This article was downloaded by: [North Dakota State University] On: 14 October 2014, At: 19:33 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Are Kidney Markets Morally Permissible If Vendors Do Not Benefit? Samuel J. Kerstein
a
a
University of Maryland, College Park Published online: 17 Sep 2014.
To cite this article: Samuel J. Kerstein (2014) Are Kidney Markets Morally Permissible If Vendors Do Not Benefit?, The American Journal of Bioethics, 14:10, 29-30, DOI: 10.1080/15265161.2014.947798 To link to this article: http://dx.doi.org/10.1080/15265161.2014.947798
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Kidney Vendors in Regulated Organ Markets
Malmqvist, E. 2013. Kidney sales and the analogy with dangerous employment. Health Care Analysis (published online December 27). doi:10.1007/s10728-013-0270-3).
Omar, F., G. Tufveson, and S. Welin. 2010. Compensated living kidney donation: A plea for pragmatism. Health Care Analysis 18 (1): 85–101.
Malmqvist, E. 2014. Are bans on kidney sales unjustifiably paternalistic? Bioethics 28(3): 110–118.
Wilkinson, S. 2003. Bodies for sale: Ethics and exploitation in the human body trade. London, UK: Routledge.
Naqvi, S. A. A., B. Ali, F. Mahzar, M. N. Zafar, and S. A. H. Rizvi. 2007. A socioeconomic survey of kidney vendors in Pakistan. Transplant International 20(11): 934–939.
Zargooshi, J. 2001. Quality of life of Iranian kidney “donors.” Journal of Urology 166(5): 1790–1799.
Downloaded by [North Dakota State University] at 19:33 14 October 2014
Are Kidney Markets Morally Permissible If Vendors Do Not Benefit? Samuel J. Kerstein, University of Maryland, College Park Julian Koplin (2014) argues forcefully that, according to available data, it is doubtful whether poor people in developing countries would benefit from selling their kidneys in regulated markets. He points to studies suggesting that in unregulated markets, kidney sellers suffer physical, psychological, social, and financial harms. Moreover, Koplin makes a plausible case that these studies, coupled with data regarding the regulated market in Iran, raise serious worries that sellers in developing countries would suffer such harms in regulated markets as well. If regulated markets in kidneys get established around the globe, organs would presumably flow from citizens of poor countries to citizens of wealthier ones. Let us focus on regulated markets in developing countries. Let us assume for the sake of argument that in such markets only vendors who give their informed, voluntary consent to nephrectomy would sell, and they would receive the promised payment, as well as appropriate medical attention, before, during, and after the procedure. Koplin gives us reasons for thinking that sellers might still typically fail to benefit. But if he is correct, might such markets nevertheless be morally permissible? In my view, the strongest basis for an affirmative answer given our assumptions would be that these markets would help to extend many lives. If the markets would significantly increase the supply of kidneys for transplant, it seems that they would do so. Consider, for example, that in 2011 in the United States the average expected life span of a 50- to 54-year-old with end-stage renal disease treated with dialysis was about 5 years, while the average expected life span of someone in this age range with the same malady but who received a transplant was about 20 years (U.S. Renal Data System [USRDS] 2013, 266).
