The current debate about organ donation and the associated advocacy for selling kidneys, while laudable for its concern about increasing the ability to save the lives of some people with chronic renal failure, is characterised by four features that locate the reasoning process within a narrow and inadequate framework. Firstly, the focus on saving lives is myopic, with the lives of the most privileged in the world receiving most attention. Secondly, the debate is firmly set within a value system in which market values dominate. Thirdly, health is considered from a highly individualistic perspective with little understanding of the importance of social solidarity in health. Finally, a constricted moral vocabulary is used to discuss the ethics of organ sales.

MYOPIC CONCERN FOR SAVING LIVES

Many articles making pleas for more organs begin by describing the number of people waiting for donated organs, the number of donors who could give organs but are not doing so, and how many lives could be saved if more organs could be made available. Great concern is expressed about a few thousand unnecessary deaths in North America or Europe and the need to avoid these.^1–4 While attention to potentially preventable deaths through organ transplantation is praiseworthy, it is striking and of concern that there is no mention in all these debates in most bioethics journals of the many millions of people dying prematurely every day because of lack of food or access to even the most basic health care. One statistic is illustrative: 34 000 children under the age of five years die every day from hunger and preventable diseases (12.4 million such deaths annually). There is also no mention of why so many preventable deaths occur, or even why these deaths are largely ignored in the bioethics literature. It may not be clear that physicians and bioethicists could have any influence in preventing these premature deaths, but we should not lose sight of the fact that the moral imperative to save lives cannot exclude those who are less visible, and that the role of medicine and public health in saving lives has to be more expansive.

DOMINANCE OF ECONOMIC/MARKET RATIONALITY

The language in which discussions about organ donation takes place is the language of the market.^2–5 It has become almost uncontested that market forces and money are the dominant forces governing health service provision. In this context little attention is paid to the possibility that seeking market solutions to organ donation will further marginalise the poor (among whom chronic renal failure is the most prevalent) who cannot afford to buy a kidney. Little is written and spoken about the virtues of being a good citizen or a good doctor who cares for others, and it seems to have been forgotten that there is more to excellent medical care and to the good life than can be described in economic terms. Friedson’s work on the forces that shape society illustrates how the dominance of market and bureaucratic “logics” eclipse the “logic” of professionalism, and overshadow the forces promoting virtue and trust.⁶

AN INDIVIDUALISTIC ORIENTATION TO HEALTH

Within a moral culture that reifies individualism, personal appeals or other approaches to encouraging donation have failed, and it seems will continue to fail. Amitai Etzioni has commendably argued for promotion of a communitarian approach that could shift the moral culture towards encouraging citizens within a nation to feel that it is their social responsibility to become organ donors.¹ While Jeff Kahn’s sceptical response that community spirit cannot be enhanced in a nation of individualists⁷ may be correct in the short term, this does not negate the desirability and possibility of promoting a more generous moral culture, as suggested by Etzioni, and seems to be achievable in some centres.⁸

LIMITED MORAL ARGUMENTS

When arguing about the ethics of organ donation it seems that only the moral theories of right and wrong action (deontology) or of balancing outcomes (utility) are debated. For example Radcliffe-Richards, who has mounted the strongest arguments against those who oppose organ sales,⁹ posits that antagonists of organ sales either object to organ sales on principle (without adequate reasoning) or believe that the harms outweigh the benefits.¹⁰ Neither she, nor many others, make reference to: (1) non-maleficence (there is accumulating evidence that removal of a kidney from a healthy person does harm¹¹); (2) considerations arising from virtue theory that would cast a different moral light on the debate; (3) the idea of the duty to care for all patients, especially the vulnerable, or (4) the fiduciary nature of the doctor-patient relationship.

CONCLUSIONS

These shortcomings all reflect the blinkered mindset from which the debate about organ sales emerges and is propagated. Excessive focus on the health of individuals, especially those who are the most privileged, with little concern for the lives of millions of others (individually and collectively), must surely now be contested. The widening disparities in health that progressively threaten all lives everywhere, as illustrated by the HIV/AIDS pandemic, call for a more comprehensive approach to global health challenges such as HIV/AIDS and malaria. Given the implications of such epidemics, and of future epidemics like SARS that in all probability lie ahead, such an approach is in the long term rational self interest of all.¹² Bioethicists should surely be able to view the ethics of medical practice and of population health from a less individualistic and parochial perspective than that of physicians, health insurance profiteers, and multinational pharmaceutical companies, and should be working tirelessly to promote global solidarity.¹³