Paying for kidneys by mattsteinglass
July 24, 2009, 9:48 pm
Filed under: Health

Megan McArdle thinks the legal prohibition against paying for kidneys is indefensible, and challenges anyone to provide a defense of it which does not involve the following:

  1. Huffy declarations that anyone who disagrees with you must be amoral
  2. Appeals to the fact that many other people are also against organ donation
  3. Invoking the infamous “ick” factor involved in selling a body part

I am determined to exercise one of our most important rights on this issue: the right not to have an opinion. But this pretty standard argument from a 2002 article in the New England Journal of Medicine opposing payment for organ donation doesn’t seem to me to involve any of the above shibboleths:

The fundamental truths of our society, of life and liberty, are values that should not have a monetary price. These values are degraded when a poor person feels compelled to risk death for the sole purpose of obtaining monetary payment for a body part.

I don’t consider this to be an overwhelmingly convincing argument in the case of kidney donations, particularly because they don’t involve much risk of death, as Megan points out. Kidney donations are a unique case among organ donations in that they don’t entail much impairment of the donor’s health. Meanwhile, there are a huge and growing number of people with chronic kidney disease, and it seems implausible that the pool of voluntary donors could ever be made large enough through non-financial incentives. There are estimates that thousands of people die every year due to shortage of kidney donors, and this paper argues that kidney transplants save society at least $90,000 per patient over dialysis, not counting the increased quality-adjusted life years for the patient.

But to see why the moral case against paid organ donations isn’t as content-free as Megan paints it, consider this argument for a market system for kidney donations, from Drs. EA and AL Friedman in the journal “Kidney International”:

The case for legalizing kidney purchase hinges on the key premise that individuals are entitled to control of their body parts even to the point of inducing risk of life.

This premise seems to me to be utterly wrong. A society in which rich smokers went around buying poor people’s lungs would be contemptible. When you get to the point where market forces allow some people to take physical possession of vital, irreplaceable parts of other people’s bodies, you are entering the territory of slavery. It’s a territory in which some of the inalienable rights that underpin a liberal democratic society — and the inalienability of one’s possession of one’s own body, as in habeas corpus, is fundamental to all other rights — can disintegrate in the face of inequalities of wealth. That’s the moral basis of the anxiety over paying for organ donations in general, and it is warranted.

In fact, the case for legalizing kidney purchase hinges precisely on the fact that it is not like other organ donations: having just one kidney does not seem awfully risky to the donor’s life. (Further, one can mitigate the risk by placing the few kidney donors who subsequently develop renal disease at the top of the list for transplants, a measure that has been advocated as a non-market way to encourage donations.) As the harm to the donor goes down, tissue donations become more similar to donating blood. Donating blood has long been (slightly) financially compensated without fear of a “slippery slope” to a paid market for, say, eyes. But that’s not to say we should allow people to sell their eyes. It’s to say that perhaps donating blood and donating kidneys are special cases, and should be treated individually rather than as part of a blanket policy towards donating “organs” or “tissue”.


23 Comments so far
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Lets call the “but what a horrible world it would be if rich people bought all of poor people’s organs” the Horrible World argument. The problem with this argument is that it assumes that poor people will sell their organs for trivial compensation, and this seems pretty implausible. People will demand relatively high prices for their organs because nobody wants to give their organs away. When they do sell them, they will do so because the money can be used to make their lives substantially better. The emotional way to make this argument is to say “Are you really against the world where a poor older brother in Mexico sells his kidney so that he and two brothers can buy a fishing boat to start a business?”.

Comment by jsalvati

1. As I’ve said, the issue is different for kidneys than for other organs. It is somewhat demeaning but not horrible for people to sell their hair, blood, sperm/eggs, and arguably bone marrow or skin grafts. The problem arises with irreplaceable organs whose loss entails diminished body function. Kidneys stand at the edge of the line; the argument is over which side they fall on.
2. I don’t assume the compensation will be trivial. Slaves were and are quite expensive and valuable. But the fact that girls in the third world are essentially sold into slavery, very often with their own consent, in order to pay off family debts, buy a fishing boat, or otherwise promote their family’s welfare is not an acceptable moral state of affairs. Selling a body part is like slavery in that it entails an irreversible reduction of one’s personal integrity for money. What is wrong with buying someone’s vote? What is wrong with buying someone’s labor and reproductive choices (who they will be allowed to have children with) in perpetuity? What is wrong with paying someone to cut off their own hand on television in order to attract advertisers? What is wrong with paying someone to do a job that results in their certain death? Here’s what’s wrong with it: other people are not meat. It is arguably okay to buy someone’s kidney because such a sale leaves them essentially whole and sound. It is not okay to buy a living person’s lung or eye or hand.

