlying principle of opt-out is that the state owns your body by assumption. Yeah, I find that wrong. And the hope of opt-out supporters is that people are not altruistic, but rather lazy or ignorant. Yeah, I find that wrong. It’s unethical, on principle.

    What about the results (what utilitarians care about)? Well, as it turns out, opt-out doesn’t guarantee higher donor rates. If it did, then its supporters better have a very good reason to show why donation rates in Sweden and Israel are so low. It’s not a surprise the Organ Donation Taskforce of the UK argues against opt-out.

    So it’s unethical and it doesn’t work. Well, that’s a big problem in my eyes. What’s the solution? The solution is to get organs to people who need them live. Maybe a market for organs can achieve that–there’s good arguments that support that claim. Maybe, though, markets are an unfair way to go about achieving that goal. So perhaps a better solution might be a system wherein the government pays donors for organs and then the government distributes these organs to people who need them, either for a fee or for free. How does that sound to you?

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    1. Well, your last proposal would at least make the distribution of organs more just, or fair and equitable. It removes a part of my objections. But on the sale side, whether it’s the state or the patients who buy the organs, I’m still stuck with the fact that poor people would be forced to do something they would normally prefer not to do, with the reductio ad absurdum of the father selling off his entire body to rescue his family. And regarding the success of lack of it of the opt out system, fairness would demand that you at least grant that the evidence is mixed (given the evidence we both bring to the table), rather than flat out state that it doesn’t work. I assume that much of the uncertainty is related to the fact that it hasn’t been tried in a lot of constituencies.

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  5. 35 year old male living in India. Non-drinker, non-smoker, Healthy no desease, ready for all tests required.AB+ blood type. Will sell kidney for the right price. Willing to travel to do operation. All expenses concerning operation to be paid by recipient. Email me at manojmzn20000@gmail.com or call me 0091 9412110033 .if interested write me an mail and I will answer all your questions. Thanks to all humble people out there.

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  6. […] There are also those who claim, perhaps not without reason, that young Muslim girls are really not ready to make an informed choice since they may have been indoctrinated from early childhood on. Creating an environment where they can meet girls who don’t cover their head will allow them to make an informed choice. And if such an environment means banning the veil in schools because peer pressure would result in the generalization of the veil, then so be it. The girls who want to wear the veil can still do it outside of school. (More on informed consent here). […]

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