The case for a Market for Kidneys
This piece was orginally written for LSE100 multidisciplinary research course, for which I received academic prize.
The medical world today faces a serious and urgent challenge: the extreme shortage of kidneys for transplants. To make up for this shortfall, a market in kidneys from living donors, although admittedly controversial, ought to be considered. This essay first demonstrates the possible socio-economic benefits of marketising kidney sales and tackles a few criticisms often raised against it. Subsequently, the essay discusses why such a market is morally and ethically permissible.
Socio-economic arguments
The case for allowing kidney sales by living donors is a simple one: it is the best solution to the dire supply shortage and black-market problems that currently exist. In the United States alone, roughly more than 4000 patients die annually while waiting for a kidney transplant (National Kidney Foundation, 2017). Globally, only one in ten people in need of a new kidney manage to get one. Although governments have tried to implement various methods to boost the number of organ donors, the shortage is still alarmingly high and costs lives (National Health Service, 2017). Aside from the rather futile government incentive programmes, only black-market incentives remain as ways to solicit a larger supply of kidneys. As revealed by WHO experts, an estimated 10,000 black market operations involving purchased human organs now take place annually (Campbell & Davison, 2012). Such a status quo is not acceptable as risky, unregulated surgeries are often pursued in black markets and the poor are heavily exploited as a result, for they not only face the danger of unsafe surgery practices, but also fail to receive proper, proportional financial compensation. In view of such shortages, and the existence of an unregulated network that is extremely abusive, proponents of marketisation such as kidney specialist Gavin Carney believes that “allowing the sale of organs would save thousands of lives and billions of dollars in care for patients on transplant waiting lists, and would shut down the black market, which has caused severe exploitation of the vulnerable.”
Granted, branding marketisation as a solution to the current problems invites serious criticisms, one of which is that it is in conflict with egalitarian principles (Voorhoeve, 2018). Opening up a market for kidneys is essentially opening up ways for the rich to exploit the poor for organs. It is indeed reasonable to predict that it is the poor who would end up being the vendor. As Greasley argues, “people living in poverty have far higher chances of needing to sell an organ than to receive one, meaning that the distribution of benefits and burdens across the privileged and the poor is not even.” In other words, the supply of kidneys may indeed be increased, but mainly to the rich at the expense of the poor.
However, two objections can be made to the above argument. First, it seems like a hypocritical argument on the supposition that such exploitations are not already happening. In America, the average time on the waiting list varies from 3 years to 10 and dialysis in America costs $80,000 per year. (Rosenberg, 2015), which effectively means only the rich can even afford to wait for a longer period of time. As for black markets, it is also often only the rich who have the connections and financial means to purchase. Hence, marketization is not drastically worsening the situation, if at all. As such, from a purely utilitarian macro perspective, even if the situation of inequality is maintained or slightly worsened, it could be well worthwhile to marketise kidney sales for the pure purpose of increasing supplies. In that case, more lives can be saved, and waiting time can be significantly shortened, allowing more low-income individuals to be able to “wait” for the right transplant, which offsets the problem of inequality to a certain extent. Moreover, it is also often the case that it is the vendor, usually the poor, themselves that are anxious to sell. Marketisation thus is a way of ensuring their safety and financial well-being by preventing them from seeking risky operations in the black markets.
Furthermore, the distribution problem also does not make grounds for banning, for we just need a better, more equitable system. The Erin and Harris proposal (EHP), in which the government acts as a collective buyer, provides a good balance to the problem and largely solves the inequality problem brought about by a completely free market of kidneys.
The second objection is that, while it is true that it is mainly the poor who would be selling, they would not exactly be made better off by a prohibition. It does not make logical sense to, on the one hand, wanting to help the poor out of poverty and on the other trying to limit their ways of doing so. Granted, empirical studies have shown that there is no material improvement to the vendors’ conditions even where full payment is reliably made (Greasley, 2014). However, such studies can be statistically misleading. People who sell their organs for money are likely to be in no condition to improve their material well-being in the first place. It is more likely a survival need rather than an economic need. Hence, it is normal that their economic conditions do not improve, but at least they are able to avoid the worse alternative – death due to extreme poverty.
Furthermore, even if vendors and recipients would always be at risk of exploitation, that does not alter the fact that if they decided to choose this option, all alternatives must seem worse to them. As Radcliffe-Richards put it, “trying to end exploitation by prohibition is rather like ending slum-dwelling by bulldozing slums” (J Radcliffe-Richards, et al., 1998): surely it ends the evil in that form, but only by making things worse for the victims. If we want to protect the exploited, leaving them in the hands of black market is not the solution. We can do it only by pulling them out of poverty, or, failing that, by controlling the trade, which is exactly what marketisation aims to achieve.
