The debate around organ markets, their emergence, function, and adjustment to the world of other, legal markets, continues to flare up. Some of the researchers argue that legal organ markets should not be considered unethical because they often help both the seller and the purchaser save one’s life (while the seller sells their organ to acquire money due to their possible difficult financial situation, the purchaser acquires an organ that is vital to their ability to stay alive) (Greasley 1).
The core principle of the market economy, the principle of voluntary exchange, is severely undermined by organ markets because the seller’s assumed acting in self-interest cannot be proven. Due to the severe inequality that strives and leads to the emergence of organ markets, sellers do not act in self-interest but rather try to survive. The only choices for an organ seller are either to leave the financial issue unresolved due to the shortage of money or to sell an organ to avoid any major threat to their life. Therefore, one cannot speak of organ markets as ones based on the principle of the open market because of the conditions in which sellers and organ vendors have to live.
An establishment of a legalized organ market would only increase the exploitation of the poor, providing more advantages for the wealthy who would be able to profit from the different status of organ vendors (Caruso 303). If organ markets were driven by market forces, the distribution of the wealth and profit between purchasers and sellers would be skewed due to the unfavorable socioeconomic status of the latter. This paper aims to discuss how unethical actions regulate organ trade, why these markets cannot be motivated by incentives that markets produce, address advantages of legalized organ trade, and show why these advantages cannot outweigh its disadvantages.
Market Forces and Organ Shortage
Organ markets continue to exist due to the “market shortage” of transplants and global shadow zones, where various goods, including body parts, are components of the international market (Lundin 227). Where the legal area (a hospital that provides transplants or donor organs) is incapable of addressing the needs of patients, illegal markets take action, providing both parties with what they (presumably) need: the seller receives a paycheck, and the buyer an organ.
The problem of such an exchange is that it is not equal and is only possible when one of the parties (the seller) experiences financial difficulties in maintaining an appropriate quality of life or even surviving. Lundin provides an example with a vendor from Moldova who was transferred to a neighboring country, had his kidney removed, experienced severe physical pain and mental harm, and eventually received $3.000 and was returned to his place of employment (230). At the same time, the transplanted organ was sold to a foreign patient who paid approximately $125,000–$135,000 for the surgery. As can be seen, not only is the exchange unfavorable to both of the parties but the main profit from it goes to the third party that is not the part of the deal per se but rather its mediator.
Another problem arises with the definition of “voluntary exchange” that defines market transactions in an open market. There is evidence that some of the sellers who acquired information about surgeries from organ traffickers were often forced to participate in the operation due to traffickers’ threats (Lundin 230). One of the interviewees confessed that he could be shot if he refused to sell his kidney (Lundin 231). As can be seen, transactions in organ markets are rarely voluntary and usually profitable only to the mediator of the deal.
The current policies on organ donation cannot cover the supply and demand gap. Approximately 95.000 Americans were on the waiting list for kidney transplantation in 2014, and only 16.500 kidney transplant operations were performed (Becker and Elias 1).
Various strategies exist to address the supply and demand in organ transplantation: some of the countries use implicit consent (if a person did not refuse to donate their organs when they were alive, their organs could be transplanted after death), whereas others demand informed consent (a paper signed by the informed donor or their family). Another way to address the gap is to pay donors for their decision, thus relying not on the altruistic approach but a utilitarian one. It is suggested that the number of kidneys available for transplantation will increase if donors are guaranteed to receive remuneration or compensation for the surgery and missed workdays. the Australian government already provides partial compensation to organ donors by covering the costs of time lost due to the surgery.
Such an approach can sound convincing and addresses the unsolved problem of thousands of patients who die before receiving a transplanted organ. Nevertheless, some of the ethical and legal considerations remain neglected by supporters of the legal organ trade. Possible exploitation and involvement of people suffering from poverty need to be addressed to understand why legal organ markets would remain unethical.
Organs and Ethics
One of the effects that emerge when markets crowd out nonmarket norms is called “commercialization”. The commercialization effect happens when the value of objects changes depending on how they were provided, via either market or another way (e.g. charity, donation). According to Sandel, “the introduction of market incentives and mechanisms can change people’s attitudes and crowd out nonmarket values” (135).
