This article was downloaded by: [University of Saskatchewan Library] On: 27 December 2014, At: 00:13 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
Regulated Markets of Kidneys in Developed Countries or How to Increase Health Inequities a
b
Julie Allard , Aviva Goldberg & Marie-Chantal Fortin a
a
Centre de recherche du centre hospitalier de I'Université de Montréal
b
University of Manitoba Published online: 17 Sep 2014.
Click for updates To cite this article: Julie Allard, Aviva Goldberg & Marie-Chantal Fortin (2014) Regulated Markets of Kidneys in Developed Countries or How to Increase Health Inequities, The American Journal of Bioethics, 14:10, 44-45, DOI: 10.1080/15265161.2014.947442 To link to this article: http://dx.doi.org/10.1080/15265161.2014.947442
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
Downloaded by [University of Saskatchewan Library] at 00:13 27 December 2014
American Journal of Bioethics
This move, however, is justifiable on the grounds that the research would meet the ethical standards of research involving human participants, and would promote the safety and well-being of the seller; this clause helps to ensure that the sellers will receive adequate postnephrectomy surveillance and follow-up care, which would work to mitigate postsale backfire. Importantly, this prototype kidney market would make it mandatory for all participants to read and demonstrate understanding of relevant empirical findings (such as those of Koplin and those he cites), prior to their participation therein—something that is altogether absent in current black markets, and (presumably) the Iranian market as well. (“Many people who have sold one of their kidneys come to view their bodies as damaged or disordered, and routinely fear their imminent demise,” “There is a statistically significant number of those that sell their kidney who come to regret their decision to do so, and reversing the nephrectomy is likely practically impossible,” “If your current or foreseeable primary mode of employment depends on physical labor, then your risk of long-term postsale backfire increases significantly,” “If you do not have adequate health care coverage, and/or have reservations
about seeking postsale medical care, then your risk of long-term postsale backfire increases significantly,” “For many people, the economic benefits of selling their kidney are temporary, and for others they are nonexistent,” etc.) This clause would serve to increase participant protection and awareness, enabling them to realistically weigh the prospect of postsale backfire with the alternative of leaving things as they are, for them. Ultimately, however, it would be up to them to decide whether to sell their kidney, in an attempt to improve their plight, with the knowledge that there is a fairly high probability that their doing so will turn out to be a mistake (for them to make). & REFERENCES Cohen, I. G. 2013. Transplant tourism: The ethics and regulation of international markets for organs. Journal of Law, Medicine and Ethics 41(1): 269–285. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18. Radcliffe-Richards, J., A. S. Daar, R. D. Guttmann, et al. 1998. The case for allowing kidney sales. Lancet 351(19120): 1950–1952.
Regulated Markets of Kidneys in Developed Countries or How to Increase Health Inequities Julie Allard, Centre de recherche du centre hospitalier de l’Universite de Montreal Aviva Goldberg, University of Manitoba Marie-Chantal Fortin, Centre de recherche du centre hospitalier de l’Universite de Montreal The article by Koplin (2014) presents a comprehensive review of existing empirical data on medical and psychological harms for kidney vendors in both legal and black-market systems. Based on this review, it seems clear that vendors in regulated markets in developed countries could also suffer great harms as a consequence of organ vending. In this commentary, we argue against a regulated market of kidneys in countries like Canada and the United States because allowing people to sell their organs will increase health inequities and will decrease the capability of the socioeconomically disadvantaged to lead fulfilling lives. Amartya Sen’s (1983) capability approach to global development (also called the human development
approach) is a useful way to understand the potential harms of a kidney vendor market. Traditional approaches to inequity reduction have focused on increasing the income of the poor or the gross domestic product (GDP) of poor countries. The capability approach focuses on “the expansion of the ‘capabilities’ of people to lead the kind of lives they value—and have reason to value” (Sen 1999b). The theory, elaborated as a statement of 10 capabilities by philosopher Martha Nussbaum, holds that the crucial good that should be promoted by a society is a set of opportunities for individuals so they can do what they are able to do and become what they are able to be (Nussbaum 2011). Removal of any of these capabilities makes life not worthy of human dignity, and the theory contends that a
Address correspondence to Marie-Chantal Fortin, CHUM, Nephrology and Transplantation, 1560 Sherbrooke East Street, Montreal, Quebec, H2L 4M1, Canada. E-mail: [email protected]
44 ajob
October, Volume 14, Number 10, 2014
Downloaded by [University of Saskatchewan Library] at 00:13 27 December 2014
Kidney Vendors in Regulated Organ Markets
