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Rapid Responses: Rapid Responses published:
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The logic of organ payments
- Tom Koch (18 June 2008)
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A World Cut in Two
- Nancy M Scheper-Hughes (21 June 2008)
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Framing the debate
- Arthur J Matas (25 June 2008)
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Zombie arguments against kidney markets
- James S Taylor (3 July 2008)
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Tom Koch, professor, bioethicist. University British Columbia, Dept. Geog. Vancouver, Canada V6T 1Z2
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Dr. Arthur J. Matas states a well known problem, the shortage of transplantable organs, and advances as an answer a market in graft organs for transplant. This would, he suggests, provide a regulated as opposed to current unregulated systems of organ sales. The sense is that sense we now have unregulated systems and an official and regulated system would be an improvement on those existing. This is at best misleading. There is no commercial organ system in place in North America. His solution doesn't fix a market problem at all but instead creats a market where commercialization has been, in the past, prohibited. Later in his article he insists that payment through a fixed package of life insurance, or long term insurance would be equitable. But as Jeremy Chapman implies in his response, this would only codify inherent economic inequalities. Only those who can afford these insurances would be eligible as recipients and the contemporary inequalities in the system would be exacerbated, not reduced. Finally, Dr. Matas asserts as fact that arguments against a market in organs fail "on detailed analysis" and in many cases offer "illogical" propositions. The first assertion is at best debatable and the second simply incorrect. There is, for example, nothing illogical about Dr. Chapman's response and his analysis is at least as strong, logically and factually, and to my mind stronger, than Dr. Matas's. Indeed, Dr. Matas's inability to deal with questions of systematic inequalities in graft organ distribution argued in my book Scarce Goods (2002), and by others, suggests that the market answer is no stronger now than it was eight years ago. The problem of graft organ scarcity is real but it is complex, especially in a health care system like the one operative in the United States. Ignoring real concerns and real limits to the market ideal will not make the market system and its attendant commodification a better answer. Tom Koch, PhD
Author: Scarce Goods: Justice, Fairness, and Organ Transplantation (2002). Competing interests: author: Scarce Goods: Justice, Fairness, and Organ tRansplantation (2002) |
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Nancy M Scheper-Hughes, Chancellor's Professor of Medical Anthropology University of Califonia, 232 Kroeber Hall, UC Berkeley 94720,USA
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The arguments for and against commercialized transplants, pro and con ‘regulated sales’ grow somewhat sharper each decade but they remain unenlightened by the anthropological and ethnographic record on the individual, social, economic, and political consequences of organ selling (1- 10). The buying and selling of kidneys, the primary organ sold by the poor and disenfranchised, even when this is ‘regulated’ by the government, leads to the same social (or global) pathology: the division of humans into ‘worthy’ patients and ‘worthless’ sellers, the later a population sometimes scarcely thought of as human. “Donors [who sell] are poor, ignorant…and many are drug users. Sometimes I hate the donors”, an Egyptian transplant doctor told Budiani [footnote 6, p. 144]. A Brazilian transplant surgeon told me something similar, “Its disgusting the way those kidney sellers prey on desperate patients”. The stigma of selling a kidney attaches not only to the sellers but to their families and their villages, often labeled derisively as 'kid-villes' or “the mutilated ones” or the “villages of half men' and to their ethnic groups. “Why should I care about the man in Romania who sold me his kidney, a Middle Eastern transplant tourist told me. “They are from a race of people [i.e. gypsies] who would sell you anything, even their own children”. The political consequences of international transplant tourism are the recycling of old racial and ethnic hatreds and blood libels, as when Moldovan villagers , hard hit by kidney hunters and organs brokers, say that 'kidney selling is a crime by Moslem Turks against Christianity' (because many sellers went to Turkey for the kidney removal). GaddyTauber,and Israeli broker arrested by police in Brazil for recruiting poor Brazilians to serve as paid donors in South Africa for Israeli and European transplant tourists, suffered abuse in his prison cell. Tauber was greeted with “Heil Hitler’ salutes by his prison guards while the local Brazilian newspapers labeled Tauber the him the “Israeli Mengele’. (10) The arguments by bioethicists and moral philosophers are based on abstractions that have nothing to do with the everyday realities of desperate transplant patients or their donors and sellers. The Iranian model of regulated kidney selling , which has been suggested as a paradigm for the world to follow, has not ended the black market there. Living donors are still recruited by middlemen and private payments (over and above the government stipend) are negotiated behind the scenes. More affluent transplant patients demand healthier, stronger, better-off kidney donors, and are willing to pay the price for a ‘higher quality’ and ‘more educated’ organ. Rather than replace the black market the government of Iran has legalized it. At the opening of the Istanbul Summit on April 30th, 2008 organized by a steering committee of The Transplantation Society (TTS), and attended by 152 professionals from seventy-eight countries and twenty national and international organizations, Francis Delmonico, displayed a single slide, the only slide projected during that intense two day meeting. It was a slide of several thin men standing in a row and displaying their nephrecotomy scars. Demonico asked: “Can we live with this? Is this what we want of transplant medicine? Is this why we became surgeons and doctos?” Despite all the differences of culture, history, language, economics local cultural context, the Summit agreed that organs trafficking, transplant tourism, and commerce in organs “inexorably leads to inequity and injustice”. Social justice, not human dignity, not the ‘sacredness’ of the body, not pro or anti market positions, but simply the recognition that this was a renegade system, regulated or unregulated,and one that was dividing nations and creating a world cut in two. Art Matas stood alone in his dissent. I sat next to, lunched and dined, and spoke with the Iranian, Filipino, Pakistani, Egyptian, South African, and Indian delegates. All of them voted for the ban on commerce in organs and transplant tourism which they said, in different tongues and using different metaphors and figures of speech, was hurting their country, demeaning their profession,harming the kidney sellers, and under-serving the real needs of transplant patients for a medically, socially, and politically ethical system. Nancy Scheper-Hughes,PhD
1. NM Scheper-Hughes, 2008. “The Illegal Organ Trade: Global Justice and the Traffic in Human Organs”, chapter 10, Living Donor Organ Transplantation, R.W.G. Gruessner and E.Bendetti,eds, pp. 106-121. 2. NM Scheper-Hughes, 2008. “Combating the Global Traffic in Humans for Organs: Opportunities and Obstacles to Cross-Cultural Engagements, paper presented at the Asian Task Force on Organs Trafficking, National Taiwan University, College of Medicine, January. 3. F.Moazam, 2008. “Battling the Trade in Organs in Pakistan”, paper presented at the Asian Task Force on Organs Trafficking, National Taiwan University, College of Medicine, January. 4. DM Tober, 2007,”Kidneys and Controversies in the Islamic Republic of Iran: the Case of Organ Sale. Body and Society 13(3: 151-170 5. NMScheper-Hughes, 2006. “Is it Ethical for Patients to Purchase Kidneys from the World’s Poor? A Debate between Tarif Bakdask and Nancy Scheper-Hughes. PLOS Medicine October 2006 3(10) www.plosmedicine.org 6. D.Budiani. 2006. “The Consequences of Living Kidney Donors in Egypt”, paper presented at the meetings of the Middle East Society on Organs Transplant, Kuwait, November. 7. NM Scheper-Hughes, 2003. “Rotten Trade: Millennial Capitalism, Human Values, and Global Justice in Organs Trafficking.” Journal of Human Rights 2 (2): 197-226 8. L.Cohen, 2002. “The Other Kidney: Biopolitics Beyond Recognition”, in Commodifying Bodies, NM Scheper-Hughes ad L. Wacquant,eds. London: Sage. 9. L.Cohen, 1999, “Where it Hurts: Indian Material for an Ethics of Organ Transplantation”, Daedalus, 128: 135-165. 10. NM Scheper-Hughes, 2006. “Portrait of Gaddy Tauber: Organs Trafficker, Holocaust Survivor”. Berkeley Review of Latin American Studies (Fall) 44-47. Competing interests: none |
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Arthur J Matas, Professor of Surgery University of Minnesota
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The biggest problem in kidney transplantation today is the shortage of organs. Five decades of trying to increase conventional organ donation has only resulted in longer waiting lists and longer waiting time for a transplant. A regulated system of compensation for donation has the potential to eliminate this problem. Those who oppose consideration of compensation for living kidney donation often confuse and conflate discussion regarding regulated and unregulated compensation systems. Both Koch (1) and Scheper-Hughes (2) have continued this tradition; both seem out of touch with the realities of the organ shortage, and both have created “straw man” arguments. Koch and Scheper-Hughes accept living kidney donation (and its risks), so their concern must be the compensation itself. Koch seemingly misunderstands my description of a regulated system. He points