Living, despite having a failed essential organ was a dream till 1954. Joseph Murray successfully performed a kidney transplant in 1954 and made the dream of many come true. Since then, organ transplantation emerged as one of the strongest branch in medical history evolving with itself a number of ethical issues. One of the highlighting ethical issues is whether a donor should be allowed to sell his organ to the recipient for money or not? I will limit my discussion on the sale of kidneys. Firstly, it is one of the major areas where transplants are taking place successfully. Secondly, the process of removing one’s kidney is not life threatening. Thirdly, everyone is born with a spare kidney; hence removal of one kidney will not affect his or her daily routine at all, as mentioned by Gill and Sade (2002, p.4). I also want to limit my discussion to living donors because obtaining kidneys from cadavers involves the issue of correct criteria of death which is another long debate. The current situation is that there is a huge shortage of kidneys. In 2001, 14,000 kidneys were transplanted, which constitutes 60% of all transplants. At the same time, 50,000 persons were in waiting list for kidneys (Munson, 2007, p.214). The kidneys obtained from cadaver are so limited in amount that we need an alternative for them. This is due to the
fact that most of them are not in a transplant condition due to old age or any other disease like HIV etc. “Between 15,000 and 20,000 decedents annually meet the physical criteria for cadaveric donation, but only about 35% of the time do their families give permission for organs to be removed” (Jacoby, 2003). Now the fact is that we need living donors. Munson (2007, p.214) mentions, “The importance of living donors can be appreciated by the fact that if only one of every 3,000 people became a kidney donor, the kidney shortage would be solved”.
The main focus of all the countries is that kidney donation should be based on altruism. In most of the countries, the statute makes it illegal to pay any compensation to organ donors or their families. The scope of this essay is to find out whether selling a kidney is morally wrong or not. The first section of essay is devoted to this purpose. The second section discusses what are the main objections raised by various experts and justifications made against them. The third section suggests a solution for the problem that whether persons should be allowed to sell their kidneys or not. Finally, the fourth section will evaluate what will happen if we allow sale of kidneys in a developing society like Pakistan. II. 1. Kantian view: Theories of Ethics
Kantian theories are one of the major sources to find out basis for morality. According to Kant, the foundation for morality is reason and not the moral sentiments or desires for moral commitment and motivation. As Benn (1998, p.92) mentioned, “Kant argued that morality and rationality coincide. To be moral is to be rational, to be immoral is to be irrational”. Kantian principles are known as categorical imperative which can be formulated in several ways. The first formulation of Kant’s Categorical Imperative is ‘Formula of Universal Law’ which says that my act is morally wrong if its consequences are unacceptable to me in case others follow the same act (Benn, 1998, p.93). If I sell my kidney and others also sell theirs, I do not think that it will create any trouble for me. Hence, it is not immoral according to this law. Let us see whether second formulation of Categorical
Imperative justifies it or not. This law says we should treat humanity including one’s self as an end in itself and not merely as a means to an end (Benn, 1998, p. 95). Thus everyone has a dignity and we should respect him or her as a person.
This idea of dignity or respect seems quite controversial. Sex before marriage in many Asian cultures is considered as undignified 1 . It is equivalent to be a slave of evil desires. Similarly, veil (covering one’s body including hairs) in many Muslim countries is considered as a women’s dignity. It is a common belief that a woman shows her body parts to attract males towards herself. Hence she is undignified as she is using her body as a mean. Therefore, we can infer that the dignity is not dependent upon the physique of a person alone. So what makes us human? Humanity, that can differentiate us from other living beings, is our ability to think. Our rationality makes us superior to others. But selling a kidney does not affect our thought process. A person remains to be as rational as he or she was before selling a kidney, according to Gill and Sade (2002, p.11). One can also object that the money should not change hands in kidney transfer because it will make a person ‘commodity’. According to Fried and Cohen, this will give someone else a right to our body (as cited in Gill and Sade, 2003, p.13). For instance, a slaughtered sheep in butcher’s shop can be seen as a commodity where each body part is tagged with some specific price. Just pay the price and buy a liver, lung, kidney or flesh, whatever you want depending on your spending power. Gill and Sade (2002, p. 13) negate this idea by saying that rights concerning bodies are restricted to the sale of a whole body. The same can be said about surrogacy. If a woman consented to ‘rent’ her womb to carry someone else’s baby, this is considered legally and ethically right in many countries. Moreover, one could argue that a person has a complete right on one’s body and it should be his or her decision what to do with it. Hence, in my view, the concept of dignity is subjective and changes from culture to culture and person to person. It depends on a person what act he or she considered as dignified. Therefore, selling a kidney is not wrong according to Kant’s first and second formulation of categorical
In this concept, bodies are considered as sacred gift of God and we have to return it to God as pure as they were at birth. So persons can use their bodies according to limitations set by God and hence adultery or sex out of marriage is a person’s response to animal desire. It is such a sin that persons are eligible to stone to death.
