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Apr-Jun2001-9(2)
DISCUSSION: ORGAN
TRANSPLANTS
The case against kidney
sales
Thomas
George
"The philosophers have only
interpreted the world in various ways; the point is to change it."
Karl Marx: Theses on
Fuerbach
I am one of those who, according to
Radcliffe-Richards et al, oppose the practice of buying kidneys from live
vendors from a feeling of "outrage and disgust." (1) These feelings are by no
means irrational. They are based on a bedrock of moral principle: that no human
being should exploit another. The opponents and proponents of the trade in human
organs are divided by this (perhaps unbridgeable) chasm - the one side is wedded
to the belief that not only are all human beings born free, but that they should
stay free; the other is not so sure. The evolution of human civilisation has
witnessed several periods of gross exploitation of human beings. Slavery, the
extermination of six million Jews, and today the transfer of body parts from one
living human being to another, for a financial consideration, are part of a
continuum of values which sees some human beings as less valuable than others.
It is this value system that those of us who oppose the sale of kidneys, seek to
change. All arguments in favour of the trade are attempts to clothe, in the garb
of reason, the concept that it is all right to remove a body part from a poor
person and put it into a rich one. But even these arguments will not bear
scrutiny and I will deal with them below. First, the argument that the
prohibition of organ sales worsens the position of the poor because it removes
an option in their already deprived lives: Here the authors (1) of the paper
have cleverly stated the most potent contrary argument themselves: the solution
is the removal of poverty. They, however, appear to consider this a distant
possibility, and in the meantime advocate the selling of kidneys as one option
available to the poor to better their circumstances. It would have been useful
if the authors had adduced material to show how and how long this so-called
option works. In the absence of any sustained means of livelihood, it is quite
probable that the money obtained by the sale of one organ will soon be gone.
What shall the seller do next? Sell another organ? An eye? A lung? And when all
the paired organs are gone?
Let us accept that the risk involved in nephrectomy
is not high. But is it not a fundamental tenet of medicine that the risk must be
in the medical interest of the patient? What medical advantage does the donor
obtain? Undoubtedly the risk is the same for those who sell and those living
donors who do not sell but donate out of regard for the recipient. Radcliffe
-Richards et al move from this fact to the inference that therefore there should
be no difference between the two groups with surprising facility. What matters
here is motive: the implicit coercion in the case of the poor who sell out of
financial compulsion. Radcliffe - Richards equating of the motives of the better
off, and comparing the risks of nephrectomy with the risks of dangerous sports
can only be described as callous. No one prevents them from campaigning against
these sports if they are so moved, but for us activists in the Third World there
are more pressing matters than looking after the well - being of the jet- set. A
profile of the sellers would be revealing. It will come as no surprise that they
all belong to the Third World. And it will also come as no surprise that besides
the wealthy in the Third World, the potential buyers will be from the rich,
white, First World and from the petroleum driven nouveau - riche! No wonder a
veritable industry of philosophers has risen in these countries to justify this
horrible practice. And in the honourable tradition of colonialism there will
always be locals ready to aid and abet the conquerors. He who pays the piper
calls the tune!
Radcliffe-Richards et al (1) seem fixated on the
belief that legalising and controlling the trade in human organs will protect
the exploited. The situation in other fields shows that this is naïve indeed. In
Hamburg, legal commercial sex workers throng the glittering Reeperbahn, while in
the sad, sordid, shadowy bylanes the illegal commercial sex workers have no
shortage of clients. This in a country where social conditions ensure much
closer adherence to the rule of law than is the case in most developing
countries, which are the main source of people willing to sell their organs. In
India, child labour is a reality. Poverty is the main reason for its existence.
The efforts of numerous groups have succeeded in making it illegal. Have they
removed an 'option' for the poor? After all, the poor consciously send these
children to work. Would it be a good idea to legalise the practice and control
it on the theoretical basis that it would improve the lot of these unfortunate
children? There are many reasons why such trades will always be open to
exploitation. The most potent one is that the victims are poor and voiceless
while the beneficiaries are generally rich and powerful.
The argument that organ selling is acceptable
because some services are available to the rich, which are not available to the
poor, is extremely strange. Do the authors believe that the presence of
undesirable practices justifies adding a few more? What will the limit be? Who
will decide how many more are to be allowed? No prizes for getting it right. The
answer is: the rich and powerful. Permit whatever is in their interest. They can
always hire a motley crew of philosophers and technicians to justify it and make
it possible. Why is altruism necessary in organ donation? It is because it will
ensure the absence of exploitation. It is nobody's case that unless some useful
action is altruistic it is better to forbid it altogether. Altruism removes the
profit - making element. It will help ensure that organ transplantation is done
in the best possible way and thereby achieve the best possible medical result.