out that there is no unregulated market in North America and suggests I am therefore providing a solution to a false problem; he then goes on to imply that there would be systematic inequalities of graft distribution if my suggestions were implemented. Scheper-Hughes provides a passionate and poignant argument against all the abuses of unregulated black markets with no oversight and no protection for either the donor or the recipient. I agree with her. In fact, Scheper-Hughes partly responds to Koch’s first point. There is no unregulated market in North America but the tremendous organ shortage in much of the world has led to development of unregulated markets in many parts of the world; it is these unregulated markets that Scheper-Hughes correctly condemns. As to Koch’s second point, I have, in great detail, described the principles and potential design of a regulated system of compensation (3, 4, 5). In that system, the government (or government agency) would evaluate and compensate the donor; there would be oversight and long-term donor follow-up; and the kidney would be allocated to those on the waiting list in the same way that deceased donor kidneys are allocated. There would be no contact between donor and recipient (and no personal payment); and all those on the waiting list would have an opportunity to be transplanted. My support of Scheper-Hughes’ concern about the outcomes of unregulated markets that have no oversight, no donor protection, and no follow-up in no way eliminates consideration of a trial of a regulated system of compensation in the parts of the world where we can provide oversight, donor protection, long-term donor care, and long-term follow- up. No such trial has been done. The underlying problem that we have is the tremendous shortage of organs; our patients are suffering and dying while waiting for a transplant. Because of the markedly increased waiting time, in parts of the United States (and in other parts of the world) the odds are now higher that an accepted transplant candidate will die while waiting than he or she will receive a transplant. Neither Koch nor Scheper-Hughes (nor any others who object to a trial of a regulated system of compensation) has put forth a realistic alternate solution. It is because of this organ shortage (and its resulting suffering and death) that there are unregulated black markets; increasing the number of available organs will eliminate (or minimize) these markets. It is time for a trial of a regulated system of compensation to determine if we can increase the number of available organs while protecting the health and dignity of the donors. It is also time to frame this debate correctly. If we are to have a meaningful discussion, we can not distort or confuse the issues. I have proposed a (well-defined) regulated system – to be instituted only in situations (or parts of the world) where we can provide donor protection, appropriate oversight, long-term donor follow-up and care, and an algorithm for allocation to all those on the waiting list. We all agree that there are problems with unregulated markets; solely depicting these problems distracts from the issues that I have raised and prevents meaningful discussion. 1) Koch T, The logic of organ payments, BMJ online, June 18, 2008. 2) Scheper-Hughes, A world cut in two, BMJ online, June 21, 2008 3) Matas AJ., The case for living kidney sales: rationale, objections and concerns. Am J Transplant, 4:2007-17, 2004. 4) Matas AJ, Why we should develop a regulated system of kidney sales: a call for action! Clin J Am Soc Nephrol. 1:1129-32, 2006. 5) Matas AJ, Design of a regulated system of compensation for living kidney donors. Clin Transplant. 22:378-84, 2008. Competing interests: None declared |
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James S Taylor, Assistant Professor The College of New Jersey 08628
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In his responses to Koch (1) and Scheper-Hughes (2) Matas reiterates his commitment to introducing a well-defined regulated market in human kidneys, to be introduced “only in situations… where we can provide donor protection, appropriate oversight, long-term donor follow-up and care, and an algorithm for allocation to all those on the waiting list” (3). Matas’ responses to Koch and Scheper-Hughes are well-taken. But given both the seriousness of the matter at hand and the tendency of (some) opponents of regulated markets in kidneys to obfuscate the critical issues it is useful to outline what precisely Koch’s and Scheper-Hughes’ objections are, and then to address them one by one. The need for this is all the more compelling since even though some of these arguments occur again and again in the debate over kidney markets, and are rebutted each time they appear, they, like zombies, simply refuse to die. Koch offers three objections to Matas’ proposed regulated market in human kidneys. First, that since there is “no commercial organ system in place in North America” Matas’ “solution doesn't fix a market problem at all but instead creats [sic] a market where commercialization has been, in the