Since the sale of kidneys does not appear to be immoral on the basis of Kantian deontological ethics, now let us turn to another widely accepted ethical theory namely, ‘Utilitarianism’. Utilitarianism is a consequentialist theory that focuses on the consequences of an act to judge it morally. An action is right if it creates a greater amount of happiness to greater number of people. The situation as illustrated by Jacoby (2003): Some 80,000 people are waiting for an organ transplant right now; another 3,000 patients are added to the waiting list each month. But in 2002, only 24,900 organs were available for transplantation, and more than 6,500 patients died while awaiting an organ that never came. According to Munson (2007, p.212), “The waiting list is growing at a rapid rate. A new name is added every eighteen minutes in 1998, every sixteen minutes in 1999, every fourteen minutes in 2001, and by 2005 it may be even ten minutes”. In such a critical situation, the consequences are quite clear. On one side there are lists of patients who will definitely die if they do not get organs for transplantation and on other hand, there are donors who can still enjoy their daily routine or rather can live a better life if they are compensated monetarily against their organs. A utilitarianist will definitely favor sale of organs as it will create greater happiness to the greater sum. Hence organ such as kidney’s sale is morally right from utilitarian perspective. Since theories of ethics clarify the matter as ethical, now discuss common
objections raised by various critics and find out whether they are justified or not. III. 1. Altruism: Objections
The concept of altruism demands that organ donation should be seen as a volunteer action with the intention of saving human life and not anything else. The organs should be treated as sacred gift to others. Altruism alone cannot raise the supply of kidneys as it lacks motivation for many (Wilkinson, 2003 pp. 112-3). A considerable amount can 6
motivate a person to provide his or her kidney because no one wants to suffer pain just to be a hero. Banning sale has not increased the amount of altruistic actions. But on the contrary, altruistic acts will not be reduced by allowing payment because they were earlier made with will (Gill and Sade, 2002, p. 21). In most of the cases which appear to be altruistic in nature, in reality, they are not. Altruism demands humanity without any intention of receiving rewards but this is not true always. A person might give kidney as a ‘gift’ to make other indebted by his or her act. Similarly a neglected person can give kidney in order to be an apple of one’s eye. Rather, the concept of altruism is beyond the thinking of majority of population in Pakistan (Moazam, 2006, pp.138&170). Most of the persons giving kidneys to their relatives or even strangers with a motive called sawaab (reward from God) or sadqa-eJaaria 2 (literally meaning charity forever or infinite charity). This motive can make altruism nullified. Hence depending alone on altruism is not a good idea but the main motive should be the rise in number of kidneys which is possible with payment against kidneys. 2. Exploitation and Coercion:
Exploitation means using a resource or a person for one’s advantage while an action is said to be coercive when the person unwillingly performs it under threat or pressure (Wilkinson, 2003, pp.9 &82). Both of them are important here because both exploitation and coercion make the most important principles of ethics ‘consent of a person’ or ‘autonomy’, doubtful. A hand full of money will attract the poor nations and the result would be that the poor are serving the rich. Most of the time a person sells his kidney in some desperate condition e.g. to earn money for survival of his or her
family. It is said that attractive 2
This concept says that if a person donates something important that provides benefits to others, each time any person gets benefit out of it, the donor will receive reward from God. e.g. planting a tree, donating an ambulance, donating a water pump to mosque, donating blood etc. It is like living a good life even after death.
monetary offers for an organ will invalidate the consent of a ‘desperate’ organ seller. But this claim is not valid when we compare it with the act of taking a life saving drug by a seriously ill patient who has ‘desperate’ desire to save his life. Desires like one’s own survival or the survival of one’s beloved ones are hence autonomous (Wilkinson, 2003, p.125). As Buttle (1991, p.98) has mentioned, in real life the poor do many tasks that the rich people would never do, just because of a lack of power, poverty or ignorance. Purchasers of organs from poor people should be condemned because rich people are using their greater power. Since under pressure of their poverty, and being powerless in such situation, donors are left with one kidney and a small amount of money. One thing is important to note here. For a decision to be coercive, there should be a coercer who uses his power to make a person sell his or her kidney, but in this case, it is poverty that is coercing. Since the recipient is not responsible for the donor’s poverty, there is no direct coercion. Similarly, poor people are exploited in black markets when middlemen take a big part of money by themselves and donors are left with little amount of money. Hence people are exploited in absence of regulated market and not because of their poverty (Wilkinson, 2003, pp.128-32). 3. Slippery Slopes:
It is often argued that allowing a kidney sale will eventually lead us to a situation where people are seen as persons who should be with one kidney. As mentioned by Gill and Sade (2002, p.21), “we will view them more as spare parts for sale and less as persons with dignity”. There are chances of kidney ‘theft’ when a kidney is commonly recognized as a property for sale.
