Jane McCredie: Organs for sale

IF someone living in desperate poverty wants to sell a kidney, do we have the right to tell them they can’t?

Expatriate Australian ethicist Professor Julian Savalescu has defended people’s right to sell their body parts:

“If we should be allowed to sell our labour, why not sell the means to that labour? If we should be allowed to risk damaging our body for pleasure (by smoking or skiing), why not for money which we will use to realise other goods in life? ... To prevent [people] making these decisions is to judge that they are unable to make a decision about what is best for their own lives. It is paternalism in its worst form.”

A debate in the March issue of the Journal of Medical Ethics centres on whether bans on the organ trade are inherently paternalistic.

Oxford University ethicist Professor Janet Radcliffe-Richards is one who believes they are, pointing out the bans have been imposed “by the people with least temptation to engage in the practice (the rich and healthy) on those with the most”.

When the trade in organs was first exposed, governments and professional bodies rushed to put in place prohibitions “as a direct response to feelings of moral outrage”, she writes, only later seeking “a justification for the original intuition that organ selling must be wrong”.

On the other hand, a colleague at Oxford, Dr Simon Rippon, argues bans on the organ trade are not necessarily paternalistic.

Although an individual might see selling an organ as their best available option, that same individual might have been better off if the option had not been there in the first place, he argues.

“… because people in poverty often find themselves either indebted or in need of cash to meet their own basic needs and those of their families, they would predictably find themselves faced with social or legal pressure to pay their bills by selling their organs, if selling organs were permitted”, he writes.

“So we would harm people in poverty by introducing a legal market that would subject them to such pressures.”

That’s not to say this isn’t already happening as a result of the black market in organs that flourishes in India and elsewhere.

For example, Dr Rippon cites anthropological work suggesting debt collectors may be more aggressive in pursuing creditors in those regions of India that have become “kidney zones”.

A survey involving 305 people in Chennai who had sold a kidney found 96% of them did so to pay off debt, receiving an average payment of just over US$1000 (A$1117) in return.

Sadly, there was little evidence of long-term benefit for these people. Average family incomes declined by one-third after nephrectomy, about 86% of participants reported a deterioration in health and three-quarters were still in debt at follow-up (on average, 6 years later).

Almost 80% of these participants said they would not recommend selling a kidney to anybody else, but does that mean they should have been prevented from doing it?

One argument not canvassed in the Journal of Medical Ethics articles might relate to harm minimisation.

If organs could be legally bought and sold, perhaps the poor of Chennai would undergo the procedure in safer conditions and receive a more ample payment for their sacrifice.

We make such arguments in relation to other activities that may cause harm, such as prostitution or drug use. Perhaps we could make it here too.

But that “original intuition” that organ selling must be wrong is a powerful one, which I struggle to dismiss.

Legalising a global trade in organs would, in effect, signal an acceptance that some people’s circumstances are so dire they have little option but to sell a kidney.

I’d rather see us doing something about the poverty that drives people to such desperate options in the first place, but I guess that’s a pipe dream.
 

Jane McCredie is a Sydney-based science and medicine writer.