No such thing as ethical organ

market
BY: Alastair V. Campbell

IN THE current controversy over whether an organ market should be

legislated, opponents of the ban have argued that an enlightened and
rational perspective would remove most, if not all, of the ethical objections.

Current international opinion, however, is unwavering in its objection to all

forms of commercialisation of the procurement process. The World Health
Organisation and the World Medical Association strongly oppose payment
for organ donation.

In a recent international summit in Istanbul on Transplant Tourism and

Organ Trafficking convened by the Transplantation Society and
InternationalSociety of Nephrology, it was reaffirmed that the ethical basis
of transplant policies and programmes should remain equitable in
allocation. Their primary objective should be to promote the optimal health
and well-being of donors and recipients.

These principles preclude financial considerations or material gain. The ban

on organ trading is not irrational, a mere emotional response or a
prejudice, but is based on good reasons.

• Organ trading is wrong in principle because it presupposes that the

body is a piece of property
akin to our material possessions (house, car, etc). While a body part
like a kidney is alienable, meaning it can be transferred to another,
it is certainly not fungible (easily replaced by something similar) or
commensurable (its value quantified and compared to another
object).

The gift of an organ is different from selling it, since the organ is
gifted out of the wish to benefit another person, not for financial
gain.

• Organ trading has negative social effects in that it undercuts the gift
relationship between
donors and recipients. Gift ethic or altruism - with its effect on social
solidarity - is the rationale for many current procurement systems
for cadaveric organs.

If a live organ market is instituted, many people may opt out from
altruistic giving - thus reducing the supply of transplantable organs.
A recent study in Austria has shown that financial incentives would
 have this effect.
Demand may also be made for certain forms of payment for
cadaveric organs.

• There is a strong reason for a universal ban on organ trading by all

countries (except Iran). Once this barrier is breached, it is hard to
justify why the law should not allow the live body trade to be
extended to other "expendable" parts like hands and single eye
corneas.

Furthermore, once the ban is lifted, the current organ traffickers will have
the justification they need. It can be argued that a regulated market will
eliminate or reduce the black market.

But so long as the national system still operates on principles of utility and
equity with regard to allocation of organs - if not, perceptions of social
injustice will arise - there will be perceptions of inefficiency for those on the
waiting list.

So in reality, the black market will continue albeit in different forms such
as offering direct higher cash payment to the vendors.

A recent review of the Iranian system in the British Medical Journal clearly
shows that the legislation of an organ market in Iran has not corrected the
problem of the black market and the exploitation of the poor as suppliers.
The article also points out that the waiting list for kidneys in Iran has not
been eliminated.

• The notion of an "ethical and regulated market" is misleading:

One, it is inevitably exploitative, with the poor being the majority, if

not all, of the vendors. Many current poor vendors have expressed
"donor regret". The selling of an organ did not help them out of
poverty and in fact had significant negative impact on their health
and employment.

Two, a market based on property and ownership would suggest that

vendors can designate the recipients of their organs. This is contrary
to the ethical principle of allocation based on need.

And three, organ shortage is a global phenomenon and an "ethical

market" will presuppose a level playing field among countries and
require international harmonisation of regulations.

• The nation's reputation as a medical hub can be eroded significantly

if it is seen as exploitative, particularly in the current global context
where human rights doctrine prohibits exploitative practices. It can
 be argued that fair compensation, health insurance and appropriate
follow- up care, etc, can be made to potential vendors.

This however would result in significant increased costs for the

national healthcare system, resulting in either less transplantation
being done or fewer resources dedicated to other health-care needs.

• It has been argued that the supply of organs will increase with an
organ market, resulting in more lives saved. This is debatable, given
that an organ trade may reduce altruistic donation (of both live and
cadaveric organs) and will attract predominantly the poor who may
provide marginal organs for transplantation.

It has been further argued that people should be allowed to sell their
organs so long as the benefit-risk ratio is favourable. One should however
look at both the short-term and long-term benefit-risk ratio.

In the short term, vendors may not have access to or be able to afford
appropriate care. In the long term, given the increasing incidence of longer
life expectancy and end-stage organ failure, the vendors themselves may
be in need o transplantation.

The Declaration that was issued from the Istanbul summit emphasised the
need for practices that support organ donation from dead donors.

It also called on all countries to address their responsibilities with respect

to exploitative practices and to develop self-sufficiency in organ donation.

The current organ shortage requires the international community to

cooperate in finding solutions and ending unethical practices.

The writer is the Chen Su Lan Centennial Professor of Medical

Ethics and director of the Centre for Biomedical Ethics, Yong Loo
Lin School of Medicine, NUS.

This article was first published in The Straits Times on July 10, 2008.