No such thing as ethical organ market

July 9, 2008
No such thing as ethical organ market
By Alastair V. Campbell, For The Straits Times
KIDNEYS FOR CASH: Pakistani men showing their scars at a police station in Lahore after they sold their kidneys last year. For many poor vendors, the selling of an organ did not help them out of poverty and in fact adversely affected their health and employment. -- PHOTO: AFP 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 International Society 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 health-care 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 of 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.