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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Harms to Vendors: We Should Discourage, Not Prohibit Organ Sales Alberto Giubilini
a
a
Centre for Applied Philosophy and Public Ethics, Charles Sturt University Published online: 17 Sep 2014.
Click for updates To cite this article: Alberto Giubilini (2014) Harms to Vendors: We Should Discourage, Not Prohibit Organ Sales, The American Journal of Bioethics, 14:10, 25-27, DOI: 10.1080/15265161.2014.947797 To link to this article: http://dx.doi.org/10.1080/15265161.2014.947797
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
Ghods, A., S. Savaj, and P. Khosravani. 2000. Adverse effects of a controlled living-unrelated donor renal transplant program on living-related and cadaveric kidney donation. Transplantation Proceedings 32:541. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18.
Downloaded by [University of Glasgow] at 20:54 06 January 2015
Lavee J., T. Ashkenazi, A. Stoler, J. Cohen, and R. Beyar. 2013. Preliminary marked increase in the national organ donation rate in Israel following implementation of a new organ transplantation law. American Journal of Transplantation 13: 780–785.
L opez-Fraga M., B. Domınguez-Gil, A. M. Capron, et al. 2014. A needed convention against trafficking in human organs. Lancet 383:2187–2189. Matas, A. J., B. Hippen, and S. Satel. 2008. In defense of a regulated system of compensation for living donation. Current Opinion in Organ Transplantation 13(4): 379–385. Radcliffe Richards, J. 2003. Commentary: An ethical market in human organs. Journal of Medical Ethics 29:139–140. World Health Organization. (2010). Sixty-Third World Health Assembly, Human organ and tissue transplantation. WHA63.22 (21 May). Available at http://apps.who.int/gb/ebwha/pdf_ files/WHA63/A63_R22-en.pdf
Harms to Vendors: We Should Discourage, Not Prohibit Organ Sales Alberto Giubilini, Centre for Applied Philosophy and Public Ethics, Charles Sturt University Selling a kidney is probably a poor decision. Julian Koplin’s (2014) review of the medical and anthropological literature indicates that “vendors will usually experience a range of significant harms that ultimately leave them worse off than before the sale” (14) in terms of physical, psychological, social, and financial consequences. Besides, circumstances related to the poor socioeconomic status of likely vendors would make them extremely vulnerable even if a legal market replaced the currently widespread black markets. For example, often poor vendors would not return to transplant centers for follow-up care because they are reluctant to disclose that they have sold a kidney, which might reduce their chances of employment. Here I want to answer two questions that Koplin’s analysis raises. The first question is whether the likelihood of extremely poor outcomes, by itself, makes the decision to sell an organ irrational. I answer in the negative. The second is whether such likely poor outcomes represent a reason against the legalization of organ sales. The answer depends on the type of promarket argument we endorse. However, I also want to stress the importance of studies like the one conducted by Koplin for debates about legal markets in organs. Koplin says that “harms to vendors have no bearing on promarket arguments rooted primarily in the value of personal autonomy” (15). While it is true that harms to vendors do not provide a reason against liberal promarket arguments, Koplin’s very exhaustive review is relevant indeed for designing and implementing public policies within a liberal framework. Although his
review does not provide strong enough reasons against the legalization of organ sales, it suggests that organ sales should be discouraged, in the same way as hazardous— but legal—activities like smoking, drinking, and gambling are discouraged. IS THE DECISION TO SELL AN ORGAN IRRATIONAL? The high risk of extremely poor health and financial outcomes of organ sales does not, by itself, make the decision to sell an organ irrational. Circumstances might be so desperate, or prospects so extremely poor anyway, that the positive value of the immediate financial gains might outweigh the negative value of the (probable) poor long-term outcomes. Likelihood of such outcomes is just one of the factors to be considered when assessing the rationality of the choice. Other factors include, at the very least, personal circumstances of the willing vendors, their personal ranking of values, and the alternatives available. Ultimately, the rationality of the choice needs to be assessed on a caseby-case basis. In 1989 the UK public was outraged over a Turkish man’s decision to sell one of his kidneys at a London clinic to pay for urgently needed care for his leukemic daughter (Brecher 1990; New York Times 1989). But whether on that occasion the choice to sell a kidney was irrational depends on how much he valued the life of his daughter and the prospect of having his daughter with him for some more years, compared to the negative value of the hardships he
Address correspondence to Alberto Giubilini, Centre for Applied Philosophy and Public Ethics, Charles Sturt University, Canberra, Australia. E-mail: [email protected]
October, Volume 14, Number 10, 2014
ajob 25
American Journal of Bioethics
probably had to go through after the operation. There is no reason to assume a priori that the choice was irrational. However, Koplin’s analysis warrants at least a presumption that selling an organ is, most of the times, a bad decision. Because the risks are very high, both in terms of probability of bad outcomes and negativity of such outcomes, the cost–benefit analysis is likely to be unfavorable on many occasions. The next question is whether individuals should be prohibited from doing something that is (probably) irrational—but that might sometimes be rational indeed—once they have understood the risk.
