Friday, July 11, 2008

No such thing as ethical organ market

BY: Alastair V. Campbell

IN THE current controversy over whether an organ market should be legislated, opponents of the ban have argued that an enlightened and rational perspective would remove most, if not all, of the ethical objections.

Current international opinion, however, is unwavering in its objection to all forms of commercialisation of the procurement process. The World Health Organisation and the World Medical Association strongly oppose payment for organ donation.

In a recent international summit in Istanbul on Transplant Tourism and Organ Trafficking convened by the Transplantation Society and InternationalSociety of Nephrology, it was reaffirmed that the ethical basis of transplant policies and programmes should remain equitable in allocation. Their primary objective should be to promote the optimal health and well-being of donors and recipients.

These principles preclude financial considerations or material gain. The ban on organ trading is not irrational, a mere emotional response or a prejudice, but is based on good reasons.

* Organ trading is wrong in principle because it presupposes that the body is a piece of property
akin to our material possessions (house, car, etc). While a body part like a kidney is alienable, meaning it can be transferred to another, it is certainly not fungible (easily replaced by something similar) or commensurable (its value quantified and compared to another object).

The gift of an organ is different from selling it, since the organ is gifted out of the wish to benefit another person, not for financial gain.

* Organ trading has negative social effects in that it undercuts the gift relationship between
donors and recipients. Gift ethic or altruism - with its effect on social solidarity - is the rationale for many current procurement systems for cadaveric organs.

If a live organ market is instituted, many people may opt out from altruistic giving - thus reducing the supply of transplantable organs. A recent study in Austria has shown that financial incentives would have this effect.

Demand may also be made for certain forms of payment for cadaveric organs.

* There is a strong reason for a universal ban on organ trading by all countries (except Iran). Once this barrier is breached, it is hard to justify why the law should not allow the live body trade to be extended to other "expendable" parts like hands and single eye corneas.

Furthermore, once the ban is lifted, the current organ traffickers will have the justification they need. It can be argued that a regulated market will eliminate or reduce the black market.

But so long as the national system still operates on principles of utility and equity with regard to allocation of organs - if not, perceptions of social injustice will arise - there will be perceptions of inefficiency for those on the waiting list.

So in reality, the black market will continue albeit in different forms such as offering direct higher cash payment to the vendors.

A recent review of the Iranian system in the British Medical Journal clearly shows that the legislation of an organ market in Iran has not corrected the problem of the black market and the exploitation of the poor as suppliers. The article also points out that the waiting list for kidneys in Iran has not been eliminated.

* The notion of an "ethical and regulated market" is misleading:

One, it is inevitably exploitative, with the poor being the majority, if not all, of the vendors. Many current poor vendors have expressed "donor regret". The selling of an organ did not help them out of poverty and in fact had significant negative impact on their health and employment.

Two, a market based on property and ownership would suggest that vendors can designate the recipients of their organs. This is contrary to the ethical principle of allocation based on need.

And three, organ shortage is a global phenomenon and an "ethical market" will presuppose a level playing field among countries and require international harmonisation of regulations.

* The nation's reputation as a medical hub can be eroded significantly if it is seen as exploitative, particularly in the current global context where human rights doctrine prohibits exploitative practices. It can be argued that fair compensation, health insurance and appropriate follow- up care, etc, can be made to potential vendors.

This however would result in significant increased costs for the national healthcare system, resulting in either less transplantation being done or fewer resources dedicated to other health-care needs.

* It has been argued that the supply of organs will increase with an organ market, resulting in more lives saved. This is debatable, given that an organ trade may reduce altruistic donation (of both live and cadaveric organs) and will attract predominantly the poor who may provide marginal organs for transplantation.

It has been further argued that people should be allowed to sell their organs so long as the benefit-risk ratio is favourable. One should however look at both the short-term and long-term benefit-risk ratio.

In the short term, vendors may not have access to or be able to afford appropriate care. In the long term, given the increasing incidence of longer life expectancy and end-stage organ failure, the vendors themselves may be in need o transplantation.

The Declaration that was issued from the Istanbul summit emphasised the need for practices that support organ donation from dead donors.

It also called on all countries to address their responsibilities with respect to exploitative practices and to develop self-sufficiency in organ donation.

The current organ shortage requires the international community to cooperate in finding solutions and ending unethical practices.

The writer is the Chen Su Lan Centennial Professor of Medical Ethics and director of the Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, NUS.

This article was first published in The Straits Times on July 10, 2008.


Rory said...

