Ethical and Social Consequences of Selling a Kidney

The controversies surrounding the ethical and social consequences of permitting the sale of organs (essentially kidneys) for transplantation are at once intense and perplexing. The intensity is easily understood because both sides of the debate believe that the stakes are very high. Proponents look to the sale of organs to resolve a life-or-death situation. Since the number of patients who have end-stage renal disease and are awaiting a transplant far exceeds the supply of organs, individuals who cannot survive despite dialysis treatment or lack access to it will die unless a kidney is available. As a dialysis patient who was also a member of the British Parliament declared in resisting a ban on commerce in organs: "Those who want organs want them now because life is finite."¹ Opponents, on the other hand, perceive sale as an egregious exploitation of the poor, a literal pound of flesh, whereby those without resources must sacrifice bodily integrity for those with resources.²

The perplexity reflects the exceptionally splintered and disjointed quality of the debate. Too many considerations are conflated into a pro or anti position, leaving readers uncertain as to precisely what practices are being advocated and under what conditions. At times, compensating donors means rewarding families for permitting the removal of a cadaveric organ; at other times, it means allowing for the purchase of a kidney from a living donor. Sometimes the discussion presumes an open market in organs (with supply and demand setting the price); other times, it presumes a regulated market (an official body fixing the price); and at still other times, it looks to a futures market (a donor agreeing to give the organ after death and receiving compensation either immediately or having it go later to the estate).^{3 - 5}

To complicate the issue further, some commentators cast the debate in philosophical terms, pitting personal autonomy (the right for individuals to make their own choices) against paternalism (which obliges third parties to protect people from themselves). Other commentators pursue practical questions, such as will a market in organs actually serve to increase supply by providing an incentive or decrease availability by subverting an ethos of altruism?⁶ All the while, some discussions focus exclusively on organ sale in developed countries, where regulatory mechanisms and social welfare systems are well entrenched. Others address developing countries, where poverty is more endemic and public health care systems are too rudimentary to support dialysis. The difficulty is that conclusions offered for first-world circumstances are regularly invoked by parties in the third world to justify their own practices. As those of us who have investigated the traffic in organs in countries such as India and the Philippines discover, surgeons and brokers are quicker to cite articles in journals of philosophy or medicine that sanction in one form or another compensation for organs than they are to respect the World Medical Association's unqualified prohibition of payment for organs.⁷

Were all these considerations not confounding enough, yet another vital one appears, organ sale as a means to promote upward mobility for the poor. Here the prototypical case involves very poor individuals in a poverty-stricken country. One interdisciplinary group,⁸ in setting out the case for allowing kidney sales, insisted that "we cannot improve matters by removing the best option that poverty has left." If the rich are allowed to pursue dangerous sports, the poor should be allowed to assume "the lesser risk of kidney selling for greater rewards . . . extricating themselves from poverty and debt."⁸ Or as a team of economists concluded, those who worry about coercing the poor actually "leave them worse off (by denying them the opportunity to receive compensation) . . . thereby exacerbating their poverty."⁹

The idea that selling one's kidney is a route out of poverty occupies a special place in the wider debate. Proponents invoke it not only to inveigh against paternalism but also to buttress the proposition that sale would increase supply (since so many people would be eager to climb out of poverty). The proposition also serves as the "hard case" that, if answered in favor of sale, makes other questions easier. So if desperately poor people in desperately poor countries were permitted to sell their organs, then surely far fewer problems would be encountered with permitting well-situated citizens in wealthy countries to sign future contracts or receive monetary rewards for agreeing to "donate" a departed relative's organ.

For all these reasons, the findings of Goyal et al,¹⁰ reported in this issue of THE JOURNAL, assume particular importance. This article will not bring closure to a debate that follows so many tangents, but the results may help close off one aspect of it. By demonstrating that the sale of organs does not serve as an escape route from poverty, indeed, that its aftereffects may even make escape more difficult, Goyal et al¹⁰ explode the proposition that sale is a win-win situation that benefits buyer and seller. In fact, as they show, 87% of those who sold a kidney reported deterioration in their health status. In addition, kidney sellers experienced a one-third decrease in average family income after their nephrectomies. Of the 292 participants who sold a kidney to pay off debts, 74% still had debts 6 years later (at the time of the survey), and those in poverty increased from 54% (presale) to 71% (postsale).

Whatever the methodological limits of a report based on 305 kidney sellers in one Indian city, the conclusions stand strong for several reasons. First, the findings make good sense. The idea that individuals heavily burdened with debt would be able to use a thousand dollars to purchase capital goods (farm equipment) or improve their market situation (by renting or buying a shop) and thereby transform their life chances was always fanciful. Moreover, the authors' conclusions are consistent with findings of anthropologists who have investigated sellers' lives. Cohen,¹¹ on the basis of his field work with 30 families in a Madras slum, concluded that "decisions to sell a kidney appear to have less to do with raising cash toward some current or future goal than with paying off a high interest debt to local moneylenders. Sellers are frequently back in debt within a few years." Cohen hypothesized that as a geographic region became known to organ brokers as a "kidney zone," their search for sellers there intensified, and simultaneously creditors became more aggressive in calling in their debts. At the same time, relatives of a patient who needed a kidney now asked themselves why they should assume the risk of donating when they could go out and buy a kidney. In other words, a market in organs stimulates a market in organs. A system of sale is not neutral but self-reinforcing.

The importance of this conclusion goes well beyond India. It is the availability of organs for purchase in some countries that allows other countries to forgo promoting and facilitating organ donation. Since Japanese citizens can purchase organs in the Philippines, Israeli citizens can purchase organs in Turkey and former Soviet Union countries, citizens in the Gulf States can travel to India to purchase organs, and Malaysians can purchase organs in China, these countries can avoid addressing their own cultural attitudes and practices that discourage donation.¹² There are serious divisions among religious and social leaders such as in Jewish and Muslim communities, about the ethics of organ donation, but rather than pursue and debate them, these countries let their patients and even their surgeons enter and feed the marketplace for organs. Indeed, some number of them will reimburse citizens who go abroad for their transplants for the standard sum allowed for the procedure at home, and physicians will provide aftercare to patients who have received transplantation abroad, with little knowledge about the actual source of the organ.¹³

Sale of organs is a zero-sum game in which any advantage to one participant necessarily leads to disadvantage to one or more of the others. The organ recipient is the only one who stands a chance for gain (organ brokers, surgeons, and hospitals notwithstanding). In broader terms, an appreciation of this fact helps clarify the policies that should be followed to raise the general standard of living. As the economist and Nobel Prize winner Amartya Sen has argued, economic development is too easily subverted by notions of a "false liberty," the kind implicit in a so-called right to sell a kidney. Such practices deflect attention from and even undermine the structural changes that are vital to modernizing an economy.¹⁴ Sale of a kidney will no more rescue an individual from poverty than it will, in aggregate, spur economic development. Thus, for everyone except recipients, commerce in organs is a dead-end proposition.