decent political order should secure to all citizens a threshold of those essential capabilities. Implementing a market in kidneys would reduce the first three essential capabilities: life, bodily health, and bodily integrity. The capability of life is the ability to live a human life of normal length. Bodily health, as Sen argues, has a status of its own as it is among the most important conditions of human life. Bodily health contributes to a person’s basic capability to function and to choose the life he or she has reason to value (Sen 1999a). As Koplin’s article clearly states, proponents of a regulated market base their argument on the low medical risks associated with living kidney donation in the developed world. They suggest that length and quality of life need not be adversely affected by elective nephrectomy. However, most living organ donors in the United States and in Canada are of middle or high socioeconomic status (Klarenbach et al. 2014), and this health status can be assumed to have a positive impact on their outcomes. Even in developed countries, groups of low economic status show higher prevalence and incidence of many diseases, including obesity, type 2 diabetes, hypertension, and coronary events (Dalstra et al. 2005; De Vogli et al. 2007). While some suggest that a regulated market in a developed nation might attract donors of all socioeconomic backgrounds, the reality of existing markets tells a different tale. The poor have always been the primary sellers of organs, even in Iran, currently the world’s only legal organ market (Koplin 2014). There is no longitudinal study of the long-term effects of nephrectomy among the poor (FryRevere 2014). It is therefore erroneous to assume that vendors of low socioeconomic status could expect to enjoy the same low risks as their wealthier donor counterparts. Allowing people to sell their kidneys could reduce their achievement of the first and second of Nussbaum’s capabilities, because it could shorten their lives and/or reduce their health. Bodily integrity is, among other things, being able to move freely and being secure against violent assault. It may be obvious that bodily integrity is violated if an organ is removed from an individual without his or her consent, but even in a regulated market vendors often face conditions that limit the validity of their consent. As Greasley (2014) writes, it seems clear that poverty contributes to the irrational decision making of kidney vendors. True consent would require freedom from coercion, which is not possible if the basic capabilities of would-be vendors are not secured. The capability of bodily integrity is violated by removing organs from people who have no choice but to sell them. Vending a kidney is not the fulfillment of a capability but the result of a capability failure, and accepting a kidney market would only worsen the failure by our culpability in it. Not only would many of the vendor’s capabilities be directly diminished by the act of selling, but by widening the gap of social inequities, the capabilities of other individuals in the community would also suffer. If a vendor is harmed, for example, the capabilities of his or her family and dependents could likewise be negatively affected.
October, Volume 14, Number 10, 2014
There are ways to increase living donation without resorting to markets, ways that respect, and even promote, the capability of the donor. As has been reported (Klarenbach et al. 2014), donation results in significant financial costs, which could be mitigated by reducing financial disincentives. Reducing disincentives could be seen as promoting control over one’s material environment (another of Nussbaum’s capabilities), since donors would not need to choose between their livelihoods and their donation. That a market in kidneys could increase health inequities is seldom mentioned in the debate on this issue, nor are the potential negative consequences of a market on donor capabilities mentioned. Proponents of a regulated market have not offered an argument that would respect the important principles embedded in the capability approach. They base their argument on respect for the vendor’s autonomy, but respect for the would-be vendors entails more than respect for autonomy alone. True respect involves the implementation of equity policies that would prevent the desperation in which selling a kidney is an individual’s only hope for improving his or her life, and in which material gain is achieved at the cost of diminished capability. &
REFERENCES Dalstra, J. A., A. E. Kunst, C. Borrell, et al. 2005. Socioeconomic differences in the prevalence of common chronic diseases: An overview of eight European countries. International Journal of Epidemiology 34(2): 316–326. De Vogli, R., J. E. Ferrie, T. Chandola, M. Kivim€aki, and M. G. Marmot. 2007. Unfairness and health: evidence from the Whitehall II Study. Journal of Epidemiology and Community Health 61(6): 51–518. Fry-Revere, S. 2014. The kidney sellers. Durham, NC: Carolina Academic Press. Greasley, K. 2014. A legal market in organs: The problem of exploitation. Journal of Medical Ethics 40(1): 51–56. Klarenbach, S., J. S. Gill, G. Knoll, et al. 2014. Economic consequences incurred by living kidney donors: a Canadian multi-center prospective study. American Journal of Transplantation 14(4): 916–922. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18. Nussbaum, M. C. 2011. Creating capabilities. Cambridge, MA: Belknap Press of Harvard University Press. Sen, A. 1983. Poverty and famines: An essay on entitlement and deprivation. New Delhi, India: Oxford University Press. Sen, A. 1999a. Commodities and capabilities. New Delhi, India: Oxford University Press. Sen, A. 1999b. Development as freedom. New York, NY: Oxford University Press.