But there is another argument that might support markets from the standpoint of the sellers. Regulated markets, one might say, express respect for the sellers’ autonomy. Let us specify that a person’s action is autonomous if and only if she is acting on some preference of hers and, based on reflection on her values, she either does or, if she thought about it, would choose to have this preference, even in light of understanding how it arose in her. Kidney sellers might be acting autonomously. They might hold, for example, that without money from a sale they would be unable to pursue effectively goals of moral importance to them, such as that of securing a good education for their children. (They might at the same time acknowledge that selling will diminish their own happiness.) Allowing market exchange respects autonomy if it provides options for individuals to effectively direct their lives in accordance with plans they reflectively endorse, contends the argument. A difficulty with this argument is that while vendors might effectively exercise their autonomy in a particular action of selling a kidney, this action might result in an overall impairment of its effective exercise (Kerstein 2009). As Koplin suggests, kidney selling is associated with psychological suffering. A study of kidney sellers in Iran has shown that vendors frequently experience feelings of worthlessness and shame. They perceive themselves as akin to prostitutes and their scars as stigmata (Zargooshi 2001). Common psychological effects of selling a kidney in Iran seem to be anxiety and depression, which can surely make it difficult for one to promote one’s ends. “Vending, especially the psychological complications, severely affected employment potential,” says one researcher (Zargooshi 2001, 1794). If vendors cannot get jobs, it is hard for them to exercise their autonomy effectively, it is reasonable to say. In sum, an appeal to the moral importance of
Address correspondence to Samuel J. Kerstein, Department of Philosophy, University of Maryland, College Park, College Park, MD 20742, USA. E-mail: [email protected]
October, Volume 14, Number 10, 2014
ajob 29
Downloaded by [North Dakota State University] at 19:33 14 October 2014
American Journal of Bioethics
respecting sellers’ autonomy does little to bolster the idea that regulated markets are morally permissible. It is worth noting a further point: The effective exercise of autonomy by people in whose region kidney selling is widespread might be truncated. As Koplin notes, people sell their kidneys in an often futile effort to repay debts. That has been true in black markets and would presumably also be true in regulated ones. But as a result of realizing that residents of a particular area are willing and able to sell their kidneys for cash, moneylenders might become increasingly aggressive in their debt collection (Cohen 1999). Being the object of aggressive debt collection can reduce the effective exercise of one’s autonomy, it is reasonable to assume. If one is forced to raise money more quickly and in greater quantities than one would have been, one might find oneself with less opportunity to promote ends one holds to be of central importance, such as that of setting up one’s own business. Living amid regulated markets might diminish one’s chances of making significant progress toward ends that one reflectively endorses. Moreover, there is reason to believe that such markets would sometimes be morally impermissible against the background assumptions we have been making. Suppose, for example, that it is the government in the developing country that is the buyer of organs. Suppose further that its policies are partly responsible for bringing about the economic conditions in which poor citizens judge it to be in their interest to sell their kidneys. In light of Koplin’s case that sellers would tend not to benefit from the transaction, it seems that the government would be unfairly exploiting its citizens. It would, in effect, be setting up its poorest citizens to allow it to use them, without their having a reasonable prospect of benefitting from this use. Even in light of the weakness of the autonomy-based argument in favor of a regulated market and of the concern regarding exploitation just raised, the life-extending benefits of regulated markets would perhaps lead some to endorse them, assuming, as we have been, that sellers give voluntary, informed consent and receive adequate medical care. But I do not believe that these assumptions are realistic. It is not safe to assume that a regulated market in a developing county would be an effectively regulated market. (Koplin alludes to this worry regarding Iran.) Poor countries tend to have poor, that is, underfunded and ineffectual, regulatory infrastructures. Several seem incapable of stopping currently illegal market exchange of kidneys. Although in India it violates regulations to donate a kidney to a stranger, for example, officials in certain areas routinely approve such donations, which are very often actually sales (Goyal et al. 2002). If current rules in the realm of transplantation are widely violated, why assume that those constituting regulated markets would be respected? Might not corrupt officials sign off on reports certifying that vendors have given their informed consent or that they are receiving adequate postoperative care? The worry here is that the lying, deception, and inadequate follow-up care that are characteristic of black markets might also