Downloaded by [University of Glasgow] at 20:54 06 January 2015
IS HIGH RISK A REASON AGAINST LEGALIZATION? Whether the high risks for vendors provide reasons against a legal market in organs depends on what type of promarket argument is considered. Cost–benefit analysis is only relevant to—that is, it provides a reason for or against—promarket arguments based on utilitarian considerations. For example, it has been argued that a black market has far worse effects on vendors than a legal market would (see, e.g., RadcliffeRichards 2012, 55). Therefore, all things considered (including the fact that it is extremely unlikely that markets in organs will be eradicated), a legal market is the lesser of two evils. This is precisely the assumption that Koplin challenges. As he argues, a legal market might entail exactly the same poor outcomes for vendors as a black market does. If Koplin’s analysis is correct, then it represents a reason against promarket utilitarian arguments. But there are other types of promarket arguments. One alternative argument is based on the priority of liberty and bodily autonomy over other types of considerations. Denying someone the choice of selling organs because this would be very risky is a form of hard paternalism that is not consistent with liberal values. The risks involved are not a strong enough reason against a legal market in organs exactly as they are not enough to prohibit people from engaging in hazardous activities that are normally legal, such as joining the army and taking up hazardous occupations (Dworkin 1994, 157). Notice that the notions of liberty and bodily autonomy here invoked are not undermined by the possibility that circumstances coerce individuals into engaging in risky activities. No doubt, many people engage in dangerous activities for financial reasons determined by poor socioeconomic circumstances. Still, making such choices illegal because they are often the consequence of dire circumstances would be an infringement upon liberty and/ or bodily autonomy. Koplin’s analysis is not relevant to this type of liberal arguments, in the sense that it does not provide reasons for or against promarket arguments based on liberty and bodily autonomy. But this does not mean that his analysis is irrelevant to discussion about how to implement policies that allow people to sell their organs.
26 ajob
DISCOURAGING, NOT PROHIBITING ORGAN SALES There is a way to reconcile the priority of liberty and bodily autonomy with the consideration of possible harms of organ sales. Respect for individual liberty is a political principle: It regulates our cohabitation with others by allowing each individual to live according to that individual’s values, without external impositions (unless such impositions are required to protect others’ basic liberties). Beneficence and nonmaleficence are moral principles: They provide substantive norms about how to contribute to other people’s wellbeing. Political principles are implemented through laws and policies, moral principles through social norms and individual behaviors. We need therefore to distinguish between the legal aspect and the social norms in the case of organ markets. Organ sales could be legally permitted in a society that nonetheless aims at reducing to the greatest extent possible the situations where vulnerable people are made worse off. Even within a liberal framework, we need not dismiss the value of liberty and bodily autonomy for the sake of promoting individuals’ well-being. The two aspects can coexist within the same policy. Consider, for instance, other types of commonly accepted policies, such as those regulating consumption of alcohol and tobacco or gambling. The liberty to drink, smoke, and gamble is often legally warranted despite the commonly acknowledged health and financial harms these activities entail. At the same time, smoking, drinking, and gambling are usually discouraged through information campaigns, advertising, taxation, and so on. In the same way, I suggest that we should allow a form of soft paternalism that does not prevent people from engaging in such a risky activity as selling an organ, provided the decision is informed and thoughtful, but that assists individuals in making the best choice. Here is where Koplin’s analysis turns out to be relevant even within a liberal framework. In light of the evidence provided and discussed by Koplin, this soft paternalism would translate into public initiatives aimed at discouraging people from donating organs. For example, campaigns against organ sales or information campaigns about the negative outcomes of organ sales could be promoted in a context where such sales, in the name of liberty and bodily autonomy, are nonetheless legal. Discouraging is as far as we can go if we want to take liberty and bodily autonomy seriously. Koplin suggests that if vulnerable people were offered effective alternative means to achieve their financial goals, then there would be reasons—namely, the poor outcomes Koplin illustrates—not to legalize organ sales and to favor instead these alternative means. This type of approach is not uncommon (Zutlevics 2001), but it overlooks the most important and simplest reason in support of a legal market in organs, namely liberty and bodily autonomy. Sure, the more options someone has to overcome financial difficulties,
October, Volume 14, Number 10, 2014
Kidney Vendors in Regulated Organ Markets
Downloaded by [University of Glasgow] at 20:54 06 January 2015
the better. If solutions like microcredit or affordable housing could be effectively implemented, probably many vulnerable people, well informed of the risks of selling organs, would prefer these alternatives over the sale of an organ. After all, offering more appealing and less risky options is another way of discouraging organ sales. But even the presence of extra—and perhaps more rational—options is not sufficient to dismiss liberal arguments in favor of markets in organs. &
Dworkin, G. 1994. Markets and the morals: The case for organ sales. In Dworkin, G., ed., Morality, harm, and the law. Oxford, UK: Westview Press. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18. New York Times. 1989. Sales of kidneys prompt new laws and debate. Available at: http://www.nytimes.com/1989/08/01/ science/sales-of-kidneys-prompt-new-laws-and-debate.html (accessed July 3, 2014).