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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Regulated Markets of Kidneys in Developed Countries or How to Increase Health Inequities a
b
Julie Allard , Aviva Goldberg & Marie-Chantal Fortin a
a
Centre de recherche du centre hospitalier de I'Université de Montréal
b
University of Manitoba Published online: 17 Sep 2014.
Click for updates To cite this article: Julie Allard, Aviva Goldberg & Marie-Chantal Fortin (2014) Regulated Markets of Kidneys in Developed Countries or How to Increase Health Inequities, The American Journal of Bioethics, 14:10, 44-45, DOI: 10.1080/15265161.2014.947442 To link to this article: http://dx.doi.org/10.1080/15265161.2014.947442
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
Downloaded by [University of Saskatchewan Library] at 00:13 27 December 2014
American Journal of Bioethics
This move, however, is justifiable on the grounds that the research would meet the ethical standards of research involving human participants, and would promote the safety and well-being of the seller; this clause helps to ensure that the sellers will receive adequate postnephrectomy surveillance and follow-up care, which would work to mitigate postsale backfire. Importantly, this prototype kidney market would make it mandatory for all participants to read and demonstrate understanding of relevant empirical findings (such as those of Koplin and those he cites), prior to their participation therein—something that is altogether absent in current black markets, and (presumably) the Iranian market as well. (“Many people who have sold one of their kidneys come to view their bodies as damaged or disordered, and routinely fear their imminent demise,” “There is a statistically significant number of those that sell their kidney who come to regret their decision to do so, and reversing the nephrectomy is likely practically impossible,” “If your current or foreseeable primary mode of employment depends on physical labor, then your risk of long-term postsale backfire increases significantly,” “If you do not have adequate health care coverage, and/or have reservations
about seeking postsale medical care, then your risk of long-term postsale backfire increases significantly,” “For many people, the economic benefits of selling their kidney are temporary, and for others they are nonexistent,” etc.) This clause would serve to increase participant protection and awareness, enabling them to realistically weigh the prospect of postsale backfire with the alternative of leaving things as they are, for them. Ultimately, however, it would be up to them to decide whether to sell their kidney, in an attempt to improve their plight, with the knowledge that there is a fairly high probability that their doing so will turn out to be a mistake (for them to make). & REFERENCES Cohen, I. G. 2013. Transplant tourism: The ethics and regulation of international markets for organs. Journal of Law, Medicine and Ethics 41(1): 269–285. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18. Radcliffe-Richards, J., A. S. Daar, R. D. Guttmann, et al. 1998. The case for allowing kidney sales. Lancet 351(19120): 1950–1952.
Regulated Markets of Kidneys in Developed Countries or How to Increase Health Inequities Julie Allard, Centre de recherche du centre hospitalier de l’Universite de Montreal Aviva Goldberg, University of Manitoba Marie-Chantal Fortin, Centre de recherche du centre hospitalier de l’Universite de Montreal The article by Koplin (2014) presents a comprehensive review of existing empirical data on medical and psychological harms for kidney vendors in both legal and black-market systems. Based on this review, it seems clear that vendors in regulated markets in developed countries could also suffer great harms as a consequence of organ vending. In this commentary, we argue against a regulated market of kidneys in countries like Canada and the United States because allowing people to sell their organs will increase health inequities and will decrease the capability of the socioeconomically disadvantaged to lead fulfilling lives. Amartya Sen’s (1983) capability approach to global development (also called the human development
approach) is a useful way to understand the potential harms of a kidney vendor market. Traditional approaches to inequity reduction have focused on increasing the income of the poor or the gross domestic product (GDP) of poor countries. The capability approach focuses on “the expansion of the ‘capabilities’ of people to lead the kind of lives they value—and have reason to value” (Sen 1999b). The theory, elaborated as a statement of 10 capabilities by philosopher Martha Nussbaum, holds that the crucial good that should be promoted by a society is a set of opportunities for individuals so they can do what they are able to do and become what they are able to be (Nussbaum 2011). Removal of any of these capabilities makes life not worthy of human dignity, and the theory contends that a
Address correspondence to Marie-Chantal Fortin, CHUM, Nephrology and Transplantation, 1560 Sherbrooke East Street, Montreal, Quebec, H2L 4M1, Canada. E-mail: [email protected]
44 ajob
October, Volume 14, Number 10, 2014
Downloaded by [University of Saskatchewan Library] at 00:13 27 December 2014
Kidney Vendors in Regulated Organ Markets