30 ajob
show up in regulated markets in resource-poor settings. Wealthy organ-importing nations might pass rules according to which, say, kidneys can be obtained only from countries that have embraced some international standard regarding the treatment of vendors. But even if a country embraces such a standard in good faith, rather than as a cosmetic measure, it might be devoid of the resources requisite to ensure that its citizens abide by it. Concerns regarding exploitation and ineffectual regulation might prompt advocates of regulated markets to limit kidney selling to citizens of developed countries who meet a certain income threshold. (So, for example, only the U.S. government could purchase organs and only from citizens who do not fall below the U.S. poverty line.) But Koplin suggests why this route is problematic. It might not result in a net increase in kidneys available for transplant. How many relatively well-off people would sell a kidney, and would the advantage gained by their sales be offset by reductions in the numbers of altruistic donations (e.g., donations from people who get no fungible recompense)? Elsewhere I have advocated robust opt-out systems of organ donation, as well as expansion of transplantation from people who die in uncontrolled settings (e.g., outside of a hospital), as means for reducing the organ shortage (Kerstein 2013). But what if such means do not sufficiently reduce the shortage of kidneys for transplant? Are there remedies other than regulated markets in developing countries? For example, would it be morally permissible to set up an “organ draft”? Such a draft, which would need legislative approval, might proceed (very roughly) as follows: Each year, those selected in a random drawing among citizens of a prescribed age would be screened for their physical and psychological suitability to donate a kidney. Remaining candidates would, as needed, then be required by law to give up their organ and be given appropriate aftercare and medical insurance. Rich and poor would have equal chances of providing a resource to their fellow citizens. & REFERENCES Cohen, L. 1999. Where it hurts: Indian material for an ethics of organ transplantation. Daedalus 128:135–165. Goyal, M., R. L. Mehta, L. J. Schneiderman, and A. R. Sehgal. 2002. Economic and health consequences of selling a kidney in India. Journal of the American Medical Association 288:1589–1593. Kerstein, S.. 2009. Autonomy, moral constraints, and markets in kidneys. Journal of Medicine and Philosophy 34:573–585. Kerstein, S. 2013. How to treat persons. Oxford, UK: Oxford University Press. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18. U.S. Renal Data System. 2013. Annual data report, Vol. 2. Available at : http://www.usrds.org/atlas.aspx Zargooshi, J. 2001. Quality of life of Iranian kidney ‘donors.’ Journal of Urology 166:1790–1799.
October, Volume 14, Number 10, 2014
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Are Kidney Markets Morally Permissible If Vendors Do Not Benefit? Samuel J. Kerstein
a
a
University of Maryland, College Park Published online: 17 Sep 2014.
To cite this article: Samuel J. Kerstein (2014) Are Kidney Markets Morally Permissible If Vendors Do Not Benefit?, The American Journal of Bioethics, 14:10, 29-30, DOI: 10.1080/15265161.2014.947798 To link to this article: http://dx.doi.org/10.1080/15265161.2014.947798
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Kidney Vendors in Regulated Organ Markets
Malmqvist, E. 2013. Kidney sales and the analogy with dangerous employment. Health Care Analysis (published online December 27). doi:10.1007/s10728-013-0270-3).
Omar, F., G. Tufveson, and S. Welin. 2010. Compensated living kidney donation: A plea for pragmatism. Health Care Analysis 18 (1): 85–101.
Malmqvist, E. 2014. Are bans on kidney sales unjustifiably paternalistic? Bioethics 28(3): 110–118.
Wilkinson, S. 2003. Bodies for sale: Ethics and exploitation in the human body trade. London, UK: Routledge.
Naqvi, S. A. A., B. Ali, F. Mahzar, M. N. Zafar, and S. A. H. Rizvi. 2007. A socioeconomic survey of kidney vendors in Pakistan. Transplant International 20(11): 934–939.
Zargooshi, J. 2001. Quality of life of Iranian kidney “donors.” Journal of Urology 166(5): 1790–1799.