REFERENCES
Radcliffe-Richards, J. 2012. The ethics of transplants. Why careless thought costs lives. Oxford, UK: Oxford University Press.
Brecher, B. 1990. The kidney trade, or: The customer is always wrong. Journal of Medical Ethics 16:120–123.
Zutlevics, T. L. 2001. Markets and the needy: Organ sales or aid? Journal of Applied Philosophy 18(3): 297–302.
A Further Lesson From Existing Kidney Markets Erik Malmqvist, Link€ oping University The target article challenges the increasingly popular portrayal of living kidney sale as potentially a mutually beneficial arrangement, capable not only of saving or improving the lives of patients in need of transplants but also of significantly benefiting poor vendors. Carefully reviewing the literature on harms to vendors in illegal kidney markets and in Iran’s legal market, Koplin (2014) argues that many of these harms would persist in the sort of legal regulated system that kidney sale advocates envision. This is an important argument. The kidney sales debate has been skewed in favor of permitting sales by a simplified view of the potential harms involved and excessive optimism about the capacity of regulation to prevent these harms (Malmqvist 2013). The article counterbalances these tendencies and thus considerably weakens the case for allowing sales. Nonetheless, some market proponents might remain unconvinced. I suggest that in addition to the lessons that Koplin draws from existing kidney markets, there is yet another one, which casts further doubt on the advisability of allowing kidney sales. Suppose that Koplin’s assessment of the harmfulness of living kidney sale in a legal regulated system is roughly correct. This might not be enough to make friends of kidney markets change their views. They could continue defending a market approach in at least three ways. First, they might propose confining the market to the societies where the harms that Koplin identifies are least likely to occur. Vendors would be much less susceptible to harms associated with low socioeconomic status, poor follow-up
attendance, and lost employment in countries with robust welfare systems and universal health care than in countries where organ trade currently abounds (Omar et al. 2010). Second, as Koplin notes, kidney sale advocates might concede that vendors would risk serious harm even in a regulated market, but argue that these harms are outweighed by the potential benefits to kidney recipients. Third, as Koplin also notes, they might appeal to the autonomy of potential vendors. People should be allowed to decide for themselves whether the risks of selling a kidney—significant as they may be—are worth taking, the argument goes, rather than having that decision paternalistically made on their behalf. Each of these responses has some prima facie plausibility. However, another look at the literature on existing organ markets makes them lose much of their appeal. Not only does this literature provide reasons to believe that vendors would risk significant harm even in a carefully regulated system of sales, as Koplin points out. It also raises serious concerns about the vendors’ consent, some of which seem likely to remain in such a system. The quality of consent in existing organ markets is often questionable, to say the least. Vendors frequently report poor understanding of the consequences of the sale, as well as coercion and deception at the hands of brokers (Awaya et al. 2009; Goyal et al. 2002; Zaarghoshi 2001). These deficiencies could presumably be reduced in a carefully regulated system where middlemen are removed and vendors receive appropriate information and
Address correspondence to Erik Malmqvist, Link€ oping University, Department of Thematic Studies, SE-58183 Link€ oping, Sweden. E-mail: [email protected]
October, Volume 14, Number 10, 2014
ajob 27
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Harms to Vendors: We Should Discourage, Not Prohibit Organ Sales Alberto Giubilini
a
a
Centre for Applied Philosophy and Public Ethics, Charles Sturt University Published online: 17 Sep 2014.
