Organ markets and human dignity: on selling your body and soul.

This article addresses the ethics of selling transplantable organs. I examine and refute the claim that Catholic teaching would permit and even encourage an organ market. The acceptance of organ transplantation by the Church and even its praise of organ donors should not distract us from the quite explicit Church teaching that condemns an organ market. I offer some reasons why the Church should continue to disapprove of an organ market. The recent commercial turn in medicine can blind us to the problem of an organ market. In addition, the reliance on the gift image in organ transplantation raises difficulties of its own. What is needed is a fuller appreciation of the fact that the human person is essentially embodied with all its parts, and not merely an autonomous being that possesses organs as properties to sell. I support this vision of the embodied human person by appealing to the writings of Immanuel Kant.     

Ambivalence,Autonomy, and Organ Sales

Recent philosophical arguments in favor of legal markets in human organs such as kidneys claim that respect for autonomy justifies such markets. I argue that these arguments fail to establish the moral permissibility of commercialized organ sales because they do not show that those most likely to serve as vendors would choose to sell autonomously. Pro‐market views utilize hierarchical theories of autonomy to demonstrate that potential organ vendors may autonomously consent to selling their organs even in the absence of any practical alternative to doing so. But central to hierarchical accounts of autonomy is the idea that persons my experience volitional ambivalence, a condition in which the will is irreconcilably conflicted. Because commercialized organ sales would create volitional ambivalence in many of those who opt to sell an organ, the choice to sell an organ would not be an autonomous one.     

Markets and The Needy: Organ Sales or Aid?

As organ shortages have become more accute, support for a market in organs has steadily increased. Whilst many have argued for such a market, it is Gerald Dworkin who most persuasively defends its ethics. As Dworkin points out, there are two possibilities here--a futures market and a current market. I follow Dworkin in focusing on a current market in the sale of organs from living donors, as this is generally considered to be the most difficult to justify. One of the most pressing concerns here is that such a market will exploit the poor. I outline this concern and scrutinize Dworkin's and others' rejection of it. Briefly, I argue that the arguments Dworkin employs for allowing the poor to sell their organs fail, and in fact better support an argument for increasing aid to the needy.     

History of organ donation by patients with cardiac death

When successful solid organ transplantation was initiated almost 40 years ago, its current success rate was not anticipated. But continuous efforts were undertaken to overcome the two major obstacles to success: injury caused by interrupting nutrient supply to the organ and rejection of the implanted organ by normal host defense mechanisms. Solutions have resulted from technologic medical advances, but also from using organs from different sources. Each potential solution has raised ethical concerns and has variably resulted in societal acclaim, censure, and apathy. Transplant surgery is now well accepted, and the list of transplant candidates has grown far quicker than the availability of organs. More than 30,000 patients were awaiting organs for transplantation at the end of March 1993. While most organs came from donors declared dead by brain criteria, the increasing shortage of donated organs has prompted a reexamination of prior restrictions of donor groups. Recently, organ procurement from donors with cardiac death has been reintroduced in the United States. This practice has been mostly abandoned by the U.S. and some, though not all, other countries. Transplantation has been more successful using organs procured from heart-beating, "brain dead" cadavers than organs from non-heart-beating cadavers. However, recent advances have led to success rates with organs from non-heart-beating donors that may portend large increases in organ donation and procurement from this source.     

An “Opting In” Paradigm for Kidney Transplantation

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors.

An “opting in” paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An “opting in” program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of “organ takers” who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who “opt in” would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive.

An “opting in” paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an “opting in” paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an “opting in” policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.     

An "opting in" paradigm for kidney transplantation

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors. An "opting in" paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An "opting in" program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of"organ takers"who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who "opt in" would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive. An "opting in" paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an "opting in" paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an "opting in" policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.     

Operation Blue,ULTRA: DION--the donation inmate organ network

Presently more than 80,000 Americans await an organ transplant, while 10 to 12 people die each day because of the lack of organs. The program proposed here would allow federal inmates additional "time off" for agreeing to become living donors or to provide organs or their bodies upon death. Such a program could add 100 to 170 thousand new organ donors to the pool, with another 10 to 12 thousand added annually. If the program were applied to all state inmates, up to 4 million new donors might be added, with another 10 to 13 thousand added annually. Given the extreme need for more organ donors and the need for more living donors, the current National Transplant Act of 1984 and the Uniform Anatomical Gift Act must be amended, while still retaining control of donation procedures.     