past, prohibited.” Second, that Matas’ idea of compensating kidney providers through life, or long-term, insurance would “only codify inherent economic inequalities,” for “Only those who can afford these insurances would be eligible as recipients and the contemporary inequalities in the system would be exacerbated, not reduced.” Finally, Koch argues that Matas is incorrect to assert “that arguments against a market in organs fail ‘on detailed analysis’ and in many cases offer ‘illogical" propositions’,” holding that “The first assertion is at best debatable and the second simply incorrect. There is, for example, nothing illogical about Dr. Chapman's response…”. (1) Scheper-Hughes offers four additional objections to Matas’ proposed regulated market in human kidneys. First, that the debate over kidney markets is “unenlightened by the anthropological and ethnographic record on the individual, social, economic, and political consequences of organ selling”. Second, that “The arguments by bioethicists and moral philosophers are based on abstractions that have nothing to do with the everyday realities of desperate transplant patients or their donors and sellers.” Third, that “The Iranian model of regulated kidney selling, which has been suggested as a paradigm for the world to follow, has not ended the black market there,” for “Living donors are still recruited by middlemen and private payments (over and above the government stipend) are negotiated behind the scenes. Thus, claims Scheper-Hughes, “Rather than replace the black market the government of Iran has legalized it.” Finally, she notes that at the recent Istanbul summit on organ trafficking there was near unanimous support “for the ban on commerce in organs and transplant tourism,” which was viewed by the delegates as “hurting their country, demeaning their profession, harming the kidney sellers, and under -serving the real needs of transplant patients for a medically, socially, and politically ethical system.” (2) Let us address these seven objections in turn. It is clear that Koch’s first concern with Matas’ proposal is not an objection, but simply a restatement of what it is. As such, it can be put to one side immediately. His second objection—that Matas’ proposal that kidney providers be compensated through the provision of insurance would “codify inherent economic inequalities” for only persons who could afford to pay for the provision of such insurances to kidney providers would be eligible as kidney recipients—can similarly be dismissed. Koch’s objection here is implicitly based on the view that under a market model of kidney procurement the recipients would be compensating the providers directly. But while this is certainly one way in which a market in kidneys could be organized it is not the only way. Rather than kidney recipients directly compensating kidney providers they could be compensated by medical insurance companies, who would then distribute the kidneys thus procured to their clients. At the same time kidney providers could be compensated by government programmes, such as Medicare or Medicaid in the United States, or the National Health Service in the United Kingdom, who could then distribute the kidneys thus procured on a medical, rather than a market, basis. Similarly, charitable organizations could procure kidneys through the provision of insurance to the providers, and then distribute them according to their own altruistic principles. Given that all of these means of distributing kidneys are compatible with their market-based procurement, Koch is mistaken to claim that markets in human kidneys would exacerbate current economic inequalities, with only the well-off having access to them. Finally, Koch is correct to note that the question of whether markets in human kidneys are ethically acceptable or not is one that is being debated—although it should be noted that this is not to say that he is right to hold that this issue is a “debatable” one, for colloquially this latter characterization holds pejorative connotations. Having noted this, however, it should be recognized that none of the arguments in the two main books that argue in favor of kidney markets—my own Stakes and Kidneys: Why markets in human body parts are morally imperative (Ashgate, 2005), and Mark J. Cherry’s Kidney For Sale by Owner (Georgetown, 2005)—have been rebutted yet. As such, the onus is firmly upon those opposed to markets in human kidneys to defend their view that the freedom of both potential sellers and potential recipients to engage in their life -saving voluntary economic transactions should continue to be proscribed by the ban on this market. It should also be noted that Koch’s response to Matas’ claim that the opponents of markets are often “illogical”—that Dr. Chapman’s response to him is not—is compatible with Koch’s claim that most of those opposed to markets in human kidneys offer illogical objections to them. Ironically enough, then, Koch’s response here to Matas is itself an illogical one—one cannot show that the claim “Most objections to this position are illogical” is false by citing only one that is