Downloaded by [North Dakota State University] at 19:33 14 October 2014
Are Kidney Markets Morally Permissible If Vendors Do Not Benefit? Samuel J. Kerstein, University of Maryland, College Park Julian Koplin (2014) argues forcefully that, according to available data, it is doubtful whether poor people in developing countries would benefit from selling their kidneys in regulated markets. He points to studies suggesting that in unregulated markets, kidney sellers suffer physical, psychological, social, and financial harms. Moreover, Koplin makes a plausible case that these studies, coupled with data regarding the regulated market in Iran, raise serious worries that sellers in developing countries would suffer such harms in regulated markets as well. If regulated markets in kidneys get established around the globe, organs would presumably flow from citizens of poor countries to citizens of wealthier ones. Let us focus on regulated markets in developing countries. Let us assume for the sake of argument that in such markets only vendors who give their informed, voluntary consent to nephrectomy would sell, and they would receive the promised payment, as well as appropriate medical attention, before, during, and after the procedure. Koplin gives us reasons for thinking that sellers might still typically fail to benefit. But if he is correct, might such markets nevertheless be morally permissible? In my view, the strongest basis for an affirmative answer given our assumptions would be that these markets would help to extend many lives. If the markets would significantly increase the supply of kidneys for transplant, it seems that they would do so. Consider, for example, that in 2011 in the United States the average expected life span of a 50- to 54-year-old with end-stage renal disease treated with dialysis was about 5 years, while the average expected life span of someone in this age range with the same malady but who received a transplant was about 20 years (U.S. Renal Data System [USRDS] 2013, 266).
But there is another argument that might support markets from the standpoint of the sellers. Regulated markets, one might say, express respect for the sellers’ autonomy. Let us specify that a person’s action is autonomous if and only if she is acting on some preference of hers and, based on reflection on her values, she either does or, if she thought about it, would choose to have this preference, even in light of understanding how it arose in her. Kidney sellers might be acting autonomously. They might hold, for example, that without money from a sale they would be unable to pursue effectively goals of moral importance to them, such as that of securing a good education for their children. (They might at the same time acknowledge that selling will diminish their own happiness.) Allowing market exchange respects autonomy if it provides options for individuals to effectively direct their lives in accordance with plans they reflectively endorse, contends the argument. A difficulty with this argument is that while vendors might effectively exercise their autonomy in a particular action of selling a kidney, this action might result in an overall impairment of its effective exercise (Kerstein 2009). As Koplin suggests, kidney selling is associated with psychological suffering. A study of kidney sellers in Iran has shown that vendors frequently experience feelings of worthlessness and shame. They perceive themselves as akin to prostitutes and their scars as stigmata (Zargooshi 2001). Common psychological effects of selling a kidney in Iran seem to be anxiety and depression, which can surely make it difficult for one to promote one’s ends. “Vending, especially the psychological complications, severely affected employment potential,” says one researcher (Zargooshi 2001, 1794). If vendors cannot get jobs, it is hard for them to exercise their autonomy effectively, it is reasonable to say. In sum, an appeal to the moral importance of
Address correspondence to Samuel J. Kerstein, Department of Philosophy, University of Maryland, College Park, College Park, MD 20742, USA. E-mail: [email protected]
October, Volume 14, Number 10, 2014
ajob 29
Downloaded by [North Dakota State University] at 19:33 14 October 2014
American Journal of Bioethics
respecting sellers’ autonomy does little to bolster the idea that regulated markets are morally permissible. It is worth noting a further point: The effective exercise of autonomy by people in whose region kidney selling is widespread might be truncated. As Koplin notes, people sell their kidneys in an often futile effort to repay debts. That has been true in black markets and would presumably also be true in regulated ones. But as a result of realizing that residents of a particular area are willing and able to sell their kidneys for cash, moneylenders might become increasingly aggressive in their debt collection (Cohen 1999). Being the object of aggressive debt collection can reduce the effective exercise of one’s autonomy, it is reasonable to assume. If one is forced to raise money more quickly and in greater quantities than one would have been, one might find oneself with less opportunity to promote ends one holds to be of central