Non-heart-beating organ donation: personal and institutional conflicts of interest

While procurement of organs from donors who are not "brain dead" does not appear to pose insurmountable moral obstacles, the social practice may raise questions of conflict of interest. Non-heart-beating organ donation opens the door for pressure on patients or families to forgo possibly beneficial treatment to provide organs to save others. The combined effects of non-heart-beating donation and organ shortages at major transplant centers brought about by the 1991 United Network for Organ Sharing (UNOS) local-use organ allocation policy created potential conflicts, including the fact that candidates for organs become potential donors far more frequently than previously. Hospitals with a major emphasis on transplantation have economic and academic interests that may have been hurt by the relative organ shortage. Some may view non-heart-beating organ donation as a way to restore weakened programs and thus unconsciously compromise recognition of problems associated with non-heart-beating donation.     

Procuring organs from a non-heart-beating cadaver: a case report

Organ transplantation is an accepted therapy for major organ failure, but it depends on the availability of viable organs. Most organs transplanted in the U.S. come from either "brain-dead" or living related donors. Recently organ procurement from patients pronounced dead using cardiopulmonary criteria, so-called "non-heart-beating cadaver donors" (NHBCDs), has been reconsidered. In May 1992, the University of Pittsburgh Medical Center (UPMC) enacted a new, complicated policy for procuring organs from NHBCDs after the elective removal of life support. Seventeen months later only one patient has become a NHBCD. This article describes her case and the results of interviews with the health care team and the patient's family. The case and interviews are discussed in relation to several of the ethical concerns previously raised about the policy, including potential conflicts of interest, the definition of cardiopulmonary death, and a possible net decrease in organ donation. The conclusion is reached that organ procurement from non-heart-beating cadavers is feasible and may be desirable both for the patient's family and the health care providers.     

SELLING SPARE PARTS AND RENTING USEFUL SPACES

In the late summer and fall of 1983 articles appeared in such publications as the New York Times, Fortune Magazine , and Science News telling of attempts to set up an agency for the selling of kidneys from living donors. The shortage of organs, especially of kidneys where the transplantation success has increased quite markedly over the past decade, has become something of a crisis. A situation of increased need and inadequate supply is also becoming a problem for such substances as human bone marrow, for use in the treatment of immune and blood diseases, and large quantities of human plasma for use by hemophiliacs. Obtaining a kidney for a patient in renal failure was difficult in the past because adequate matching is likely only between very close relatives. Now with new immunosuppressant drugs such as cyclosporine, close matches have become less important. Cadaver organs or marrow from unrelated living donors can be used with far greater success. The supply problem is still immense and the literature is filled with suggestions for appropriate and efficient means of organ acquisition. One of the latest suggestions involves a system of salvaging based on implied consent of deceased donors. The organs would be taken without asking directly for permission from family. The relatives would have the right to object to the organ removal, but unless they did so, the organ would be taken when needed.     

Individualism–collectivism and organ donation intentions

This article investigates the impact of individualism–collectivism on a person's willingness to donate organs. In Study 1, an online survey showed that individualism–collectivism was significantly and positively associated with participants' willingness to register as organ donors while perceived benefit mediated this relationship. Study 2 demonstrated the causal effect of individualism–collectivism on organ donation intentions using a priming technique. Participants primed with collectivism were more likely to register as organ donors than those primed with individualism. Our findings provide unique insights into whether cultural values (i.e., individualism–collectivism) can predict people's organ donation intentions.     

Earning points for moral behavior: organ allocation based on reciprocity

Anticipating the reevaluation of the Dutch organ procurement system, in late 2003 the Rathenau Institute published a study entitled 'Gift or Contribution?' In this study, the author, Govert den Hartogh, carries out a thorough moral analysis of the problem of organ shortage and fair allocation of organs. He suggests there should be a change in mentality whereby organ donation is no longer viewed in terms of charity and the volunteer spirit, but rather in terms of duty and reciprocity. The procurement and allocation of donor organs should be seen as a system of mutually assured help. Fair allocation would imply to give priority to those who recognize and comply with their duty: the registered donors. The idea of viewing organ donation as an undertaking involving mutual benefit rather than as a matter of charity, however, is not new. Notwithstanding the fact that reference to charity and altruism is not required in order for the organ donation to be of moral significance, we will argue against the reciprocity-based scenario. Steering organ allocation towards those who are themselves willing to donate organs is both an ineffective and morally questionable means of attempting to counter organ shortage.     

Where it Hurts: Indian Material for an Ethics of Organ Transplantation

This article focuses on ethical issues surrounding the selling and buying of human organs. The author argues that most people who sell their organs (mainly kidneys) in India do so in order to pay already existing debts. The transaction is only temporarily an exchange of “life for life,” and most “donors” are back in debt soon after the operation. The author discusses the flexible ethics that reduce reality to dyadic transactions and the purgatorial ethics that collapse real and imaginary exploitation in the service of complex interests. He also offers a sophisticated discussion of the ethics of publicity and public ethics. He emphasizes the lack of factual information, intentional manipulation of information, and the dissemination of kidney panics and kidney scandals, especially by the new developing bioauthorities and bioethical brokers.     

