The Ethics of Human Rights (68): The Case Against the Sale of Human Organs

Or, better, a case against it. I believe that trade in human organs is morally wrong, at least if this trade is free and unregulated (but perhaps also when it’s regulated in some way). I don’t think the same case can be made against the sale of body products such as blood, hair etc., although some of the arguments against the sale of organs may also apply to the sale in body products. I will bracket this problem for now and concentrate on organs.

I make the argument against organ sales knowing full well that there’s a huge problem of organ shortages and that some people will benefit from free organ trade, and may even lose their lives if free trade is not allowed. Hence, if I claim that free organ trade is morally wrong, then I’m not necessarily making the claim that it should be forbidden in all circumstances. If there are other wrongs, such as people avoidably losing their lives, that overwhelm the wrongs resulting from organ trade, then the former wrongs may be preferable all things considered. However, I believe that the latter wrongs are commonly underestimated by those defending the legality of organ sales. I also believe that there’s a blind spot common among those who claim that the wrongs resulting from a ban on sales typically outweigh the wrongs resulting from a free organ market: it’s not as if the only choice is the one between the status quo – which is in most cases a ban on sales resulting in organ shortages – and a free organ market. There are other and perhaps better solutions to the shortage problem, even in the short term.

Here are some of the reasons why I believe a free organ markets causes serious wrongs:

1. Coercion by poverty

Not a single wealthy person will ever need or want to sell his or her organs. In a system of free organ trade, it’s the poor who will sell their organs to the rich. Maybe a legalized market will reduce the wealth disparity between buyers and sellers to some extent, given the fact that the number of potential sellers will be higher in a free market and that the number of potential buyers will not. This increase in supply compared to demand, following legalization, will reduce prices somewhat, making it feasible for more people to buy organs. Still, it will almost always be the relatively rich buying from the relatively poor, especially if the market is a global one (and I find it hard to understand arguments in favor of a free market limited to national borders).

Many of these poor will be desperately poor, particularly if the market is globally free. A decision to sell an organ isn’t made lightly, and requires some level of financial desperation. The extraction of an organ still carries a substantial risk (e.g. 1 in 3000 die from a kidney extraction even in the best medical circumstances), and few will be willing to take this risk from a baseline situation of wellbeing or happiness that is moderately high and that can not or need not be substantially improved by financial means.

Hence, if organ trade is allowed, many sellers will be desperately poor people, and there will be more of those in a legalized market than in a black market. Now it’s clear that desperation can be coercive: it forces people to do things that they would not otherwise do, that entail risks that they would avoid at higher levels of wellbeing, that may be harmful for them, and that go against their better judgment. If coercion is wrong, then free organ trade is wrong because free organ trade multiplies the number of desperately poor people that feel coerced to sell their organs.

2. Trade instead of justice

It’s reasonable to assume that rich people are responsible for the poverty that exists in the world, if not directly through their actions (trade policy, colonization etc.) then through their failure to prevent or remedy poverty. It will almost invariably be the same rich people who will want to buy organs from poor people. Now, if you first create poverty (or fail to do something about it, which in my mind is equivalent) and then tell poor people that you’ll give them money but only if they give you their organs in return, then you add insult to injury: you have a moral duty to give them your money unconditionally. Insisting on the possibility of trade while neglecting the necessity of justice is wrong.

3. Objectification and instrumentalization

There are some other good reasons why it’s wrong to buy an organ from someone, even if this person willingly agrees to the sale on the basis of informed consent, and even if he or she isn’t coerced into the sale by his or her poverty and isn’t someone who has a moral and unconditional right to the money he or she would get from a sale. For instance, buying an organ from someone means treating this person as an object and a means. It’s a failure to respect the person’s dignity as a being that should be treated as an end in itself rather than as a shop or an organ factory. It’s not outrageous to view organ trade as a new form of cannibalism.

4. Unjust distribution

The previous 3 arguments against organ trade focused on the wrongs it imposes on the sellers. But even the buyers are treated unjustly in a system of free organ sales. If the distribution of organs is regulated solely by way of free trade, then the patients who are most in need of an organ are not the ones who will get the organs. It will instead be those patients able to pay most who will get them.

