The Ethical Question Regarding the Legalizing Commodification of Organs in the U.S.
The world of healthcare has drastically changed in response to the wave of new biotechnologies and medical discoveries hitting this last half century. An implementation of these paradigm shifting innovations hinges on two conditions for bringing the technologies to market. A primary condition requires access to proper financial funds while the second and less obvious one involves obtaining the necessary biological materials to create the product. Not surprisingly, this latter variable becomes the limiting factor in medicine’s innovation equation since synthetic materials cannot always replace parts of an ailing natural body. Because humans are living longer on average than they were 50 years ago, there is also a greater probability that something will go wrong in the body. An example of this paradoxical phenomenon can be found in the field of human organ and tissue transplantation. In 1954, a surgeon named Joseph Murray successfully performed the world’s first whole organ transplantation with a set of identical twin brothers named Robert and Richard Herrick. Murray not only achieved whole organ transplantation, but also showed that live donation was possible when he transferred one of Ronald’s healthy kidney lobes (renal transplantation) into Richard (Mezrich, “When Death Becomes Life”). Murray went on to perform the first deceased-donor transplant in 1962; however, his operation on the Herrick twins would set up a precedent in the field of transplant surgery. As of 2019, most the body’s major organs - including heart, lung, liver, and skin - have been used for transplantation. However, renal failure is still “one of the top 10 causes of death” globally with roughly 100,000 people on the waitlist for a deceased donor kidney every year (Hidden Brain, “For Sale, By Owner”). On average, 130,000 organ transplantations are completed worldwide (World Health Organization, “Human Organ Transplantation”). This figure might appear large. However, the number only constitutes 10% of the global need for donor organs. While the ethical constitution of “brain-dead”- the medical condition referring to the vegetative state where a patient’s vital organs may still function but who’s brain shows no activity waves suggesting higher consciousness, remains a separate but equally important question for our society when talking about commodification, I would like to discuss the shortage of donor kidneys in the United States and an option that could solve it: legalizing the commodification of human organs.
The kidney is one of few internal organs which allow live-donor transplantation because it just so happens that humans are born with two renal lobes but only need one to stay alive. When more than 8,000 people die on the waitlist annually, and 100,000 (based on a 2015 report) left hoping for another year, this waiting game becomes dangerous at best, lethal at worst. Patients will walk this dangerous tightrope for a 6-year average before receiving an organ if the disease has not killed them already. For this reason, countries outside the U.S received one-fifth of their kidney donations through the “black market” in 2010 (Yanklowitz, The Atlantic). The black market for kidneys has been an issue in impoverished and “developing nations,” taking advantage of the most vulnerable individuals. Examples of historically high traffic areas include China and India. In fact, one 2010 study found that nearly one-fifth of kidneys are sold on the “black market” (Yanklowitz, The Atlantic), while a separate study conducted by Global Financial Integrity - a human rights advocacy group based in Washington D.C - estimated an annual profit of almost $1 billion USD is generated from this illegal market worldwide. Countries without government control to prevent coercion of the poor and vulnerable exhibit the greatest likelihood of engaging in the illegal trafficking of organs. This results in the coercion of people in poor and developing nations into selling organs for survival and while under duress. This statistic is partly why the commodification of organs appears repugnant. The black market also fosters “transplant tourism,” a phenomenon where a poor kidney might be bought for $5,000 and then turned around and sold at a $150,000 price tag (Yanklowitz, The Atlantic). Given this knowledge, I am compelled to support the legalization of buying and selling of human organs within the most conservative guidelines. I refer to the case of repugnant transactions as the main reason for my view, concluding that our aversion is economically irrational and ethically unreliable.
A repugnant transaction is “a transaction that some people would like to engage in, and other people don’t think they should be allowed to,” according to an episode of NPR’s Hidden Brain podcast titled “For Sale, By Owner – The Psychology of Repugnant Transactions.” In the conversation, Nobel Prize-winning economist Alvin Roth explains that “repugnant” implies morally ambiguous ground which some people label as unethical “even it’s hard to see how those other people are harmed.” The second half of the concept, “transactions” is defined as a service or duty one party performs for another in exchange for monetary betterment, usually in the form of being paid a finite amount of money. When putting the two words together, repugnant transactions “force us to define the boundaries of what is acceptable to buy and sell…[putting] morality into conflict with economics.” The commodification of organ donations is initially repugnant to many because it slaps a price tag on the recipient’s life, creating a buy-in point in obtaining the life-saving organ. However, there is no hard and fast science for why some may be repulsed by the thought of monetizing organ donation. As Verdatam reiterates, “part of it might be a moral problem. Part of it might be a safety problem. Part of it might be a money problem. And what our minds are doing in some ways are integrating all of those to create the intuition of the whole thing is wrong” (Hidden Brain, “For Sale, By Owner”).