decent political order should secure to all citizens a threshold of those essential capabilities. Implementing a market in kidneys would reduce the first three essential capabilities: life, bodily health, and bodily integrity. The capability of life is the ability to live a human life of normal length. Bodily health, as Sen argues, has a status of its own as it is among the most important conditions of human life. Bodily health contributes to a person’s basic capability to function and to choose the life he or she has reason to value (Sen 1999a). As Koplin’s article clearly states, proponents of a regulated market base their argument on the low medical risks associated with living kidney donation in the developed world. They suggest that length and quality of life need not be adversely affected by elective nephrectomy. However, most living organ donors in the United States and in Canada are of middle or high socioeconomic status (Klarenbach et al. 2014), and this health status can be assumed to have a positive impact on their outcomes. Even in developed countries, groups of low economic status show higher prevalence and incidence of many diseases, including obesity, type 2 diabetes, hypertension, and coronary events (Dalstra et al. 2005; De Vogli et al. 2007). While some suggest that a regulated market in a developed nation might attract donors of all socioeconomic backgrounds, the reality of existing markets tells a different tale. The poor have always been the primary sellers of organs, even in Iran, currently the world’s only legal organ market (Koplin 2014). There is no longitudinal study of the long-term effects of nephrectomy among the poor (FryRevere 2014). It is therefore erroneous to assume that vendors of low socioeconomic status could expect to enjoy the same low risks as their wealthier donor counterparts. Allowing people to sell their kidneys could reduce their achievement of the first and second of Nussbaum’s capabilities, because it could shorten their lives and/or reduce their health. Bodily integrity is, among other things, being able to move freely and being secure against violent assault. It may be obvious that bodily integrity is violated if an organ is removed from an individual without his or her consent, but even in a regulated market vendors often face conditions that limit the validity of their consent. As Greasley (2014) writes, it seems clear that poverty contributes to the irrational decision making of kidney vendors. True consent would require freedom from coercion, which is not possible if the basic capabilities of would-be vendors are not secured. The capability of bodily integrity is violated by removing organs from people who have no choice but to sell them. Vending a kidney is not the fulfillment of a capability but the result of a capability failure, and accepting a kidney market would only worsen the failure by our culpability in it. Not only would many of the vendor’s capabilities be directly diminished by the act of selling, but by widening the gap of social inequities, the capabilities of other individuals in the community would also suffer. If a vendor is harmed, for example, the capabilities of his or her family and dependents could likewise be negatively affected.
October, Volume 14, Number 10, 2014
There are ways to increase living donation without resorting to markets, ways that respect, and even promote, the capability of the donor. As has been reported (Klarenbach et al. 2014), donation results in significant financial costs, which could be mitigated by reducing financial disincentives. Reducing disincentives could be seen as promoting control over one’s material environment (another of Nussbaum’s capabilities), since donors would not need to choose between their livelihoods and their donation. That a market in kidneys could increase health inequities is seldom mentioned in the debate on this issue, nor are the potential negative consequences of a market on donor capabilities mentioned. Proponents of a regulated market have not offered an argument that would respect the important principles embedded in the capability approach. They base their argument on respect for the vendor’s autonomy, but respect for the would-be vendors entails more than respect for autonomy alone. True respect involves the implementation of equity policies that would prevent the desperation in which selling a kidney is an individual’s only hope for improving his or her life, and in which material gain is achieved at the cost of diminished capability. &
REFERENCES Dalstra, J. A., A. E. Kunst, C. Borrell, et al. 2005. Socioeconomic differences in the prevalence of common chronic diseases: An overview of eight European countries. International Journal of Epidemiology 34(2): 316–326. De Vogli, R., J. E. Ferrie, T. Chandola, M. Kivim€aki, and M. G. Marmot. 2007. Unfairness and health: evidence from the Whitehall II Study. Journal of Epidemiology and Community Health 61(6): 51–518. Fry-Revere, S. 2014. The kidney sellers. Durham, NC: Carolina Academic Press. Greasley, K. 2014. A legal market in organs: The problem of exploitation. Journal of Medical Ethics 40(1): 51–56. Klarenbach, S., J. S. Gill, G. Knoll, et al. 2014. Economic consequences incurred by living kidney donors: a Canadian multi-center prospective study. American Journal of Transplantation 14(4): 916–922. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18. Nussbaum, M. C. 2011. Creating capabilities. Cambridge, MA: Belknap Press of Harvard University Press. Sen, A. 1983. Poverty and famines: An essay on entitlement and deprivation. New Delhi, India: Oxford University Press. Sen, A. 1999a. Commodities and capabilities. New Delhi, India: Oxford University Press. Sen, A. 1999b. Development as freedom. New York, NY: Oxford University Press.
ajob 45