5. Crowding out altruism

There’s even an argument that points to possible harm to society as a whole. If more and more human relationships are brought within the cash nexus, then giving and altruism will be crowded out. It’s obviously the case that when people can get money for something, they will stop giving it for free. Human nature is what it is. But given what it is, we shouldn’t encourage its darker sides. It’s reasonable to assume that free donation of organs will all but disappear when people can get cash for them. And it’s also reasonable to assume that this reduction in altruism can have a ripple effect throughout society and in many other fields of life, especially when we take account of the fact that more and more activities have already been brought within the cash nexus: sex, reproduction, politics

No one assumes that everything should 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). So we have to stop somewhere and disallow the trade of some things. Why should it be evident that organs are not one step too far?

Alternatives

If organ sales do have harmful consequences, then what are the alternatives? If we don’t want to allow those willing to sell to go about and legally sell their organs to those capable of buying them, then how do we solve the shortage problem and save the lives of those in need of organs? We can do several things:

  • We can try to increase the number of free cadaveric donations, by improving the way we approach bereaved relatives, by introducing a system of presumed consent, by promoting explicit consent (for example through the introduction of regulations that allay fears that doctors will stop life support when they need organs, or through some sort of priority system in which those who have pledged cadaveric donation can jump the queue when they themselves need organs) etc.
  • We can try to increase living donation, by way of awareness campaigns.
  • We can hope for scientific breakthroughs that make cadaveric recovery of organs easier or live donations less risky, or that make it possible to grow organ in vitro.

Organ sale is certainly not the only solution to the shortage problem.

A final remark: given the fact that proponents of organ trade often rely on the right to self-ownership – the right to do with your body as you please – we may have to tone down the importance of that right. Which is something we’ll have to do anyway: for instance, there’s no welfare state if the right to self-ownership is absolute.

The Ethics of Human Rights (30): Organ Donation and Presumed Consent

Health and survival are human rights. Many people’s health and survival depend on organ transplants. However, there are more people requiring organs than people donating them. Hence, the question of how to increase organ availability, which I have discussed many times before on this blog (see here for instance). My favorite policy is presumed consent : if people during their lifetime don’t explicitly opt-out and deny the use of their organs after death, it is assumed that they consent to this use. There’s evidence that presumed consent raises donation rates by perhaps 20-30%.

However, presumed consent may perhaps not be enough to eliminate the shortage. And although it may solve part of the problem, it may also create some problems. Some people might feel uneasy when the state can automatically decide what happens to their bodies or to the bodies of their loved ones after death. The public might also start to wonder whether surgeons would become too eager to harvest organs, stop life support somewhat early and move the border between life and death (the definition of the moment one dies isn’t an unchanging variable throughout human history). But that’s also a problem with opt-in systems.

Another problem with presumed consent, but also other types of cadaveric donation such as opt-in, is the constraint imposed by the number of people who die in a way that makes their organs available for transplant.

Does all this mean we have to abandon cadaveric donations in general and presumed consent in particular? And rush towards a free market in organs for the living? That could perhaps eliminate the shortage completely, at least for those able to buy the organs and on the condition that there are enough desperate souls “willing” to sell. The latter is of course a condition that’s easily met when we allow international free trade – many places in the world are vast resources of desperateness.

(If you doubt the risk of free trade pushing desperate people to sell their organs, look at Iran. Most donors in Iran are extremely poor. Maybe you think it’s good that poor people have options to do something about their poverty. I agree, but I prefer that they have other options and aren’t forced to commodify themselves, especially when this commodification entails health risks).

I don’t think free organ trade of live donations is a good idea, given the problems with that option outlined here. (Although I might be persuaded by the argument that prohibition of a widespread activity is always futile and a regulated market a lesser evil; e.g., one could offer tax credits for live donations). There’s still a lot of elasticity in presumed consent and the few problems it raises can be solved, in my opinion. The horror story of doctors switching off life support and plundering bodies is precisely that, a story. Countries that are reluctant to implement presumed consent because of such reasons can be convinced, I think, especially given the success of other countries that have it.

Even in countries that have presumed consent and that have therefore increased organ availability, things can be improved. The rights of relatives to veto could be restricted. (Personally, if I would have made the conscious choice of opting in or of not opting out, I wouldn’t be comfortable with the possibility that my relatives have the right to disrespect my will after death). In addition, the transplant system (logistics, transport, availability, procurement etc.) could be made more effective, including in countries that decide to stick with opt in.

Beyond presumed consent of cadaveric donation, live donation of certain organs could be encouraged (though preferably not through market systems). Countries that don’t want to go to presumed consent could make it more likely for people to opt in in a system of cadaveric donation: Israel for example allows opt-in donors and their families to jump the waiting line for transplants when they should need an organ themselves. That’s an interesting idea, but it could throw up some other problems. Also, technology could come to our aid; perhaps in some time we can make organs from stem cells.