If people are provided with money for their decision to donate an organ, the wish can cease to be voluntary and transform into an action stimulated by monetary reward. Such transformation is especially dangerous to vulnerable populations who will see organ donation as a means to receive money, thus increasing organ donations from people with a complicated socioeconomic background. A similar story occurred with blood donations in the UK and USA: while the citizens of the UK provided blood for transfusions voluntarily, commercial blood banks in the USA paid some of the donors for collecting their blood.
The second strategy was less efficient and resulted in higher costs, wasted blood, and a greater risk of acquiring blood contaminated with hepatitis (Sandel 135). As can be seen, the effect of commercialization backfired, and what once was considered a voluntary act of altruism transformed into a way of making money, thus attracting donors who potentially should not have been donating blood at all (those with hepatitis). Monetary reward, however, increased their interest and negatively influenced the effectiveness of donations.
Another evidence is provided by Caruso et al. who argue that merely making people think about money can increase their support for the free market economy and justify social inequality (301). In each of the experiments, participants who were exposed to money and compared to the control group provided more support for the free market economy when they filled out a questionnaire prepared by the researchers. The authors state that when people recall the concept of money, their view of existing social structures related to free-market changes, making them believe that these structures are fair and appropriate (Caruso et al. 306). It appears that a similar cognitive process might influence the support for legal organ markets, where transactions that involve organs are seen as fair just like any other operations of a free market.
It is more than likely that in a legal organ market the supply side would consist of poorer individuals willing to sell their organs and the demand side would constitute richer individuals who can afford to buy an organ (Greasley 2). It is true that the organ vendor is informed about the transactions they want to participate in and provides their consent; however, it is also evident that they would not provide any consent if the particular circumstances (poverty) were not pressing them to do it. Still, the difficulties related to the management of organ markets should not be seen as the only reasons to ban them from existence. Their inevitable reliance on the inequality of exchange participants is another issue because they will take advantage of those suffering from poverty or financial difficulties.
The problems of selling one’s body parts, poverty, consent, and choice are entwined. On the one hand, if a government fails to improve the individual’s financial well-being, it should not interfere with their attempts to improve their financial status. On the other hand, the person’s choice to sell an organ does not automatically resolve the problem of poverty that led them to this decision in the first place. It should also be noted that the money the person will acquire from the donation might not be sufficient enough for long-time improvements in their quality of life. This assumption was proven to be true: first, the majority of interviewees in one research confirmed they agreed to participate in kidney surgery due to debts they could not pay off (Greasley 3).
Second, after the surgery, the income of families declined, and some of the individuals were unable to pay off debts for six years after the procedure. Moreover, they also suffered from long-term pain at the surgery site and had to deal with back pain as well. As can be seen, selling one’s organ does not help the organ vendor improve their income or resolve financial difficulties.
Organ Trade and Physical Health Outcomes
Another aspect that should be considered when reviewing regulated organ markets from an economic perspective is health outcomes for organ vendors and their following ability (or inability) to work. Disabilities worldwide cause a significant effect on states’ budgets because they reduce employees’ ability to perform at work and result in additional hospital admissions and readmissions, sick leaves, or even the inability to work. This, if measured on a larger scale, can negatively influence the average income of families in an area where organ traffickers actively operate.
The post-transplant morbidity of organ vendors is not high; in fact, the risks are even lower or equal to those people whose occupation implies being involved in dangerous events, such as roofing, firefighting, etc. However, the outcomes of such surgeries are often more severe than supporters of organ markets expect. Studies show that the overall health status and renal function of kidney vendors worsens after the surgery, and vendors are at risk of acquiring long-term renal impairments (Koplin 9).
Chronic kidney disease and hypertension were common illnesses observed in Moldovan victims of organ trafficking. It should also be noted that postoperative outcomes were perceived as more negative by vendors rather than donors or individuals who had nephrectomy for any other reason. The majority of kidney vendors agreed that the surgery had a negative (or extremely negative) effect o their physical well-being, resulting in chronic pain, weakness, and inability to perform labor-intensive work (Koplin 10).