Click for updates To cite this article: Alberto Giubilini (2014) Harms to Vendors: We Should Discourage, Not Prohibit Organ Sales, The American Journal of Bioethics, 14:10, 25-27, DOI: 10.1080/15265161.2014.947797 To link to this article: http://dx.doi.org/10.1080/15265161.2014.947797
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
Ghods, A., S. Savaj, and P. Khosravani. 2000. Adverse effects of a controlled living-unrelated donor renal transplant program on living-related and cadaveric kidney donation. Transplantation Proceedings 32:541. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18.
Downloaded by [University of Glasgow] at 20:54 06 January 2015
Lavee J., T. Ashkenazi, A. Stoler, J. Cohen, and R. Beyar. 2013. Preliminary marked increase in the national organ donation rate in Israel following implementation of a new organ transplantation law. American Journal of Transplantation 13: 780–785.
L opez-Fraga M., B. Domınguez-Gil, A. M. Capron, et al. 2014. A needed convention against trafficking in human organs. Lancet 383:2187–2189. Matas, A. J., B. Hippen, and S. Satel. 2008. In defense of a regulated system of compensation for living donation. Current Opinion in Organ Transplantation 13(4): 379–385. Radcliffe Richards, J. 2003. Commentary: An ethical market in human organs. Journal of Medical Ethics 29:139–140. World Health Organization. (2010). Sixty-Third World Health Assembly, Human organ and tissue transplantation. WHA63.22 (21 May). Available at http://apps.who.int/gb/ebwha/pdf_ files/WHA63/A63_R22-en.pdf
Harms to Vendors: We Should Discourage, Not Prohibit Organ Sales Alberto Giubilini, Centre for Applied Philosophy and Public Ethics, Charles Sturt University Selling a kidney is probably a poor decision. Julian Koplin’s (2014) review of the medical and anthropological literature indicates that “vendors will usually experience a range of significant harms that ultimately leave them worse off than before the sale” (14) in terms of physical, psychological, social, and financial consequences. Besides, circumstances related to the poor socioeconomic status of likely vendors would make them extremely vulnerable even if a legal market replaced the currently widespread black markets. For example, often poor vendors would not return to transplant centers for follow-up care because they are reluctant to disclose that they have sold a kidney, which might reduce their chances of employment. Here I want to answer two questions that Koplin’s analysis raises. The first question is whether the likelihood of extremely poor outcomes, by itself, makes the decision to sell an organ irrational. I answer in the negative. The second is whether such likely poor outcomes represent a reason against the legalization of organ sales. The answer depends on the type of promarket argument we endorse. However, I also want to stress the importance of studies like the one conducted by Koplin for debates about legal markets in organs. Koplin says that “harms to vendors have no bearing on promarket arguments rooted primarily in the value of personal autonomy” (15). While it is true that harms to vendors do not provide a reason against liberal promarket arguments, Koplin’s very exhaustive review is relevant indeed for designing and implementing public policies within a liberal framework. Although his
review does not provide strong enough reasons against the legalization of organ sales, it suggests that organ sales should be discouraged, in the same way as hazardous— but legal—activities like smoking, drinking, and gambling are discouraged. IS THE DECISION TO SELL AN ORGAN IRRATIONAL? The high risk of extremely poor health and financial outcomes of organ sales does not, by itself, make the decision to sell an organ irrational. Circumstances might be so desperate, or prospects so extremely poor anyway, that the positive value of the immediate financial gains might outweigh the negative value of the (probable) poor long-term outcomes. Likelihood of such outcomes is just one of the factors to be considered when assessing the rationality of the choice. Other factors include, at the very least, personal circumstances of the willing vendors, their personal ranking of values, and the alternatives available. Ultimately, the rationality of the choice needs to be assessed on a caseby-case basis. In 1989 the UK public was outraged over a Turkish man’s decision to sell one of his kidneys at a London clinic to pay for urgently needed care for his leukemic daughter (Brecher 1990; New York Times 1989). But whether on that occasion the choice to sell a kidney was irrational depends on how much he valued the life of his daughter and the prospect of having his daughter with him for some more years, compared to the negative value of the hardships he
Address correspondence to Alberto Giubilini, Centre for Applied Philosophy and Public Ethics, Charles Sturt University, Canberra, Australia. E-mail: [email protected]
October, Volume 14, Number 10, 2014
ajob 25
American Journal of Bioethics
probably had to go through after the operation. There is no reason to assume a priori that the choice was irrational. However, Koplin’s analysis warrants at least a presumption that selling an organ is, most of the times, a bad decision. Because the risks are very high, both in terms of probability of bad outcomes and negativity of such outcomes, the cost–benefit analysis is likely to be unfavorable on many occasions. The next question is whether individuals should be prohibited from doing something that is (probably) irrational—but that might sometimes be rational indeed—once they have understood the risk.