not! Thus, without additional evidence to the contrary Matas’ claim here stands. Scheper-Hughes’ responses to Matas fare no better than Koch’s. Schepher-Hughes first charges that the debate over kidney sales remains “unenlightened by the anthropological and ethnographic record on the… consequences of organ selling”. There are two responses to be made here. The first is that the “anthropological and ethnographic record” that she refers to pertains to the illegal, unregulated market in kidneys—and so is simply irrelevant to discussions of legal, regulated markets. The second is to note that her charge is simply untrue. Both her own work (4- 6) and that of Madhav Goyal (7) is frequently cited within this debate. Those opposed to kidney markets wrongly hold that it shows what the consequences of any market in kidneys will be, while those in favour of them correctly note that the legalization of markets in kidneys will help prevent the documented abuses by providing a safe legal alternative for would-be kidney providers. While Scheper-Hughes’ first objection is thus both irrelevant and untrue, her second—that “[t]he arguments by bioethicists and moral philosophers are based on abstractions that have nothing to do with the everyday realities of desperate transplant patients or their donors and sellers”—is just untrue. In Stakes and Kidneys, for example, I examine the available data concerning both illegal markets in kidneys and their legal counterparts, together with the data pertaining to the risks of nephrectomy as compared with other dangerous activities to put the risk of kidney selling into its proper context. To do so, I draw on (among other sources) both anthropological and ethnographic data (including Scheper- Hughes’ own), medical data, morbidity and mortality statistics from Government sources, and published interviews with kidney providers and recipients. Moreover, Scheper-Hughes is—or should be—aware of the wealth of evidence concerning “everyday realities” that is marshaled to support markets in kidneys, for she has reviewed (for The Lancet) the pro-market books that present it (including mine) (8). Just as Scheper-Hughes’ second objection is better than her first (being only untrue, rather than both irrelevant and untrue), so too is her third, which is not untrue—just irrelevant. Here, Scheper-Hughes holds that Iran has only legalized a black market, offering as evidence for this the fact that persons sometimes pay more for a kidney than the Government sanctioned minimum. This is simply what has happened; what was previously an illegal market is now legal and regulated, just as the ending of Prohibition in the United States legalized the former black market in alcohol. And, just as the repeal of Prohibition ended the abuses associated with the black market in alcohol, so too has the legalization of the market in Iran made things better and safer for all concerned. Scheper-Hughes is also no doubt right that some people pay more than the Government minimum for kidneys. But it is unclear why this is a moral problem. After all, most people in the United States are paid more than the minimum wage, but I assume that Scheper-Hughes does not think that their employers are acting wrongly in so doing. Scheper-Hughes’ observations of the market in Iran thus do not support her objections to markets at all. What, then, of Scheper-Hughes’ final objection—that many of the delegates to the Istanbul summit are horrified at the effects of transplant tourism and organ trafficking? Again, this objection is irrelevant, for it is based on conflating illegal markets with legal, regulated markets. If one is really interested in eliminating these evils then one should work to legalize and regulate markets in human kidneys, to provide both providers and recipients with a safe, legal, environment in which to engage in their voluntary, life-saving transactions. And this, of course, is precisely what Matas is arguing that we should do (3). James Stacey Taylor Department of Philosophy The College of New Jersey Ewing, NJ 08628 USA (1) Koch T, The logic of organ payments, BMJ online, June 18, 2008. (2) Scheper-Hughes, A world cut in two, BMJ online, June 21, 2008 (3) Matas AJ, Framing the debate, BMJ online, June 25, 2008 (4) Scheper-Hughes, NM, 2008. “The Illegal Organ Trade: Global Justice and the Traffic in Human Organs”, chapter 10, Living Donor Organ Transplantation, R.W.G. Gruessner and E.Bendetti,eds, pp. 106-121. (5) Scheper-Hughes, NM, 2006. “Is it Ethical for Patients to Purchase Kidneys from the World’s Poor? A Debate between Tarif Bakdask and Nancy Scheper-Hughes. PLOS Medicine October 2006 3(10) www.plosmedicine.org (6) Scheper-Hughes, NM, 2003. “Rotten Trade: Millennial Capitalism, Human Values, and Global Justice in Organs Trafficking.” Journal of Human Rights 2 (2): 197-226 (7) Goyal, M. et al., 2002. “Economic and Health Consequences of Selling a Kidney in India,” JAMA 288: 1589-1593. (8) Scheper-Hughes, NM, 2005. “Book Review: The Ultimate Commodity.” The Lancet 366: 1349-1350, October 15. Competing interests: None declared |
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