Moral and Ethical Arguments
Apart from socio-economic considerations, moral challenges are often raised against the case as well. One of which often cited is that of allowing people to do serious damage to themselves for the sole purpose of making money (Jha & Chugh, 2006). However, I believe that kidney sales should be a viable personal choice and there is no moral problem at a personal level. Referring to Mill’s harm principle, choosing to sell body parts is well within one’s “natural rights” and is indeed permissible, as no harm is done to others. By doing so, society’s utility is also improved in the most significant way possible – a direct saving of lives. The marketisation of kidney sales can thus be considered as a push towards utility maximisation, which can even be viewed as morally good.
Next, it is often asserted that organ transplant must be altruistic to be acceptable, and thus payment should not be part of the equation. There are a few problems with this line of reasoning. Firstly, altruism does not dictate one to be a “donor” rather than a “vendor”. Radcliff-Richards gives an analogy that, “if a father who saves his daughter’s life by giving her a kidney is altruistic, it is difficult to see why his selling a kidney to pay for some other operation to save her life should be thought less so” (J Radcliffe-Richards, et al., 1998).
Secondly, an action being altruistic is never a prerequisite for the action not being prohibited. Hence, altruism is hardly a reason to forbid people from collecting money from the act of offering kidneys.
Another objection is presented by Simon Rippon, that “an option to vend creates pressure to vend”, where “many, especially those in poverty, will ‘find themselves faced with social or legal pressure to pay the bills by selling their organs’” (Rippon, 2014).
However, Rippon’s analysis demonstrates a misunderstanding of the EHP. Consider this empirical example set forth by Luke Semrau: “in the USA, about 35 000 people were added to the waitlist in the USA in 2012, making that about 1 in 9000 people would need to become vendors annually if all kidney shortage were to be sourced from the market.” As he argues, there is no compelling reason for us to believe that permitting 1 in 9000 to vend annually will somehow ‘fundamentally change’ how people relate to their body parts. Rippon's claim that vending will be ‘simply expected (Rippon, 2014)’ of those in financial need is hence unfounded. It is more likely the case that the practice will never be sufficiently common to influence societal expectations in the ways painted by Rippon. In other words, giving people the option to vend is unlikely to give rise to a significant pressure to vend.
In conclusion, permitting a market for kidneys from living donors is not only morally permissible but also rather socially and economically desirable. Slight inequality problems may arise from marketisation, but they could be readily offset by the benefits and protection it brings to the socially vulnerable and the poor. Setting aside the shortage problems, the mere notion of “organ donation” gives off a hypocritical vibe, as everyone involved in the process is paid except the donor. If, as the defenders of prohibition often argue, organs are valuable and integral to human dignity (Greasley, 2014), is it then not an insult to human dignity not to compensate those giving away their organs? Or even if, arguendo, there are indeed moral concerns regarding kidney sales, it should be held that no intangible moral concerns should be as important as the tangible results of saving human lives.
Bibliography
Campbell, D., & Davison, N. (2012, May 27). Illegal kidney trade booms as new organ is 'sold every hour'. Retrieved 2018, from The Guardian:
https://www.theguardian.com/world/2012/may/27/kidney-trade-illegal-operations who
Greasley, K. (2014). A legal market in organs: the problem of exploitation. Journal of Medical Ethics(40), 51-56.
J Radcliffe-Richards, A. S., Guttmann, R. D., Hoffenberg, R., Kennedy, I., Lock, M., Sells, R. A., & Tilney, N. (1998, June 27). The case for allowing kidney sales. The Lancet, 351(9120), 1950-1952.
Jha, V., & Chugh, K. S. (2006). The Case Against a Regulated System of Living Kidney Sales. Nature Clinical Practice Nephrology(2(9)), 466-467. Retrieved from Medscape: https://www.medscape.com/viewarticle/543585
National Health Service. (2017, Mar 9). Waiting time to kidney transplant down 18% but shortage of donors still costing lives. Retrieved from Organ Donation NHS: https://www.organdonation.nhs.uk/news-and-campaigns/news/waiting-time-to kidney-transplant-down-18-but-shortage-of-donors-still-costing-lives/
National Kidney Foundation. (2017). ORGAN DONATION AND TRANSPLANTATION STATISTICS. Retrieved from National Kidney Foundation:
https://www.kidney.org/news/newsroom/factsheets/Organ-Donation-and Transplantation-Stats
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Rosenberg, T. (2015, July 31). Need a Kidney? Not Iranian? You’ll Wait. Retrieved 2018, from The New York Times: https://opinionator.blogs.nytimes.com/2015/07/31/need-a kidney-not-iranian-youll-wait/?_r=0
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