Comment by mattsteinglass

I agree with you – Humans are not meat – other humans should not have the right to make laws to tell them what to do with their bodies. That’s abhorrent and demeaning, no matter how noble the sentiment.

Comment by jb

jb, why is it illegal to sell oneself into slavery? It’s a market transaction like any other. If someone wants to buy a slave and the potential slave needs the money for his brother to buy a fishing boat, what’s the problem?

Comment by Matt Steinglass

Since you can’t actually surrender your free will, you can’t legitimately sell it. Attempting to sell oneself into slavery would be fraud. Secondly, people of sound mind do not sell themselves into slavery, so it would be an invalid contract. Thirdly, people who do express an interest in selling themselves into slavery are almost certainly being coerced, and a contract signed under duress is not valid. Fourthly, humans are more than the sum of their parts – someone who has lost an eye in an accident is no less human than someone with two eyes. Even if they sold the eye, they’re still fully human.
Fifthly, if I were to donate an eye, I would get something significant in return – a deep sense of smug self-satisfaction at how much better I am than everyone else. Just because it can’t be taxed doesn’t mean it isn’t a very valuable return-on-investment.
Sixthly, there are all sorts of laws out there of the form “humans have the right to do what they want, except when those actions have significant cost to others” – thus smoking bans, helmet laws, drug laws, etc. I understand the logic of these laws, even though I generally think they’re far too severe and patronizing. But in any case, selling parts of your own body doesn’t cause cancer in others, it doesn’t present a significant risk of brain damage, doesn’t emit carbon, doesn’t increase traffic accidents, doesn’t cause stampedes out of theaters. It has no bad side effects, other than your squeamishness. But the idea of two men having sex makes me a little squeamish, but that doesn’t mean they shouldn’t be allowed to do it.

A rational society should allow human action by default, and only restrict things when there’s a clear negative externality. If you can demonstrate that there’s a significant social economic cost associated with organ sales, I’m willing to listen. But using words like ‘demeaning’ just says to me that you mean well, but don’t have a logical argument to back it up.

Comment by jb

You write that “people of sound mind do not attempt to sell themselves into slavery”. This is not true. All over the third world, there are people who have knowingly entered into slavery. They sign contracts that result in them spending the rest of their lives (or, sometimes, a shorter fixed term) working, often under horrible conditions, for an employer who controls every aspect of their life, with no option to leave. The “duress” that causes them to do so is economic duress, to themselves or their families. Millions of debt peons in India, sex slaves in Cambodia, and foreign construction workers in the Persian Gulf have sold themselves into slavery. But, one objects, it’s not quite slavery; the Persian Gulf workers and sex slaves will eventually serve out their contracts (maybe; in fact many end up too deep in debt to ever leave) or be let go when they’re too old, while the debt peons can in the last extremity run away to become beggars, and no one can forcibly bring them back. Well, maybe. When they sell their bodies, they may possibly be able to get them back if they change their minds. In contrast, if you sell your eye and then change your mind, you can’t. You sell a part of yourself forever. I think this is wrong. I think you own your eye in the way you own your brain, your heart, your religious faith, and your vote: if you were to sell it, you should always be able to demand it back if you change your mind. It is “inalienable” from you. And that makes the sale meaningless.

A more general point is that under conditions of great inequality, monetary duress is just as powerful as physical duress. The best example of a contemporary society where market incentives lead people to mutilate their bodies is India. In “Slumdog Millionaire”, the scene in which the beggar gang leader deliberately blinds the children is portrayed as non-consensual, but the horrible truth is that, as with sex slaves, the mutilation is often consensual and results from the duress of poverty. As a result of these kinds of responses to vast inequality of wealth, in India, people’s station in life is literally marked upon their body. In such a society the idea that everyone is equal can only be a hollow joke.

