North American Philosophical Publications

Is a Market in Human Organs Necessarily Exploitative Author(s): Mark J. Cherry Reviewed work(s): Source: Public Affairs Quarterly, Vol. 14, No. 4 (Oct., 2000), pp. 337-360 Published by: University of Illinois Press on behalf of North American Philosophical Publications Stable URL: http://www.jstor.org/stable/40441269 . Accessed: 05/06/2012 19:13
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Public Affairs Quarterly 2000 Volume14,Number October 4,

IS A MARKET IN HUMAN ORGANS NECESSARILY EXPLOITATIVE?

Mark J. Cherry

a in of market humanorgansfor possibility creating for-profit in manyfeelings deep moralrepugnance. of ignites transplantation Proposalsto brokerorganshave been denouncedby the UnitedStates the the Society, Congress, NationalKidneyFoundation, Transplantation and the American Society of Transplant Surgeons. Professional who were involvedin have resolved to expel members organizations suchdealings(Fox and Swazey 1992,p. 65). As theU.S. Task Force on the summarized objection:"We findthispractice OrganTransplantation and and to be unethical to raise seriousquestionsabouttheexploitation for thepoor"(1986, p. 98). The potential coercionof people,especially in commerce human to whichis perceived underlie organs, exploitation, of the is heldto trump possibility increasing transplants. life-sustaining because they Certainuses of humantissue are morallyimpermissible as as as them things, less thanhuman, human beingsby treating "injure Financial incentivesare objects for use" (Nuffield1995, para. 6.7). believed to undermine consent,to coerce the poor into selling their the to and improperly commodify organs,to violate humandignity, to is The argument thattherichexploitthefactof poverty human body. coerce the poor into selling their organs, which given better the poor would not have done. While such views circumstances summarize the apparent global consensus that marks worldwide of prohibition the sale of human organs, as I will argue, closer examination reveals significant groundsforconcludingthata market thancurrent wouldlikelybe moresuccessfulin preventing exploitation bureaucraticproceduresfor procuringand allocating governmental organsfortransplantation. commercializaIn this regard,RichardTitmuss'sclaims regarding of tion of the blood supplyprovidea usefulsummary objectionsto a in market in market human arguedthata for-profit bodyparts.Titmuss 337

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blood products leads to less blood available fortransfusions, greater a likelihoodof distributing blood contaminated withdisease, inefficient of a increasein priceper management the available supply, significant of blood, and imposessocial costs on thepoor (1971, p. 246). pint
. the of erodes [Commercialization]. . represses expression altruism, thesenseofcommunity, lowersscientific limits bothperstandards, in sonal and professional sanctionsthemakingof profits freedom, between dochospitalsand clinical laboratories, legalizes hostility torand patient, areas of medicineto thelaws of the subjectscritical social costson thoseleast able to bear places immense marketplace, them the poor, the sick and the inept increasesthe dangersof in unethical behaviour varioussectorsof medicalscience and pracin in more tice,andresults situations which proportionately andmore blood is suppliedbythepoor. . . and categories exploitedhuman of of populations highblood yielders. (pp. 245-246)

It is important note the special moralcosts Titmussidentifies: a to 1) decreaseof altruistic sentiments, an erosionof a sense ofcommunity, 2) 3) a lowering of scientific standards,4) limitationson personal on as freedoms, limitations professional freedoms, well as 6) the 5) his between In ofhostility and physicians. addition, legalization patients that a profit from servicesor 8) criticisms 7) presuppose making hospital from servicesis morally and 9) thattheforces the of laboratory suspect, market than It on benefit. is clearthat Titmuss does not bring moreharm the motive leadingto thewise use ofresources, does as nor regard profit he considerthe market place thatrewardsresponsiblefreedecision a whileproviding the making, tutelage concerning consequencesof one's choices and thelimitations thehumancondition. of Such positionsare rhetorically compowerful, theyoversimplify yet plex issues. In this essay, I will focus on such concernsonly as they bear on the particular criticism thata market humanorgansis exin Whilelimiting breadth mythesis, the of thisallows for careful ploitative. of thiscentral and forceful whichis often heldto exploration objection, be decisive againstsuch a market. will considerwhether for-profit I a commercial market wouldexploitthepooron thegrounds thatit would likely 1) have a negativeimpacton the physicalhealthof vendors;2) benefit whileharming, at best onlymarginally or recipients benefiting, vendors; 3) coerce the poor into selling organs; or 4) improperly human body parts. At each step the analysis considers commodify whether and how the market need, or mayexploitpersonsin greatest whether the forbidding sale of organsis itselfexploitative. The core notionis thatto exploit someone is to benefitby taking unfair advantageof thatperson.For example,A mayexploitB whenA benefits from transaction is harmful B, or from a that to which receives A

