Canadian broadcasting reports that University of Calgary researchers suggest paying kidney donors could be “less costly, more effective” and payments could boost donations. Is this a good idea and if not, why?
First, we must never underestimate the suffering and anguish of the people on a waiting list for a kidney transplant and of their families, and we have obligations to do what we can to help them. Payment might increase the supply of organs, so must be considered.
A favourable economic cost/benefit assessment, such as the Calgary researchers report, is not alone, however, sufficient to justify paying donors. As American physician-ethicist Daniel Sulmasy says, “Cost-effectiveness assessment (CEA) is not a morally neutral way to make … decisions. It is not rationality itself. Rather, it represents a particular view about the rational that prizes efficiency over fidelity and outcome over process. It assumes one can commensurate everything that human beings value in monetary terms. … A critic of CEA might very well believe … that other things in addition to the net cost-effectiveness ratio ought to be considered to determine the right and just decision.”
Michael Sandel, the Bass Professor of Government at Harvard University, in his book, What Money Can’t Buy, explains what some of these “other things” could be.
Sandel warns that we must consider the dangers in taking market reasoning beyond its application to material goods. Applying market reasoning to procuring organs and, thereby, allowing them to be bought and sold would corrupt a societal good – the act, itself, of the gift of an organ – and eliminate an altruistic activity – the altruism involved in unpaid organ donation.
Moreover, selling parts of the human body devalues human beings, and both reflects and causes a loss of respect for the individuals whose organs are sold, and for human beings, in general. We prohibit slavery, where the whole person becomes just a commodity which/who can be bought and sold, or selling a child, for just these reasons.
Then there is the harmful impact on important shared values established and upheld by organ donation, in particular, that we care for each other when we are weak, sick, vulnerable or in need, just because we are members of the same community.
Selling organs for transplant converts social or even familial relationships to market relationships. The CBC article informs us that, “The researchers used $10,000 [as the payment for a kidney] because in an earlier survey, they found 54 per cent of respondents who previously would not consider giving a kidney might consider doing so for a relative for a payment of $10,000.” (Emphasis added.) These potential donors are clearly not inspired to donate by just altruism or familial bonds, or, perhaps, at all by those factors. How much might they want to be paid to donate to a stranger? Does everyone, at some point, have a price they would accept?
Payment also raises problems of fairness and justice. Government funded schemes can be devised to overcome some of these problems, but, in general, only the poor sell and, with private schemes, only the rich can buy. This means one group of people are subject to all the burdens and another group receives all the benefits, in short, burdens and benefits are not equitably distributed. Moreover, the rich can have access to transplants which may be life-saving (if kidneys are allowed to be sold, hearts from cadaver donors will follow), that the poor can’t afford.
Payment also raises the dangers of abuse and coercion, especially of the most vulnerable people. In this regard, the international impact of changing Canadian law to allow payment is relevant. It would indicate payment is ethical and accords with respect for human rights, when, in fact, we know that the “organ sales industry,” the raison d’être of which is profit-making, is neither. The trafficking in people and organs and the exploitation and abuse of vulnerable people to which this industry gives rise, is the reason ethical transplant physicians, in the countries where it operates, adamantly oppose allowing payment. The Declaration of Istanbul 2008, affirmed by the World Health Organization, rejects payment for organs and establishes guidelines meant to ensure ethics and respect for human rights prevail in procuring organs for transplantation.
Finally, advances in medical science might solve the ethical problems raised by the shortage of organs and considerations of payment to increase the supply. When we can create organs in the laboratory, which exactly match the recipient, donors will, not only, be unnecessary, but would be an inferior source.
Sandel points out that markets embody norms; they are not mere mechanisms. So we must decide whether a market in organs and all this engenders is a norm we want to adopt. In making that decision, we should keep in mind that paying for organs involves putting a price on what we consider priceless.
Margaret Somerville is the founding director of the Centre for Medicine, Ethics and Law at McGill University. This article was originally published in The Globe and Mail, Canada.