Those opposed to monetizing transplantation of living-donors cite the risk of coercion, where the act takes advantage of those with the least agency to say no given their impoverished state. Coercion “[adds] money to transactions that might not otherwise involve money... you do it for the money and in the absence of money, you wouldn't do it,” according to Roth. However, this definition is flawed when applying it to professional careers as a form of payment in order to live. Also, there is a more than likely chance that individuals who are doing it illegally will not stop doing something just because there are regulations, but it will decriminalize the act and make it more safe for the people involved if the government was monitoring the behavior with policy to enforce. Legalizing commodification would make the process safer with regulations in place then it is now, no matter what side a person is for the morality of the issue. As Roth further points out in his example on being paid to teach economics, “I'm betting you don't feel coerced. We feel paid. We feel appreciated for the work that we do. So at least to an economist, it's not obviously coercive to say to someone I'll pay you to do something that you otherwise wouldn't do.” Perhaps coercion is not at the heart of what makes selling organs repugnant or even unethical. Instead, it is Roth’s theory that “money suggests something - a more arm's length transaction,” which appears socially foreign to deeply relational human beings. For an act as intimate as an organ being physically placed inside a patient to sustain his/her life, a personal desire for an emotional connection between donor and recipient is understandable. In the same way having a doctor take the Hippocratic Oath to do no harm is comforting for the sake of a fiduciary relationship, despite the surgeon getting paid to perform the operation. The doctor is not just performing an operation because of the money incentive at the end but presumes to have a desire to do good in the world and help people.
It is illegal to buy and sell organs for monetary gain in the United States. Organ transplantation, officially governed by the National Organ Transplant Act of 1984, utilizes a recipient waitlist which grants organs based on a patient’s initial time of entry to the list, medical need for the organ, and estimated survivability through the surgical procedure (Marcus, The Wall Street Journal ‘WSJ’). In fact, commodification of organs is illegal in every country in the world, except for Iran. Notably, a recent study found that Iran was able to cut its recipient waitlist while simultaneously “virtually eliminating” (Yanklowitz, The Atlantic) the presence of a black market. There is still a rigorous background check for potential donors, and medical integrity is not compromised. First, a potential donor visits the regional office to receive medical clearance for general physical health. If cleared, the individual is matched with a potential recipient based on blood type. Iran’s government ensures the transaction between both parties and even provides benefits such as exemption from military service for the donor. This system is not without its faults. First, it bans foreigners from partaking in the program. In some cases, there is a shortage of resources to follow up with the donor and to cover all the medical costs beyond the initial procedure. The perceived social shame in selling one’s organ for money does not dissipate just because the act is legal. As Roth later shows, “when you interview organ donor sellers in Iran, often they wish to remain anonymous. So, it is a legal transaction, but it's not one that they are happy to have advertised to their friends and colleagues that they've done. So that suggests that it's operating in something of a shadow” (Hidden Brain, “For Sale, By Owner”).
So, legalization may not resolve a person’s initial repugnant feelings towards certain behaviors, even if the beliefs are founded on irrational sentiments. Still, repugnancy towards these behaviors and their imperfect means must not hinder the effort for a worthy end. Additionally, commodifying renal transplants will not inherently cut all the waiting time for recipients since it always takes “time to arrange a kidney” (Hidden Brain, “For Sale, By Owner”). However, commodification can make this time “substantially shorter than in countries that primarily depend on the deceased donation and on altruistic donation of kidneys by living donors” (Hidden Brain, “For Sale, By Owner”) as saw in Iran. It has the added benefit of bringing an illegal activity into the light, allowing for government regulations, and leading to a greater collective safety. There are ways to incentivize donors without dealing with direct monetary compensation. A couple practical options include (1) chain donations and (2) receiving priority on the recipient waitlist. The first choice allows a donor to increase a chosen recipient’s position on the waitlist with whom he/she does not match blood type if he/she agrees to match with another recipient still on the list. The second choice of ‘chain-donations’ allows multiple incompatible donor-recipient pairs to exchange kidneys between matching individuals in the group. However, both options are highly involved and unpredictable, in the end costing time which recipients might not have. In the time while we are waiting for innovations like Rice University’s 3D printed micro lungs - penny sized alveoli sacs grown in hydrogel using a patient’s own live cells (Deisler, Seeker) - to be feasible on a large scale, exploring options like legalizing compensation for renal donations is a fair effort in the incentivization for live-donations since current economy has failed to address the lethal deficit between supply and demand in the medical field of organ transplantation.
“Human Organ Transplantation.” Transplantation, World Health Organization, 11 Dec. 2013.
Marcus, Amy Dockser. “How to Provide Better Incentives to Organ Donors.” The Wall Street Journal, Dow Jones & Company, 25 June 2018.
Mezrich, Joshua D. When Death Becomes Life: Notes from a Transplant Surgeon. Harper, an Imprint of HarperCollins Publishers, 2019.
Deisler, Amanda. “This 3D Bioprinted Organ Just Took Its first ‘Breath.’” Elements S4 E46. YouTube. Uploaded by Seeker Media, 3 May 2019.
Vedantam, Shankar, et al. “For Sale, By Owner: The Psychology of Repugnant Transactions.” Hidden Brain, National Public Radio, 4 Mar. 2019.
Yanklowitz, Shmuly. “Give a Kidney, Get a Check.” The Atlantic, Atlantic Media Company, 27 Oct. 2015.