I’ll try one more way of explaining why people’s possession of vital parts of their body should be considered “inalienable”, i.e. not for sale, like their possession of their mind or their vote. We can generally justify unequal distributions of wealth on the basis that they are Pareto-optimal: they maximize the monetary value of the different items to those who hold them. But of course we also recognize that monetary value is not the same as use-value. Just because a billionaire will pay more for a ’66 Les Paul than I would doesn’t mean he’ll get more enjoyment out of it than I would. In general, we don’t scrap the market system for some kind of use-value-maximization-by-decree system, because those kinds of systems generally suck for multifarious reasons. Usually, nobody can do a better job of determining what an item is worth to someone than they can, by spending money for it. But in the case of items that are an irreplaceable part of your body, like your eyes, this is not actually the case. Bill Gates may be willing to spend $20 billion to save his eyes, and I may only be willing to spend $100,000, but I guarantee you that I want my eyes just as badly as Bill Gates does his. And we can generalize this to be true of basically everybody in the world. For this reason, submitting body parts to valuation by the market is guaranteed to generate a completely distorted calculation of how much these parts are really valued by real-world people, in the context of a highly inegalitarian distribution of wealth, otherwise known as life on Planet Earth.

Comment by mattsteinglass

your points about the third world are well taken – I was specifically thinking of markets in the US and other rich countries where “being poor” is difficult, not a tragedy.

Your last point about the economics doesn’t work for me. You say “submitting body parts to valuation by the market is guaranteed to generate a completely distorted calculation…” But I don’t see why that is the case. You only have so much time in this world, but people seem to be able to set fair prices for trading that. They seem to be able to set fair prices for sperm and eggs. Those are comparatively renewable resources vs. eyes, of course, but then there’s surrogate parenting, which seems to have a reasonably solid dynamic. The point here is that I don’t find your claim that markets are guaranteed to be flawed to be persuasive without more explanation.

Another thought – a market in eye donations would set a rough price for the value of a healthy eye, even if it was deeply flawed, there would still be a number. This could spur all sorts of innovations in artificial eyes, eye regrowth, etc. That doesn’t really exist right now, partially, at least, because there simply is no way to evaluate how much people are willing to pay. Surely you have to agree that if selling eyes results in a thriving market in artificial eyes, everyone is better off?

Comment by jb

It’s true that in the US we don’t have the kinds of extreme inequality that lead people to voluntarily mutilate themselves or sell themselves into slavery in the third world. (Mostly. The situation with undocumented migrant agricultural laborers in the US sometimes gets pretty close.) And one can argue that since kidney sales will take place illegally in the third world anyway, we’re better off legalizing them in the US so they’ll be safer, and removing some of the market for the dangerous third-world kidney sales. But mostly I think our discussion here is a little off-point in terms of the kidney transplant issue. The thing about kidneys is that there really is a large market for them because failure is relatively common and transplants are relatively straightforward, and giving up a kidney doesn’t harm the donor’s health much. That’s what makes the whole issue a borderline situation. The discussion I started about eyes is kind of far-fetched, but I brought it up because I wanted an example of something that would really mark you if you were to sell it, and that you’d really miss. But I think there’s a more general point here about our difference in political philosophies, which is that I think there are a fair number of things that should not be sold and should not have a market value, not because selling them is impossible but because selling them undermines some of the principles on which society is based. I don’t think that to say you own something should always be the same as saying you can sell it however you like. I think you’d agree with this when negative externalities can be shown, but I think I see a lot more of these cases than you generally do.

Comment by mattsteinglass

I am 22 years old, male, married, Indonesia, healthy, want to donate the one of my kidney. My blood group is O+, I’m not drink, not use drugs, and never have any kidney deseases. I want to donate my kidney for the exchange just for US$25,000.00 for my kidney, because I have a financial problem and I must gift lived for my wife and my daughter for they further. If you want to get your life back, so do I. I just want to fix my life further with my family. I hope u can help me. I am serious and if you don’t trust me, you can come to my country or pick up me for the transplant in other country. If you interest, please feel free to contact me at my private e-mail : or contact me on +62 838 5838 199
Thank you…

nb: you pay the expence of the HLA test (Pre-transplant test), because now I’ve nothing for pay that.

Comment by ageng ehrnowo

i want to donate my kidney in just$100000

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