importance, such as that of setting up one’s own business. Living amid regulated markets might diminish one’s chances of making significant progress toward ends that one reflectively endorses. Moreover, there is reason to believe that such markets would sometimes be morally impermissible against the background assumptions we have been making. Suppose, for example, that it is the government in the developing country that is the buyer of organs. Suppose further that its policies are partly responsible for bringing about the economic conditions in which poor citizens judge it to be in their interest to sell their kidneys. In light of Koplin’s case that sellers would tend not to benefit from the transaction, it seems that the government would be unfairly exploiting its citizens. It would, in effect, be setting up its poorest citizens to allow it to use them, without their having a reasonable prospect of benefitting from this use. Even in light of the weakness of the autonomy-based argument in favor of a regulated market and of the concern regarding exploitation just raised, the life-extending benefits of regulated markets would perhaps lead some to endorse them, assuming, as we have been, that sellers give voluntary, informed consent and receive adequate medical care. But I do not believe that these assumptions are realistic. It is not safe to assume that a regulated market in a developing county would be an effectively regulated market. (Koplin alludes to this worry regarding Iran.) Poor countries tend to have poor, that is, underfunded and ineffectual, regulatory infrastructures. Several seem incapable of stopping currently illegal market exchange of kidneys. Although in India it violates regulations to donate a kidney to a stranger, for example, officials in certain areas routinely approve such donations, which are very often actually sales (Goyal et al. 2002). If current rules in the realm of transplantation are widely violated, why assume that those constituting regulated markets would be respected? Might not corrupt officials sign off on reports certifying that vendors have given their informed consent or that they are receiving adequate postoperative care? The worry here is that the lying, deception, and inadequate follow-up care that are characteristic of black markets might also
30 ajob
show up in regulated markets in resource-poor settings. Wealthy organ-importing nations might pass rules according to which, say, kidneys can be obtained only from countries that have embraced some international standard regarding the treatment of vendors. But even if a country embraces such a standard in good faith, rather than as a cosmetic measure, it might be devoid of the resources requisite to ensure that its citizens abide by it. Concerns regarding exploitation and ineffectual regulation might prompt advocates of regulated markets to limit kidney selling to citizens of developed countries who meet a certain income threshold. (So, for example, only the U.S. government could purchase organs and only from citizens who do not fall below the U.S. poverty line.) But Koplin suggests why this route is problematic. It might not result in a net increase in kidneys available for transplant. How many relatively well-off people would sell a kidney, and would the advantage gained by their sales be offset by reductions in the numbers of altruistic donations (e.g., donations from people who get no fungible recompense)? Elsewhere I have advocated robust opt-out systems of organ donation, as well as expansion of transplantation from people who die in uncontrolled settings (e.g., outside of a hospital), as means for reducing the organ shortage (Kerstein 2013). But what if such means do not sufficiently reduce the shortage of kidneys for transplant? Are there remedies other than regulated markets in developing countries? For example, would it be morally permissible to set up an “organ draft”? Such a draft, which would need legislative approval, might proceed (very roughly) as follows: Each year, those selected in a random drawing among citizens of a prescribed age would be screened for their physical and psychological suitability to donate a kidney. Remaining candidates would, as needed, then be required by law to give up their organ and be given appropriate aftercare and medical insurance. Rich and poor would have equal chances of providing a resource to their fellow citizens. & REFERENCES Cohen, L. 1999. Where it hurts: Indian material for an ethics of organ transplantation. Daedalus 128:135–165. Goyal, M., R. L. Mehta, L. J. Schneiderman, and A. R. Sehgal. 2002. Economic and health consequences of selling a kidney in India. Journal of the American Medical Association 288:1589–1593. Kerstein, S.. 2009. Autonomy, moral constraints, and markets in kidneys. Journal of Medicine and Philosophy 34:573–585. Kerstein, S. 2013. How to treat persons. Oxford, UK: Oxford University Press. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18. U.S. Renal Data System. 2013. Annual data report, Vol. 2. Available at : http://www.usrds.org/atlas.aspx Zargooshi, J. 2001. Quality of life of Iranian kidney ‘donors.’ Journal of Urology 166:1790–1799.
October, Volume 14, Number 10, 2014