Furthermore, vendors from third-world countries experience more difficulties compared to those in the developed world due to their socioeconomic status. Since they might face insufficient nutrition, lack access to water, or rely on labor-intensive work to support themselves and their family, nephrectomy will have a much more negative impact on their ability to work, thus leading to even more complicated socioeconomic problems. Exposure to violence and infections with little medical help in third-world countries can result in larger fatal outcomes or reduce their life expectancy significantly.
Even if organ vending itself is legalized, it is incapable of resolving other issues such as poverty rates and rates of unemployment, low wages, and restricted access to health care institutions. In an open market, it is expected that both the buyer and the seller gain profit from trade via market incentives. However, organ vendors gain very little compared to buyers, and sometimes the profit (a sum of money) they gain does not cover the losses (health issues, inability to work) they endure. Therefore, a legalized organ market will remain unregulated and lead to unequal distribution of profits and losses among trade participants.
Legal Regulation of Organ Trade
To understand why legalized organ markets driven by market forces will not be able to function successfully and ethically, it is important to know what suggestions are being made about the regulation of organ trade. Different researchers suggest various approaches toward the legalization of organ markets.
Mattie points out that today the inequality between rich buyers and poor sellers exists because of the auction-like sales of organs in black markets; some of them cost up to million US dollars in internet auctions such as eBay (369). The author points out that current black markets exist exactly because of the low supply and high demand for organs (Mattie 369). Patients who have to endure painful and extremely costly procedures such as, for example, dialysis (approx, $80.000-100.000 annually), are willing to spend their money on an organ acquired from a black market rather than wait for a legal transplant for several more years (or until their death). A government-regulated system, however, would eliminate such auctions, possibly because the cost of an organ would be lower than in current black markets.
Cohen suggests that price controls and a restriction of the compensation’s form might be efficient in legalization too (80). Price controls would be performed by the government or other bodies and determine price floors and price ceilings. A nonmonetary compensation for organ donors would be provided in the form of gifts, paid scholarships, or housing allowances, thus encouraging donors to participate in surgeries and, at the same time, supporting their perception of a donation as an altruistic action.
Another approach to define paid organ donations is attempted by Mahoney, who argues that paid organ donations should not be necessarily called “sales” but rather “rewarded gifts” (31). This way, the language of the market is abandoned in favor of potential donors who would like to view the surgery as a part of a donating framework. Thus, in this case, it would not be the commercialization of organ donations but rather a rewarded decision to become an organ donor.
Advantages of Legalized Organ Trade
It would not be appropriate to discuss organ markets as ones that could be driven by market forces without providing and reviewing opinions of the opponents of the author’s point of view (i.e. supporters of the market legalization). The close examination of these points of view will help the reader understand why organ markets cannot function as legal markets do due to ethical reasons.
First, legal organ markets would be able to save thousands of lives by providing needed organs for patients on the waiting list. Compensating donors would attract “nonaltruists” who are more interested in the monetary reward, whereas altruists would receive an additional incentive in the form of money (Mahoney 33). Both sides of the trade (or exchange) would profit from the deal, and sellers would also be able to receive medical care and attend follow-ups.
Second, it is possible to establish a list of individuals who will be allowed to buy and sell organs. The state or another body responsible for legal organ trade could prequalify prospective donors by requiring them to participate in different screening tests, which will target their physical and mental health. Moreover, to ensure that individuals living in poverty will not sell their organs due to difficult financial situations, hospitals and transplant facilities can ask donors to provide proof that their average income is higher than a certain threshold (Cohen 82).
Third, it may also seem reasonable to restrict certain kinds of organs from being sold and examine for what purposes these organs are used after the purchase. This way, those in need of an organ will be allowed to purchase (legally) an organ from an institution or another body that legally sells and buys organs (for example, the state, as it does in Iran). At the same time, some of the organs or other biological objects (e.g. fetuses) will not be allowed to sell or will only be sold for research purposes (Cohen 83). If this approach is used, organ supply will increase, but the regulation of organ markets will also be possible.
Another option that is rarely discussed in debates about organ markets is the legalization of organ markets that use cadaveric organs only (organs taken from a deceased individual). For now, hospitals are only allowed to use cadaveric organs in some of the countries if the patient has not objected to it and/or signed a paper where they give informed consent to it. This practice is complicated by the involvement of an individual’s family that might object to cadaveric donations. Family members refuse to “sell” body parts of their loved ones, and rewarded donations do not work in this case. However, if cadaveric rewarded donations are legalized, and all patients with terminal illnesses capable of communicating are asked to provide their consent, it is more likely that the organ market will acquire more organs than it has right now.
