The shortage of organs for transplantation is so acute that a growing number of economists and bioethicists are advocating the sale and purchase of organs, in particular, kidneys. It is not surprising that some economists adopt this position. Members of the Chicago School of Economics believe the marketplace can fix many types of social problems; if you would allow people to sell their kidneys and reap the financial rewards, they will do so eagerly and in large numbers, thereby meeting the needs of would-be recipients, who would be happy to pay for them.
What is more unexpected is to see a number of bioethicists lining up with economists. These bioethicists are so opposed to paternalism that they would not allow the state to intervene in order to override the wishes of sellers, protecting them from themselves. Both camps buttress their positions with a claim that those who are free to sell their kidneys will benefit greatly, using the proceeds to climb out of poverty.
But to look at their arguments closely is to see how wrong and how fanciful they are. In the first instance, there is no agreement on just what a market in organs would look like. Some proponents want to pay families for selling the kidney of a deceased relative. Others want to encourage kidney sale from living persons. Some want to see an open exchange of organs so that the market will balance supply and demand and in this way set the right price. Others prefer a regulated market, with an official body setting the price. Many of these discussions focus their attention on organ sale in developed countries, where there are regulatory mechanisms and social welfare in place. But the principles are often extended to developing countries to justify sales in such places as India, China, and the Philippines.
Second, proponents of sale have very little to say about the values that our Western culture now carries about the integrity of the body. It is unthinkable to chop off the hands of a robber or to whip a felon, both of which were once commonplace. They also ignore the desperation that must be involved in selling a kidney. To claim that since we already allow commerce in sperm, eggs, blood, and hair we should allow commerce in kidneys is spurious. It is by no means apparent that the principles (or lack of principles) involved in approaching college girls, subjecting them to the process of superovulation, and giving them $5,000 should be defended, let alone generalized.
Third, as we have recently learned, selling a kidney does not improve the social and economic circumstances of the seller. A team of investigators (as reported in the Oct. 2, 2002, issue of the Journal of the American Medical Association) interviewed some 305 sellers of kidneys in one Indian city six years after the transaction and learned that most of them had done so to escape debt but were now right back in debt.
A Berkeley anthropologist also did field work, which was reported in Daedalus in 1999, with 30 families in an Indian slum and found the same dynamic at work: Sellers trying to escape debt but in a short time, returning to debt, with one kidney less. He additionally found that sale begets sale. No sooner does a slum become known as a source for kidneys than debt collectors call in loans and put pressure on its residents to sell. So too, families with a relative who needs a kidney come to the slum to purchase an organ, thinking it a less risky alternative than having the family member donate it.
I wrote a commentary for JAMA about the Indian studies and concluded my thoughts there as I will conclude them here: Kidney sale is a zero-sum game in which recipients win and sellers lose. As Amartya Sen, the Nobel Prize winner in economics in 1998, contends, economic development will not go forward through a widespread sale of kidneys. Commerce in organs is a dead-end proposition.
Dr. David J. Rothman is the Bernard Schoenberg Professor of Social Medicine and director of the Center for the Study of Society and Medicine.