It is common in developing countries that a person’s kidney is stolen on gun point (Wade, 2010) or if a person is admitted for appendix removal, his kidney is also stolen by so called ‘doctors’. Freshly buried dead bodies can also be stolen for their kidneys. There are also chances that poor will no longer left with any relative who can donate because everyone will think about selling instead of giving. One result
could also be that by allowing kidneys sale, we have to allow liver, pancreas and so on and finally that situation might lead us to legalization of prostitution. If we look at these slippery slopes, there is one thing common, i.e. the absence of proper market or presence of black market. If there are authorized institutions for buying and selling of organs then no one else would be able to do such crimes. An important thing is that all those slippery slopes mentioned were equally applicable in case of surrogate mothers but we can see that there are no such cases in countries where surrogating is legal. Moreover, these are too far and vague ideas which can not form the basis of law. IV. Solution
Erin and Harris(2003, p. 137) proposed a solution to this problem by suggesting that there should be a geographically limited market of organs where people are allowed to sell their organs to only one authoritative institute who will then distribute the organs according to the need of recipients. In this way, the exploitation of poor countries will be eliminated. Richards (2003, p.140) replied that this is not at all a solution. Same rules, if applied to international trade, would result drastic for poor nations. They need help instead of being banned from world market altogether. Moreover, medical or organ tourists are one of the major earning sources of many developing countries. Such market will destroy their economy as well. As we see, selling of kidney is morally permissible and all the objections raised against it are justified. Now let us see what will be the condition of a poor nation when such market will be available to the residents of that country. What cultural values will work and how the market will regulate itself. Being a Pakistani and having much knowledge about the
native culture and religious beliefs, I am hypothetically applying the idea of open market for selling of kidneys to specific institutions in Pakistan. V. Kidney Market in Pakistan
Let’s suppose kidney sale is legalized and there is an institution named “Kidney Transplantation Centre” which is authorized in selling and buying of kidneys. There are competent doctors, transplantation surgeons and medical staff. Donor and recipients are 9
informed about any procedure and risks involved in the transplantation procedure. The kidney will be bought for about $ 3000 and sold for same amount to the recipients. Hence there will be no profit in kidney exchange and the institute makes money only through its services provided for transplantation surgery or other related costs. So there are no chances of corruption. The system is fair enough and everyone has a chance to either buy ‘health or life’ or gain money. Now what will happen? The poor will find it as an opportunity to make money. Others, who have no genuine problem, will find it an interesting source of money. Since being a social animal, we mimic other’s behavior. If my neighbor is selling his kidney for money, why can not I? So everyone will rush towards selling his or her kidney. Generally, in Pakistani society females are not given the same importance as the males.
Most of the times, all the decision related to their lives are taken by the ‘head of the family’ i.e. males. Especially in rural areas where illiteracy is a major problem, women are considered as property of husbands. Hence, they will be the most vulnerable group to be presented as ‘volunteer’ to sell her kidney. Since many women are dependent on their husbands for economic reasons, they will ‘volunteer’ themselves for selling kidneys because they cannot let the bread winners i.e. males to go through the risks of being physically weak through surgery. People’s positive attitude towards an act sets a norm and then the action is judged as morally acceptable. For instance, we have a negative attitude towards selling of blood and hence anyone who sells his blood is considered unethical. Similarly, if we legalize kidney sale, people’s attitude towards it will be positive and those who are donating kidney for purely altruistic reason would feel themselves deprived of money and hence they will definitely prefer to sell the kidney because there is no harm and everyone has a right to sell. The situation will arise when everyone will be left with one kidney only. And if a poor with only one kidney left is diagnosed with kidney failure then? How can he buy a kidney? He has sold his wife and children’s kidneys. He is looking towards his relatives now. But the problem is that most of them have sold kidneys to earn money and those