I am all in favour of an ethical and unregulated market. That is, the only way organ donation can be ethical, is if it is unregulated and it is placed into a free market. One may give an organ as one pleases, just as one would trade any other item. It is their moral right, as a human being, with their own body as their own possession, and their choices as their own, to choose whom they will trade with, for what cost, and what they will trade.
I don't argue that it would be the solution to any shortage of organs; what I argue is that it is immoral and illegal to tell place legislation telling him what he may or may not do.
As a rational human being, my only way to survive is by choosing the actions that will best benefit me. If you don't allow a man this right, you are not allowing him to live.

My biggest objection, is at the point you make central to your argument, you make it throughout your article:
"This is contrary to the ethical principle of allocation based on need."
"Organ trading is wrong in principle because it presupposes that the body is a piece of property
akin to our material possessions (house, car, etc). "
"an "ethical market" will presuppose a level playing field among countries and require international harmonisation of regulations".

Essentially, you believe that organ donation isn't about a private, voluntary judgement of the individual, but about a sacrifice to another man's need. Furthermore, you state that this being the case, the government would have to be involved, stepping up international regulations and laws to control the whole business.

What I question are your premises, that this need be mandated by the ethics of Altruism, and that it need be regulated by the government.
I do not argue the practicality of, say, poor people donating organs. I don't believe it is in their best interest. Neither is it in ones best interest to buy alcohol, to take drugs, to avoid stable employment; but the government has no right in forcing people to make decisions one way or the other.

Government regulation takes any kind of 'gift-giving' or warm sentiment out of the equation, and forces a gun to the head of donors and recipients, telling them that they may not choose to trade organs freely, but must subscribe to the government's mandated waiting list, ordered by whatever arbitrary system they set up for deciding who is 'most needy'.

I am not attacking you, so please don't get defensive at me. I question your premises, and I want to show you that the code of altruism and government regulation is not the only aspect to look at this issue from.

Thank you.

(This is a bit off topic, but the song 'You Can't Take It With You When You Go' was playing on your site when I read this post. Is that related to getting a Donor card?)


hi ..

first of all - this article was not written by me - and frankly i have some reservation on certain points that were articulated in the article but in the macro scheme of things, the article does provide a different and broader perspective into the matter that is worth evaluating.

my humble response to your biggest objection, i don't think that giving should be merely be driven from an altruistic point of view but it, undeniably, is one of the ways one could do it. yes, monetary values is a strong motivation force - and to each his (or her) own.

so that sets the premise to my response - removed solely altruism as the primary motivation factor.

i totally agree with you on the point of individual choice and freedom that which you have given the example of to a person "buying alcohol, take drugs ...". on the basis of individual freedom and what not - i am open to this.

however, i am of the idea that individual freedom should be allowed but not at the cost of others - and in which case taking drugs and alcohol - should be and is regulated in many or every developed country.

the motivation of the regulation here is perhaps for the sake of the general public - as my earlier point. thus the manifestation of laws against drunk driving, or making a scene in public under the influence of alcohol, or drug possession. so hence, on the premise of those examples you have quoted - in the current context - has a certain government involvement through laws and such. so how should that be different from organ donation? which has also a larger repercussion on the others of the society.

and the irony is further that the term "donation" itself - in the literal sense - has an altruistic flair?

now, you said something along the line of govt removing whatever warm and fuzzy feeling in the "giving" - now consider when one who is desperate for a next meal and would trade anything for precisely that - would that be ethical to throw the green in his face - and then say "no .. no .. no .. your kidney first". how is that different from the govt pointing a gun at someone (as you have mentioned and me merely quoting you) when in the circumstance of the poor man who is driven but by his situation to accommodate whatever to meet his needs? would there still be warm-fuzziness? or merely the actualization of the evolutionist's adaptive theory - survival.

my question further would that person be able to correctly evaluate the amount that is worth for his "donation" - for that matter, how much would it worth? which is precisely - going back to the article amd its fundamental message - there is "no such thing as an ethical organ market"

now this is not to say that i totally disagree with your point and in fact you have raised some good points - but the reality is beyond idealism - you most initial point - on an ethical and unregulated market is simply impossible as far as human nature and human dynamics and freud's ID - thanatos and darwin's adaptive theory are concern.

Finally on your wonderful statement which i totally agree: "As a rational human being, my only way to survive is by choosing the actions that will best benefit me. If you don't allow a man this right, you are not allowing him to live" - my only response is in the general message of this response - no man is an island.



and no - that song has got nothing to do with this entry.