《人体器官移植条例》颁布后面临的问题与对策

《人体器官移植条例》规范引导着我国器官移植健康发展,然而,随着《条例》对器官移植供、受者条件的严格限制,尸体供器官数量迅速下降,亲属活体移植逐步占据主导地位,由此引发一系列问题。结合《条例》,就器官来源短缺、保障活体供者安全、亲属活体供者选择和器官移植伦理委员会作用等问题做出较详细的分析,提出解决方法和对策。     

Some Must Die

The transplantation and procurement of human organs has become almost routine in American society. Yet, organ transplantation raises difficult ethical and psychosocial issues in the context of “controlled” death, including the blurring of boundaries between life and death, self and other, healing and harming, and killing and letting die. These issues are explored in the context of the actual experiences of organ donors and recipients, brain death, the introduction of non‐heartbeating donor protocols, and the increasing reliance on living donors. The author draws on a thematic analysis of the way that organ transplantation is presented in the media, films, and science fiction and on his clinical experience as a psychiatrist working with transplant patients, their families, and the nurses and physicians who care for them.     

Why liberals should accept financial incentives for organ procurement

Free market libertarians have long supported incentives to increase organ procurement, but those oriented to justice traditionally have opposed them. This paper presents the reasons why those worried about justice should reconsider financial incentives and tolerate them as a lesser moral evil. After considering concerns about discrimination and coercion and setting them aside, it is suggested that the real moral concern should be manipulation of the neediest. The one offering the incentive (the government) has the resources to eliminate the basic needs that pressure the poor into a willingness to sell. It is unethically manipulative to withhold those resources and then offer payment for organs. Nevertheless, the poor have been left without basic necessities for 20 years since the passage of the prohibition on incentives. As long as the government continues to withhold a decent minimum of welfare, liberals should, with shame, cease opposing financial incentives for organ procurement.     

Organ transplants,foreign nationals,and the free rider problem

There is strong sentiment for a policy which would exclude foreigners from access to organs from American cadaver donors. One common argument is that foreigners are ‘free riders’; since they are not members of the community whichgives organs, it would be unfair to allow them toreceive such a scarce resource. This essay examines the philosophical basis for the free rider argument, and compares that with the empirical data about organ donation in the U.S. The free rider argument ought not to be used to exclude foreign nationals because it is based on fallacious assumptions about group membership, and how the ‘giving community’ is defined. Polls show that even among the seventy-five per cent of Americans who support organ donation, only seventeen per cent had taken the small step of filling out donor cards. Therefore, it goes against logic to define the giving community as coextensive with American residency, while excluding foreigners who might well have become donors had they lived in countries which provided that option.     

A quasi-experimental investigation of message appeal variations on organ donor registration rates.

OBJECTIVE: Approximately 6,000 Americans die every year awaiting an organ transplant. Health promotion interventions may alleviate the shortage of viable organs by increasing the number of registered organ donors. This study is the first to evaluate the differential effectiveness of various organ donor messages in naturalistic settings. DESIGN: A 4 (Appeal)x4 (Exemplar)x4 (Location) counterbalanced quasi-experimental design was implemented. MAIN OUTCOME MEASURE: The behavioral outcome measure was the number of individuals who registered to be organ donors at computer kiosks. RESULTS: A number of significant main effects and interactions emerged. Most notably, of the 4 different appeals (counterargument, emotional, motivating action, dissonance), counterargument was by far the most efficacious, especially in academic-type settings (library, university, community college); the emotional appeal was most successful in hospitals. CONCLUSIONS: The findings from this study have implications for both organ donor investigations and health campaign research in general. Statistical interactions highlight the importance of evaluating multiple exemplars in multiple locations for each type of appeal when conducting health campaign research.     

Directed Organ Donation: Discrimination or Autonomy?

abstract   Numerous measures have been proposed to change the collection procedure in order to increase the supply of organ donations. One such proposal is to give the candidate donors the right to direct their organs to groups of recipients characterised by specific features like sex, age, disease and geographic location. Four possible justifications for directed donation of organs are considered: the utilitarian benefit, the egalitarian principle of justice, the maximin principle of justice and the autonomy principle. It is concluded that none of these principles justifies the acceptance of designated donations. When potentially life-saving resources are distributed, only a pure egalitarian distribution is in agreement with the principle of justice.s