who are left with two kidneys are thinking why? Why I give my kidney to someone as free if it is worthy of $ 3,000? So what is going wrong here? The involvement of money has deprived us of the feelings of love and sympathy. Is life worth without these emotions? There is another situation arising. Poverty has a vicious circle that never ends or at least cannot end with such a sale. Since I have sold my kidney, and no body blamed me for that as it was legal, why not to sell a lobe of my liver? It is as important as kidney and selling it should not be problematic. And then pancreas, lungs, parts of flesh etc. Then finally a person might feel, since I am unemployed and of no use to my family why not to sell my heart so that the money received will help my family 3 . Wait a minute, where this society is heading towards? The poor is offering his life for the rich? This is not the situation a utilitarian would agree with or even Kantian principles allow us. According to Kant, committing suicide is an immoral act as its results would be unacceptable for us if we universalize it. Similarly, this act is against my dignity and rationality. Moreover, exploitation at such a large scale is causing unhappiness in the world as compared to its benefits. This is clearly a morally wrong situation according to utilitarianism. Hence legalizing kidney’s sale is not in accordance with ethical theories when we see the results. We can see that in real world, there are morally acceptable acts but they cannot be legalized. Most of the laws are based on utilitarian principles and hence if the act is right still its consequences can stop us from legalizing it. We can take the example of smuggling. Trading gold between countries is not an immoral act but since its trading beyond certain amount will create bad consequences, it is illegal. Same is true in the case of dumping a product in foreign market. Thus, we conclude that sale of
kidneys for money should be strictly prohibited by using laws against it. A survey was carried by Rid, Bachmann, Wettstein and Biller-Andorno (2009, pp. 558564) on Swiss students and were asked whether they would sell their kidney to a regulated kidney market or not and 66% were of the view that they would only sell their 3
This often is reported as the main reason behind suicide bombers in Pakistan.
kidney to overcome a financial situation. This shows that even developed nations do not find it acceptable to sell their kidneys even if there is a regulated market for such purpose. On the other hand, in a survey on kidney sellers in India, it was shown that there was not any economic gain of selling a kidney by donors while they have to suffer various health problems after the surgery (Goyal, Mehta, Schneiderman and Sehgal, 2002, pp. 1589-93). Hence, the sale of kidney is just ‘a drop of water in a deep sea’ and there is no net gain. The poor will remain in the same conditions regardless kidney sale is legalized or not. What on the contrary can be done to save so many lives? We can promote virtues like altruism, love for humanity or heroic act of giving something a ‘gift of life’. The main idea behind is to just discourage the involvement of money. The concept of sawaab and sadqa-e-jaaria would be promoted with the help of religious scholars. Through sadqa-ejaaria of kidney, a person can continue to live in this world in pieces and earn good deeds even after death. In Pakistan, people have nominated certain religious scholars as ‘moral authority’ and refer to them when they have doubt about any action’s morality. Since donating an organ is not prohibited in Islam (Moazam, 2006, p.32), we can educate these religious scholars and prove them that donating a kidney is to save a human life which is equivalent to save whole humanity. The same argument can also help us in getting kidneys from cadavers by convincing their kin that this act is according to their religion. There is also a misconception among many people in Pakistan. It relates to physical health of a kidney donor. It is said that removing one kidney will make a person impotent or physically weak enough that he or she will not be able to do his routine work. Hence donors are considered as unfit or handicapped. They are also considered ‘unfit’ for marriage as they cannot work hard to earn good money for the family or to produce children. This misconception is related to both men and women (Moazam, 2006, pp.16367). There should be an educational program for such purpose. Doctors can help to guide people about the nature of surgery and its after effects. Hence, in this way we can raise the number of kidneys without exploiting developing countries and in accordance with ethical and legal systems.
This essay is a discussion on whether the sale of a kidney against some monetary value be allowed ethically or not. Since the kidney obtained from cadaver contains various other issues like the criteria of death, we limited our discussion to the sale of kidney from living donors only. The discussion starts with the question that every one is born with an extra kidney and if he or she gets an opportunity to sell it, whether his or her action is moral or not? First we have seen that according to Kantian first and second formulation of categorical imperative, the act of selling kidney is morally permissible. For a utilitarianist, its consequences make it ethical. The next section discussed various objectives including the concept of altruism, exploitation, coercion and slippery slopes. Through deep analysis of each of them in turn, we come to the conclusion that all these objections are weak and hence selling of kidneys should be legalized. People should be allowed to sell and buy kidneys from a single institution which is authorized by the state. Then we discussed a hypothetical case in which we examined a market in Pakistan where kidney selling is allowed. The results of the market turn out to be so drastic that we have to leave the idea of legalized kidney market. Hence we conclude that although sale of kidney is morally permissible act, but its consequences on a developing country will make it impossible to legalize it. We should now focus on alternative ways of
obtaining kidneys, like promotion of various cultural and religious believes as the waiting list for organ transplantation is increasing at a rapid rate.
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