It will also ensure that no vital organ is removed from a living person. On the
other hand, trade in kidneys definitely puts one on the slippery slope to
selling vital organs as documented elsewhere. (2) Here, the authors utilise the
familiar stratagem of positing and demolishing imaginary weak arguments against
their stated position, while ignoring the real and powerful
argument.
The authors end with an emotional appeal that
feelings of repugnance among the rich and healthy cannot justify removing the
only hope of the destitute and dying. A powerful statement indeed, but on whose
behalf? Is the only hope for the destitute the sale of body parts? Is this
modern form of slavery where one sells oneself piecemeal, as opposed to the old
form where the entire person was sold the only hope for the poor of the 21st
century? Or are the authors unaware that there is enough for all if only the
rich were not so greedy? (3) Although they themselves state that the real
solution to selling is the removal of poverty, they quickly move on to the
reasons why selling is acceptable today. The entire tenor of their article
suggests that they are not interested in this the real option. Perhaps it is
difficult to push this idea in the West where the dominant paradigm is to
maintain the current wasteful level of living, never mind that it is at the
direct cost of millions of other human - beings living elsewhere. How much
easier to go for the soft option of buying kidneys from the poor and making this
appear as good for both the seller and the buyer. As for the dying, it is clear
that the authors are not concerned about the poor who are dying, as they cannot
afford transplantation and all the costs after transplantation. As for those who
can afford transplantation, is the transfer of a kidney from a poor person
really the best option? People who have undergone dialysis do not seem to think
it such an unpleasant experience, as the authors would have us believe. (4) Let
us not forget also that transplantation is not the end of the story but that the
patient has to be on lifelong immunosuppression, which is quite an expensive
proposition. However, it is true that many who would be helped by
transplantation are unable to get an organ. The real solutions lie in
popularising cadaver transplantation and increasing the donation rate from the
brain-dead, and working on technology to make dialysis cheaper and more
(tolerable). Radcliffe - Richards et al state that a vendor will never be a
potential donor even after death. This is by no means certain. Methods can be
found to increase donation rates from the brain - dead and from cadavers. One
has only to see the amazing success of the Sri Lankan eye donation programme to
understand what can be achieved. This is the difficult option but the only
sustainable one. Nothing can justify using one human being as an organ farm for
another.
References:
1.Radcliffe-Richards J, Daar AS, Guttman RD, et
al, for the International Forum for Transplant Ethics. The case for allowing
kidney sales. Lancet 1998: 351: 1950-52.
2. Pande GK, Patnaik PK, Gupta S, Sahni P
(eds). Brain death and organ transplantation in India. Page 30. The National
Medical Journal of India, New Delhi 1990.
3. Antia NH. Global policies and peoples
health. Natl Med J India 1993; 6: 1-3 4. Lyon S. Organ donation and kidney
sales. Lancet 1998; 352: 483 - 492
Dr Thomas George,
Southern Railway Hospital, Perambur, Chennai, 600 023. Email:george@medicalethicsindia.org.
Excerpts from the World Medical Association statement on human organ and tissue donation and transplantation, adopted by the 52nd WMA General Assembly in Edinburgh, Scotland, October 2000:
"The WMA considers that policies and protocols concerning organ and tissue
donation and transplantation must be developed in recognition of the medical
ethics that underlies the practice of medicine and the patient-physician
relationship…"
"The expression of compassionate concern for others suffering from ill
health and disability through voluntary altruistic giving," "free and
informed decision making about medical treatments," "Privacy and the dignity of
the patient," "timely access, on just and equitable terms and conditions, to
necessary and effective medical treatment …"
"Awareness and choice should be facilitated in a coordinated multi-faceted
approach by a variety of stakeholders and means... "
"Physicians have an obligation to ensure that interactions at the bedside,
including those discussions related to organ donation, are sensitive and
consistent with ethical principles and with their fiduciary obligations to their
patients…"
"… the potential donor's wishes are paramount. In the event that the
potential donor's wishes about donation are unknown and the potential donor is
…unable to express his/her will, the family or a specified other person may
serve as a substitute decision-maker …"
"In order for the choice to donate organs or tissues to be duly informed,
prospective donors or their substitute decision makers should, if they desire,
be provided with meaningful and relevant information..."
"Protocols for free and informed decision making should also be followed in
the case of recipients..."
"… there should be explicit policies open to public scrutiny governing all aspects of organ and tissue donation and transplantation, including the management of waiting lists for organs and tissues to ensure fair and appropriate access..."
"Payment for organs and tissues for donation and transplantation should be
prohibited. A financial incentive compromises the voluntariness of the choice
and the altruistic basis for organ and tissue donation. Furthermore, access to
needed medical treatment based on ability to pay is inconsistent with the
principles of justice… However, reasonable reimbursement of expenses …is
permissible."
Statement atwww.wma.net/e/policy/17-180_e.html