Wednesday, March 12, 2014

Selling a Kidney: Would the Option Necessarily be Beneficial?

The March 2014 issue of the Journal of Medical Ethics has a symposium on the issues of whether people should be allowed to sell a kidney. The lead article by Simon Rippon, "Imposing options on people in poverty: the harm of a live donor organ market," is freely available on-line, but you need a subscription to read the comments.

Rippon aims to tackle head-on the claim, popular among economists, that offering people an additional option--in this case to sell a kidney--must make the people better off, because they don't need to choose the option, but if they wish to do so, they can. He clears the ground by saying: "I know of no good reason for believing that there is anything intrinsically wrong with buying or selling
organs. It is certainly difficult to imagine any plausible explanation of the wrongness of selling organs that would not equally count against giving them away. It is true that these two types of act differ in that giving organs away is presumably motivated altruistically, whereas selling need not be—but it is not usually considered intrinsically wrong to act from non-altruistic motives. Even if giving organs away is morally better than selling them, it is implausible to suggest that we therefore ought to encourage donation by banning selling entirely, when the cost of doing so might be measured in the loss of thousands of innocent lives due to an inadequate supply of organs. For this reason I will set aside this objection to organ markets, and turn to another. My objection will not depend on the claim that there is anything intrinsically morally wrong with selling or buying organs."

Instead, Rippon makes an argument that when an option is available, at least some people will find themselves under social pressure to select that option, or will be held responsible for failing to choose it. "For example, imagine a cashier at a rural filling station that is potentially vulnerable to an overnight robbery. It may be better for the cashier to have no key to the safe (and to have a
prominent sign displaying that information) than for the cashier to have the key which gives him the option to open it. Possession of the key would make the cashier vulnerable to threats, and the filling station worth robbing."

If selling a kidney was a legal option, Rippon argues: 

"This means that even if you have no possessions to sell and cannot find a job, nobody can reasonably criticise you for, say, failing to sell a kidney to pay your rent. If a free market in organs was permitted and became widespread, then it is reasonable to assume that your organs would soon enough become economic resources like any other, in the context of the market. Selling your organs would become something that is simply expected of you as and when financial need arises. ... 
We should ask questions such as the following: Would those in poverty be eligible for bankruptcy protection, or for public assistance, if they have an organ that they choose not to sell? Could they be legally forced to sell an organ to pay taxes, paternity bills or rent? How would society view someone who asks for charitable assistance to meet her basic needs, if she could easily sell a healthy ‘excess’ organ to meet them? ... Wherever there is great value in not being put under social or legal pressure to sell something as a result of economic forces, we should think carefully about whether it is right to permit a market and to thereby impose the option on everyone to sell it."

The idea that certain activities should be banned not because they are necessarily wrong, but because otherwise there would be social pressure to participate, has some intuitive plausibility, but in practice, it leads to some of our trickiest social issues. For example, some European countries have at times banned headscarves, thus meaning that Islamic women are not under social pressure to wear them. There are arguments for banning circumcision, to protect families from social pressure to have the procedure done. That said, the concern that powerless people might be pressured into selling a kidney seems to me a legitimate concern and counterargument. The commenters on Rippon's essay raise a number of possible responses.

In one of the comments, Gerald Dworkin offers several responses. He argues the possibility of selling a kidney shouldn't be settled by pointing to a few possible bad outcomes, but instead requires a balancing of costs and benefits, in the context of a regulated market: "To do so
he must establish that there is a class of harms that (1) are likely to occur, (2) are significant enough to outweigh the enormous benefit of saving people’s lives, and (3) cannot be mitigated sufficiently by intelligent regulation ..."

Dworkin points out that if Rippon's concerns were likely to occur, we have already entered that world. "But we already have formal markets in blood, tissues, sperm and eggs. And lest one think that the sums offered in these markets are trivial, it is not uncommon for infertile couples to make offers of US$50 000 for eggs that meet their specifications. Is there any evidence of the kinds of speculative harms adduced by Rippon—ineligibility for bankruptcy protection or for public assistance—in these markets?"

In addition, Dworkin draws an provocative parallel to the arguments over physician-assisted suicide, another area in which there is fear of social pressure if the option is open. He writes: "To use an analogy, many of the same arguments apply to legalising physician-assisted suicide. Those who are dying, and using up family resources, may be pressured into such suicide by family
members. They may be looked upon as ‘selfish’ by society for using scarce resources. But, on the other side, if we keep assisted-suicide illegal, we prevent dying patients from ending their life
sooner rather than later. I think the ability to determine the timing of your death is sufficiently important to expose those who do not wish to die sooner to pressures they will have to resist.
Similarly, I believe that greater access to organs necessary to continued life for many people justifies imposing risks of social pressures which, at the moment, we have little evidence will occur (or not) and have even less evidence are not preventable by regulation."

My sketch here cannot do justice to all of the arguments involved, but I will add two points. First, at present, the main source of kidney donations is people who die unexpectedly, with a few voluntary donors. In the meantime, thousands of Americans die every year awaiting a kidney transplant. I can easily imagine that a substantial group of healthy people might not be willing to donate a kidney for free, but would be willing to do so for substantial compensation, and encouraging transplants from healthy donors could save thousands of lives. Second, it troubles me that we often expect the donors of kidneys and blood to act out of sheer altruism, but we have no such expectation of any of the other participants in an organ transplant, like the health care providers or the hospital.

For those interested in how economists view this issue, the Journal of Economic Perspectives had a Symposium on Organ Transplants in the Summer 2007 issue with two Nobel laureates among the authors. (Full disclosure, I've been the Managing Editor of JEP since 1987.) All articles in JEP are freely available, courtesy of the American Economic Association.