PHIL103: Moral and Political Philosophy

Paying people to donate their kidneys is one of the most contentious ethical issues being debated at the moment. The most common arguments against this practice include:

• Donor safety

• Unfair appeal of financial incentives to the economically disadvantaged

• Turning the body into a money-making tool "commodity'

• Wealthy people would be able to access more readily

The idea of nonfinancial incentives may be rising in popularity as a way to entice people to donate their organs. Financial incentives aimed at encouraging living donation have received much attention from bioethicists lately. Most experts argue that buying and selling human organs is an immoral and disrespectful practice. The moral objection raised most is that selling organs will appeal to the socioeconomically disadvantaged (poor, uneducated people) and these groups will be unfairly pressured to sell their organs by the promise of money. This pressure could also cause people to overlook the possible drawbacks in favor of cash incentives. On the other hand, wealthy people would have unfair access to organs due to their financial situations. It has been noticed that almost all of the people sold their kidneys to pay off debts and those will still had debt some time later but they will have a deterioration in their health status after donation and most of them would not recommend to others that they sell kidneys. Arguments that favor the buying and selling of human organs are scarce, but a few do exist. One of them is that payments aren't necessarily a bad idea if they work to increase the number of donated organs. The position contends that donating an organ is a relatively small burden compared to the enormous benefit reaped by recipients. Some argues that buying and selling organs is not morally objectionable, but that the system as it exists is inadequate to provide appropriate safeguards. This critique extends not only to the medical system, but also to legal and religious safeguarding organizations as well. It is an important ethical issue in organ transplantation. Whatever the perceptions of this practice in developed countries, it is widespread across the world. There are regional variations in its acceptance and practice. In France it is crime to get involved in paid organ donation. Most of the international organizations and forums have called fora moratorium against the sale of organs but the debate is not yet over. Recently the existing arguments against paid organ donation have been re-examined and found to be unconvincing. It is argued that the real reason why organ sale is generally thought to be wrong is that (a) bodily integrity is highly valued and (b) the removal of healthy organs constitutes a violation of this integrity. Both sale and (free) donation involve a violation of bodily integrity. In case of free donation the violation of bodily integrity is typically outweighed by the presence of other goods: mainly, the extreme altruism involved in free donation. There is usually no such outweighing feature in the case of paid donation. Given this, the idea that we value bodily integrity can help to account for the perceived moral difference between sale and free donation. International trade in human organs, particularly in the developing countries of the world where cadaveric organs are not easily available and where there is marked disparity in wealth. As a consequence, a deplorable type of medical practice has emerged, where human kidneys are bought from the poor for transplantation into the wealthy clientele with soaring profits for brokers, private hospitals and physicians. It is estimated that since 1980, over 2,000 kidneys are sold annually in India, Iraq, Philippines, Iran and elsewhere. to wealthy recipients from the Middle East, the Far East and Europe. Human organ ("Kidneys") trade which has shifted from India to Pakistan. Media, in particular had gone to the extent of labeling it as shifting of "Kidney Bazar", "Bombay Bazar" from India to Karachi, Lahore and Islamabad. Fig (10).

Figure 10.