Downloaded by [University of Glasgow] at 20:54 06 January 2015
IS HIGH RISK A REASON AGAINST LEGALIZATION? Whether the high risks for vendors provide reasons against a legal market in organs depends on what type of promarket argument is considered. Cost–benefit analysis is only relevant to—that is, it provides a reason for or against—promarket arguments based on utilitarian considerations. For example, it has been argued that a black market has far worse effects on vendors than a legal market would (see, e.g., RadcliffeRichards 2012, 55). Therefore, all things considered (including the fact that it is extremely unlikely that markets in organs will be eradicated), a legal market is the lesser of two evils. This is precisely the assumption that Koplin challenges. As he argues, a legal market might entail exactly the same poor outcomes for vendors as a black market does. If Koplin’s analysis is correct, then it represents a reason against promarket utilitarian arguments. But there are other types of promarket arguments. One alternative argument is based on the priority of liberty and bodily autonomy over other types of considerations. Denying someone the choice of selling organs because this would be very risky is a form of hard paternalism that is not consistent with liberal values. The risks involved are not a strong enough reason against a legal market in organs exactly as they are not enough to prohibit people from engaging in hazardous activities that are normally legal, such as joining the army and taking up hazardous occupations (Dworkin 1994, 157). Notice that the notions of liberty and bodily autonomy here invoked are not undermined by the possibility that circumstances coerce individuals into engaging in risky activities. No doubt, many people engage in dangerous activities for financial reasons determined by poor socioeconomic circumstances. Still, making such choices illegal because they are often the consequence of dire circumstances would be an infringement upon liberty and/ or bodily autonomy. Koplin’s analysis is not relevant to this type of liberal arguments, in the sense that it does not provide reasons for or against promarket arguments based on liberty and bodily autonomy. But this does not mean that his analysis is irrelevant to discussion about how to implement policies that allow people to sell their organs.
26 ajob
DISCOURAGING, NOT PROHIBITING ORGAN SALES There is a way to reconcile the priority of liberty and bodily autonomy with the consideration of possible harms of organ sales. Respect for individual liberty is a political principle: It regulates our cohabitation with others by allowing each individual to live according to that individual’s values, without external impositions (unless such impositions are required to protect others’ basic liberties). Beneficence and nonmaleficence are moral principles: They provide substantive norms about how to contribute to other people’s wellbeing. Political principles are implemented through laws and policies, moral principles through social norms and individual behaviors. We need therefore to distinguish between the legal aspect and the social norms in the case of organ markets. Organ sales could be legally permitted in a society that nonetheless aims at reducing to the greatest extent possible the situations where vulnerable people are made worse off. Even within a liberal framework, we need not dismiss the value of liberty and bodily autonomy for the sake of promoting individuals’ well-being. The two aspects can coexist within the same policy. Consider, for instance, other types of commonly accepted policies, such as those regulating consumption of alcohol and tobacco or gambling. The liberty to drink, smoke, and gamble is often legally warranted despite the commonly acknowledged health and financial harms these activities entail. At the same time, smoking, drinking, and gambling are usually discouraged through information campaigns, advertising, taxation, and so on. In the same way, I suggest that we should allow a form of soft paternalism that does not prevent people from engaging in such a risky activity as selling an organ, provided the decision is informed and thoughtful, but that assists individuals in making the best choice. Here is where Koplin’s analysis turns out to be relevant even within a liberal framework. In light of the evidence provided and discussed by Koplin, this soft paternalism would translate into public initiatives aimed at discouraging people from donating organs. For example, campaigns against organ sales or information campaigns about the negative outcomes of organ sales could be promoted in a context where such sales, in the name of liberty and bodily autonomy, are nonetheless legal. Discouraging is as far as we can go if we want to take liberty and bodily autonomy seriously. Koplin suggests that if vulnerable people were offered effective alternative means to achieve their financial goals, then there would be reasons—namely, the poor outcomes Koplin illustrates—not to legalize organ sales and to favor instead these alternative means. This type of approach is not uncommon (Zutlevics 2001), but it overlooks the most important and simplest reason in support of a legal market in organs, namely liberty and bodily autonomy. Sure, the more options someone has to overcome financial difficulties,
October, Volume 14, Number 10, 2014
Kidney Vendors in Regulated Organ Markets
Downloaded by [University of Glasgow] at 20:54 06 January 2015
the better. If solutions like microcredit or affordable housing could be effectively implemented, probably many vulnerable people, well informed of the risks of selling organs, would prefer these alternatives over the sale of an organ. After all, offering more appealing and less risky options is another way of discouraging organ sales. But even the presence of extra—and perhaps more rational—options is not sufficient to dismiss liberal arguments in favor of markets in organs. &
Dworkin, G. 1994. Markets and the morals: The case for organ sales. In Dworkin, G., ed., Morality, harm, and the law. Oxford, UK: Westview Press. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18. New York Times. 1989. Sales of kidneys prompt new laws and debate. Available at: http://www.nytimes.com/1989/08/01/ science/sales-of-kidneys-prompt-new-laws-and-debate.html (accessed July 3, 2014).
