Market of organs is unethical under any circumstances

EDITOR—Although we admire Harris and Erin's commitment to solve the dilemmas posed by a shortage of organs, we strongly disagree not only with their conclusions but also with their assumption—namely, that the selling and buying of human organs can be made ethical. 1

Harris and Erin harness their theory to the laudable commitment to raise donation rates but arrive at the definition of an ethical market by promoting a system that seems to depend only on a restricted group of citizens—those who find the monetary incentives proposed appealing.

Firstly, the integrity of the human body should never be subject to trade. Can we truly define this system as ethical because the selling and buying of organs is administered by the state?

Secondly, how can a system be called ethical when it implicitly penalises the weakest people and exacerbates discrimination based on census? Will a healthy well-off citizen ever decide to give away part of his or her body for monetary gain? Donation rates might be boosted, but, although both the rich and the poor will continue benefiting from transplantation indiscriminately, organ procurement will be increased only by contributions from poor people.

Any commitment towards raising donation rates can be better channelled by using targeted investments, as shown by our experience at the Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT), a transplant programme recently established in an area with a large shortage in cadaveric organs. Living donation was vigorously pursued from the start of the programme in July 1999. Of 120 transplants performed to date (livers and kidneys), 33% have been from living donors, all family related. At the same time, however, considerable energy has been invested in promoting cadaveric donation. Those efforts have been rewarded by a 314% increase in the donation rate (from 2.8 donors per million in 1999 to 8.9 in 2001).

Any financial incentive to organ procurement, even if government regulated, must be avoided as it dangerously undermines human dignity by obscuring the difference between being human and marketing. We recently expressed our concern about the American Medical Association's suggestion of exploring monetary incentives for organ donation,2 and we are frightened by the enthusiastic support for it by such notable experts as Harris and Erin.

Proposal is problematic

EDITOR—The American Medical Association may be eight years behind a proposal from Harris and Erin for an ethically defensible market in organs,1 but they in turn were three years behind my proposal that the NHS become the sole purchaser of live donated kidneys.2

One serious potential problem with such a proposal, referred to by me but not by them, is the impact it may have on the cadaveric donation of organs other than kidneys (which cannot be the subject of live donation). If the market in live kidneys leads to a collapse in organ donation, heart and liver transplantation could be seriously damaged. I know of no way of assessing how serious this danger is other than empirically.

The assertion in some rapid responses that a net flow of organs from the poor to the rich would result is not a good argument against a market.3^–5 Even though it is probably true, the consequence would be a net flow of cash from the richer (via taxation and the NHS budget) to the poorer, which is surely a good thing. How can reducing the options open to poor people be to their benefit? It is notable that those who argue that poor people should not be allowed to sell organs are in general not poor themselves.

Defending the indefensible?

EDITOR—We welcome the continuation of the debate on the ethics of buying and selling organs from living donors.1 Unfortunately the statement by Harris and Erin, with its strong advocacy of paid donation, misses some important issues.

They propose that the market would be made ethically defensible by being monopsonistic and having the NHS as sole purchaser, which avoids potential donor exploitation. The NHS is an unusual healthcare delivery system, being “free at the point of delivery.” This argument must not be allowed to slide into justification of such a market in a mixed healthcare system where people who can afford it take up private health care, as this continues the risk of exploitation of vulnerable donors.

Even if the monopsonistic broker is an NHS-like beast, no guarantee exists that it would not still prey on vulnerable people, but at a state rather than an individual level since poor people are the most likely volunteers to sell their organs. Furthermore, a system similar to that described may be controlled locally, but could lead to major problems if applied on a wider scale.2 Financial compensation for donors would probably differ between countries encouraging “transplant tourism.” At worst the poor of the developing world could become a vast organ reservoir for elderly people with degenerative disease in the developed world.3

The potential for harm to the donor must be acknowledged, and this highlights the moral difference between the sale of organs and voluntary donation. Multidisciplinary teams looking after a donor may be uncomfortable with participating in paid donation; bodily integrity is highly valued, and its violation is not well compensated for except by spiritual or philosophical gains.4 Recently published guidelines on living donor transplantation emphasise the paucity of information on long term consequences of living kidney donation and urge lifelong follow up for donors.5 Presumably the monopsony would also provide this aspect of care?

Fair distribution among recipients is an important principle of organ allocation. While nodding to this, Harris and Erin immediately break the principle of equity of access by suggesting a preference for living donors who subsequently require transplantation. This argument slips easily into preferential access for other groups—for example, age bias.

Transplantation in general and paid donation in particular are frequent subjects of philosophical and ethical debate. If society chooses the road to paid organ donation, the accompanying debate must be transparent and complete.