Kidney bazar

The drawback is that physical harm comes to one person for the benefit of another. However, this is considered an acceptable side effect because of the rule of choosing between the lesser of two maladies, i.e. one person dies and one lives, or, two people live, both with physical deformities. It is not surprising, therefore, that this practice of trading in human organs has alarmed the medical profession, the public and many governments and it has rightly been condemned by all major religions, and by most transplant societies. Organ sale has serious negative impact on all aspects and on everyone involved in the process of transplantation, including the donor, the recipient, the local transplant program, the medical profession and the moral and ethical values of the society. Most ethicists believe that organ sale is an affront not only to altruism, but also to basic human dignity as opposed to a utilitarian approach to the important issue of transplantation for the following main reasons: (a) Organ sale promotes coercion and exploitation of the poor. (b) It promotes poor quality of care to the donor and particularly to the recipient as a result of poor standards of donor selection and inadequate screening for transmissible disease. (c) It benefits ruthless entrepreneurs, greedy doctors who care for their egos and financial gain. It is also against the patient's right for autonomy. It is contrary to accepted moral and ethical beliefs of most societies, including the major religions of Islam, Christianity, and Judaism. It diminishes the current benefit of altruistic donation by living donors and the families of cadaveric donors. It makes human organs a commodity for profit and sale thus inviting corruption and an unjust and unfair system of organ access and distribution and it predisposes to criminal tendencies of selling, kidnapping or killing children and women for organ sale, which has been reported. Some proponents of organ sale claim that well-controlled organ purchase does have several major advantages: by making more organs available it can reduce the waiting time for organs, reduce the number of deaths among waiting list patients as well as reduce the overall cost of treatment of patients with end-stage kidney disease. Some professionals in the transplant community believe that it will be much more productive as well as protective from sale of organs by vendors, at least in the developing countries where cadaver organs are not available, if the practice of organ sale is regulated by an independent organization. They argue that the feeling of repugnance of organ sale for the rich and the healthy should not justify removing the only hope for the destitute and dying. Cameron and Hoffenberg have recommended that organs be paid for through nationally established organ sharing networks to ensure the quality of care received by donors and to promote the equity of distribution which will involve the ethical and medical problems that exist with organ sale. Radcliffe-Richards et al. have emphasized that current exploitation of donors and lack of informed consent through organ purchase are due to poverty and lack of education, which do not justify banning organ sale. They suggest that a national organization be established to regulate the sale of organs or provide educational and appropriate consultation to patients to enable them to have informed consent and even a 'guardian' for the donor. Also this organization will regulate and control organ vending, proper selection, payment of fees and provision of necessary care which will prevent the current exploitation, the risk of removing organs, both for the donor and the recipient, and provide screening and counseling, together with reliable payment and financial incentives. They believe that this will not affect cadaveric donation, since payment can also be made to the family of the deceased. Some have proposed a market for organ donation or sale. The proponents of this model propose a legitimate governmental or nonprofit nongovernmental organization to take charge for the responsibility of compensating the donor, without any direct contact between donors and recipients. This would eliminate profit-seeking middlemen and organ brokers. While in certain instances, this practice has led to elimination of the waiting list, evidence for negative impact of kidney donation for the donors have been reported. The best is to avoid people and their organs of being a commodity in the market weather it is an open black market or an organized and controlled market. In addition to direct payment, various other forms of compensation such as life and health insurance, medal of honor, reimbursement for travel expenses, compensation for time out of work, or a tax credit have been proposed. The potential problem with this model is that if it is not well organized, it will open the door to an organ market, where the organs are sold to the highest bidder, benefiting the rich and disadvantaging the poor. Concern has also been raised that this will reduce altruistic kidney donation and discourage deceased multi-organ donation. However, some believe that it does not preclude increased donation, and others have shown that it has not inhibited the establishment of deceased donor transplantation programs. Opponents to any form of compensation and an organ market cite the concern that the poor will be viewed as mere providers of spare parts and will live with fewer organs, adding to this their list of disadvantages. According to this viewpoint, the market will be driven by poverty and the poor will be a disadvantage compared to the healthier, feeling a disproportionately higher pressure to sell their organs Fig (11). On a global scale this could translate into people from rich nations travelling to poor countries to buy organs. There is the concern that the market could potentially lead to demeaning bodies to "articles of trade". Degrading human relationships, and particularly damaging the altruistic bond. There is also the concern about the occasional coercion of a spouse by an addicted spouse into selling an organ to pay for the addiction.

Figure 11.

Major destination host countries WHO publications

With related donor transplantation, altruism is the expected driving force; however, regarding unrelated donors, several valid question have been raised. Why should the unrelated donors not be at least partially rewarded for their donation? Why should they be expected to undergo the surgery and live with one less organ for the rest of their lives? Are the other parties involved (physicians, surgeons, nurses, etc,) providing their services only altruistically? Why should the only individuals sacrificing their bodies not be appropriately acknowledged? Although current laws in most countries and guidelines by WHO and professional societies prohibit the sales of organs, it has been debated that provision of financial incentive seems not only fair, but may also encourage donation and subsequently benefit the patients on the waiting list. The main opponents of providing financial incentives have voiced concern over "devaluing" the body to a mere commodity and the potential for commercialization. Some would argue that the body is a property and, in fact, the most valuable commodity that an individual possesses. They would contend that the owner of this property has a right to sell part of it for his/her better good.

There is little doubt that commercialization of organ donation is fraught with drawbacks, dangers and potential immoral consequences. On the other hand, it is clear that efforts to increase the rate of organ donation through education have failed and sole moral incentives have not worked. Organs are currently limited by supply, and in the hope of expanding the available organs, it seems prudent to provide incentives not only to encourage donation, but also in order to express appreciation. In the process, we should be cognizant of the fact that we might be sacrificing some good for the sake of other potentially more meritorious goods, weighing the ethical and morals risks of one against the other. The obligation of society is to establish safeguards to protect all parties involved, as well as the humane inter-relationship between donor and recipient. In this regard, the method of acknowledging the good deeds of donors is of paramount importance.

It is clear that we need to look for feasible, ethical alternatives to the current model. This is not limited to whether or not donors should be compensated. Now that living unrelated transplant (LURT) has become an ever increasing reality Fig (12). Society and the transplant community should devise safeguards to scrutinize the process.

Figure 12.