Counter-Objections to Advantages of Legalized Organ Trade
All of the opinions displayed above are solid and reasonable examples of how organ trade can be useful and even life-saving in modern society. Nevertheless, these views do not take into consideration significant facts that make legalized organ trade an unethical and even dangerous market. First, it is more than likely that altruistic donors will not be motivated by rewards since they will perceive organ donation as a sale.
At the same time, those interested in rewards might follow the scenario with blood banks that was described earlier; some individuals might provide false data about their health status and any chronic illnesses to participate in organ trade, which can pose a risk to purchaser’s and seller’s lives. Describing donations as “gifts” would be deceptive, which might repel some of the potential donors.
Restricting certain individuals from buying and selling organs might be appropriate, but the state will need to provide detailed instructions to explain why some of the individuals are not allowed to do so. This limit can also be harmful to persons with a difficult economic background. For example, if their friend or distant relative with the same financial status (below the established threshold) agrees to sell their organ to the individual, the friend may be prohibited from it because he or she does not fit specific criteria. Would it be reasonable to wait for another seller with a better socioeconomic status in this case? If not, would it be possible to break the rule? In any case, it appears that some of the individuals will be at higher risk of not receiving an organ than others.
As to organ restriction, it is hard to estimate what organs would not be allowed for sale and how it would affect other individuals on the waiting list. What criteria would define which organs are prohibited from being purchased? How will the state guarantee that patients in need of those organs restricted from trade will still receive them? It is possible to assume that such organs as kidneys, pancreas, lungs, liver, and others will be sold because live donors of these organs can continue living without severe complications (for some organs, only a part of them can be donated). If a heart is prohibited from being sold, does this mean that individuals in need of heart transplantation will have to turn to medical tourism to acquire the organ? It is possible to provide cadaveric heart transplantation, which will also need additional regulations.
Another point often neglected by researchers who examine the problem of organ markets is the seeming inability to make them function in the same conditions as legal markets do. As Columb points out, the discourse around organ trafficking has “been diffused into a moralistic debate over organ sales collapsing a complex humanitarian issue into a narrow bioethical calculus” (5). Organ markets cannot function as other legal markets do because they emerge as an answer to complex societal issues driven by inequality, exploitation, and extreme poverty rates. A similar market (sexual trafficking) also emerges from the mentioned problems, and the attempts to legalize it sometimes lead to even greater rates of human trafficking and pose more risks to sex workers who are unable to work legally and have to obtain clients via black market (Cho et al. 78).
Therefore, this market cannot be motivated by the incentives that markets produce due to complex trades based mostly on unethical practices that cannot be regulated by standard rules applied in marketing and business.
As can be seen, organ trade emerges from a variety of societal issues that have to be addressed first to understand why organ trade is an example of unethical economics. The unequal distribution of income, discrimination, inequality, and poverty all contribute to the flourishing of illegal organ trade, making sellers and purchasers unequal. The relationships between wealthy buyers and poor sellers lead to unfavorable conditions for the latter who have to suffer from physical and mental harm.
Illegal surgeries have a greater negative impact on them because organ vendors are not taken care of: they do not receive painkillers after the procedure, are not advised by a professional doctor, and cannot visit follow-ups (Rippon 148). Donors and organ vendors cannot be compared due to the conditions they live in: donors from first-world countries are more likely to receive sufficient nutrition, health care, and consultations from a medical professional, whereas organ vendors often depend on labor-intensive work to support themselves and have to endure a decline in income after the surgery is conducted.
Organ trade cannot be seen as a procedure standard for open markets because the principle of voluntary exchange does not apply to it; organ vendors often sell their body parts due to economic pressure, and the profit gained from the deal is not only short-term but also leads to other losses related to health and occupation. The legalization of organ trade cannot address the problem of illegal organ trafficking because it can only be eliminated when examined on a larger scale and with a focus on humanitarian issues that initially created this type of market.
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