REFERENCES
Radcliffe-Richards, J. 2012. The ethics of transplants. Why careless thought costs lives. Oxford, UK: Oxford University Press.
Brecher, B. 1990. The kidney trade, or: The customer is always wrong. Journal of Medical Ethics 16:120–123.
Zutlevics, T. L. 2001. Markets and the needy: Organ sales or aid? Journal of Applied Philosophy 18(3): 297–302.
A Further Lesson From Existing Kidney Markets Erik Malmqvist, Link€ oping University The target article challenges the increasingly popular portrayal of living kidney sale as potentially a mutually beneficial arrangement, capable not only of saving or improving the lives of patients in need of transplants but also of significantly benefiting poor vendors. Carefully reviewing the literature on harms to vendors in illegal kidney markets and in Iran’s legal market, Koplin (2014) argues that many of these harms would persist in the sort of legal regulated system that kidney sale advocates envision. This is an important argument. The kidney sales debate has been skewed in favor of permitting sales by a simplified view of the potential harms involved and excessive optimism about the capacity of regulation to prevent these harms (Malmqvist 2013). The article counterbalances these tendencies and thus considerably weakens the case for allowing sales. Nonetheless, some market proponents might remain unconvinced. I suggest that in addition to the lessons that Koplin draws from existing kidney markets, there is yet another one, which casts further doubt on the advisability of allowing kidney sales. Suppose that Koplin’s assessment of the harmfulness of living kidney sale in a legal regulated system is roughly correct. This might not be enough to make friends of kidney markets change their views. They could continue defending a market approach in at least three ways. First, they might propose confining the market to the societies where the harms that Koplin identifies are least likely to occur. Vendors would be much less susceptible to harms associated with low socioeconomic status, poor follow-up
attendance, and lost employment in countries with robust welfare systems and universal health care than in countries where organ trade currently abounds (Omar et al. 2010). Second, as Koplin notes, kidney sale advocates might concede that vendors would risk serious harm even in a regulated market, but argue that these harms are outweighed by the potential benefits to kidney recipients. Third, as Koplin also notes, they might appeal to the autonomy of potential vendors. People should be allowed to decide for themselves whether the risks of selling a kidney—significant as they may be—are worth taking, the argument goes, rather than having that decision paternalistically made on their behalf. Each of these responses has some prima facie plausibility. However, another look at the literature on existing organ markets makes them lose much of their appeal. Not only does this literature provide reasons to believe that vendors would risk significant harm even in a carefully regulated system of sales, as Koplin points out. It also raises serious concerns about the vendors’ consent, some of which seem likely to remain in such a system. The quality of consent in existing organ markets is often questionable, to say the least. Vendors frequently report poor understanding of the consequences of the sale, as well as coercion and deception at the hands of brokers (Awaya et al. 2009; Goyal et al. 2002; Zaarghoshi 2001). These deficiencies could presumably be reduced in a carefully regulated system where middlemen are removed and vendors receive appropriate information and
Address correspondence to Erik Malmqvist, Link€ oping University, Department of Thematic Studies, SE-58183 Link€ oping, Sweden. E-mail: [email protected]
October, Volume 14, Number 10, 2014
ajob 27