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A value (Feinberg1983, p. 201). In addition, mayexdisproportionate froman exchangewhen B's abilityto choose is ploit B if A benefits even ifB's choice is notstrictly (Wertheimer involuntary compromised, inducements often works offering 1992,p. 213). Market by exploitation such thatintrinsically unattractive to thosewho are vulnerable options thebestavailable. Regarding all things considered, become, organsales, will tipthebalance of interests, incentives theconcernis thatfinancial the organsto therich.Givenconditions inducing poorintosellingtheir to financial incentives undergo the ofpoverty, poorwill have significant therisksof surgery. include:Harmful The possibilitiesformarket exploitaexploitation whileorgan vendors from suchtransactions in tion, which gain purchasers in are,on balance,harmed. advantageousexploitation, which, Mutually it fromthe transaction, is in a way that vendorsbenefit thoughorgan more benefitsubstantially For example,if purchasers remainsunfair. of takesunfair to or thanvendors, ifoffering purchase advantage organs thensuch exchangesmaybe exvendors'impoverished circumstances, and in Moralistic gain purchasers vendors exploitation,1 which ploitative. consented is fundamentally a from transaction to, which,even if freely immoral. Here, a primaryconcern is that organ sales improperly humanbodyparts. commodify I. Harmful Exploitation requires exploitation organsales involveharmful Assessingwhether an The questionis notwhether orconsidered" an "all things judgment. on but whether balance the costs harmful elements, gan markethas contransactions beneficial Mostuncontroversial the outweigh benefits. tain negativeelements.Individuals may preferto receive expensive or medical treatment automobilerepairforlittleor no cost. Yet, such who ask or do circumstances notentailthatphysicians auto mechanics, thatphysicians it others.Generally, is presumed forpayment, exploit for and auto mechanicsmaypermissibly requirecompensation the serthe to the and vices provided that benefits theindividual outweigh costs. the to evaluateorgansellingas a social practice, Moreover, adequately but is individual harmed, whether, is notwhether particular any question on balance, the expectedvalue of such exchangesis negative.For exon is employment injured thejob, suchthat ample,"If a worker severely is we is a net harmto thatworker, do not say thatsuch employment as harmful a practice" (Wertheimer 1992, p. 215). The issue is not ex individual post, to is an whether organmarket harmful anyparticular as ex it is typically ante harmful a social practice. butwhether

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An initialconsideration whether market humanorganswould a is in lead to less organavailabilityand therefore, ceterisparibus, to more extensivehumansuffering. Policies thatexpandthe number living of donorswouldmultiply availability transplantable the of redundant body to parts.If such a policyencouragedthe familiesof deceased patients makethoseorgansaccessible,it wouldalso increaseavailability nonof redundant cadaver sources. Expandingthe pool of living organsfrom and cadaverdonorswouldthen save lives and reducesuffering. conThe cernremains that market a If decreaseorganavailability. potential might donorssell exclusively thehighest to bidder, rich,or those onlythevery withpremiere would be able to purchaseneeded organreinsurance, Otherpotentialrecipientswould suffer and perhapsdie. placements. termson waitinglists mightdevelop forthe poor who would Longer thenbe competing thediminishing for number donated less expenof or sive, perhapsinferior, organs. effect" Titmuss,forexample,argues thatthereis a "crowding-out withregard blood: thatfinancial to incentives notadd to a fixedsupdo ply of altruisticdonations,but ratherreduce total levels of blood He thatthemarket wouldnotmorethanmakeup availability. presumes forany donationshortfalls. concernis thattheveryexistenceof a The market undermines internal the altruistic of motivations donors(Frey 1998, p. 439; Lepper and Greene 1978). For example,once a market exists,familymembers maybe less inclinedto donateto a relativein need.Envision,forexample, callous individuals a or chiding friend fammember: ownorgan!If youhad savedyourmoney, ily "George, buyyour for you could have purchased yourown replacement kidney transplant. for Whyshouldwe give you one?" Financial incentives organprocurementare believed to undermine freedom donateone's organs.If the to an organmarket created, is whileonlysome will exercisetheliberty to the freedom all to donate will thereby limited.The market of be sell, and narrows choicesforall men.... It the allegedly"limitstheanswers is theresponsibility thestate... to reduceor eliminate control of or the forcesof market coercionswhichplace menin situations whichthey in have less freedom littlefreedom make moralchoices and to beor to have altruistically theyso will" (Titmuss1971, p. 242). Importantly, if thiscriticism be turned its head. Prohibition an organmarket can on of of precludesthefreedom all to sell their organs.Giventhatwitha general prohibition organvending on to onlysome will exercisetheliberty of In the donate,thefreedom all to sell, iftheyso will,is limited. short, effect" in Indeed,itseffects "crowding-out operates bothcircumstances. are likelyto be significantly whenthefullcoerciveforceof the greater is government used to "crowdout" any who maydesireto sell.

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would lead to less organavailability Concernsthatan organmarket thatthe willingness doto are, however, likelyunjustified. Presuming than is coercedaltruism, those natebodyparts motivated actualrather by to of who are willingto donateoughtto continue be willingregardless market. a measuresolelyof thewillingAs theexistenceof a for-profit ness to partwithone's organs,those who are willingto donate body mostorgan partsoughtalso to be willingto sell suchparts.Regardless, The motivations donorsare to family members. donationsfrom living the are suchdonations likelyto maintain same forceregardsupporting market: less of theexistenceof a for-profit love, beneficence, loyalty, or avoidance of the shame of failingto donate.These guilt, gratitude, extendsto all possible recipidonorswhose altruism are notgenerally witha their stemsfrom ents;rather, relationship particular willingness to are Such transfers unlikely changeeitherin genpatient. particular donationto sale) or in relativenumber eral character (i.e., (i.e., from that thandriven need). The motivations currently becomeother supby are members also likelyto support to donations family family portorgan to organs.Indeed,manymay replacement poolingofresources purchase resourcespreferable. financial findthepoolingof of the Furthermore, development such a market providesno reason or to stop askingpatients, theirfamilies,to considerdonation.Addisuchas required tionalstrategies designedto increaseorganavailability, notto be seen as exclusivealternaor directed donation, ought request tivesto themarket. maylead to the parallelstrategies multiple Pursuing thegoal of increasthat It organavailability. maybe, however, greatest wouldbe more human and suffering, availability, thusreducing ingorgan securedwiththeexistenceof an organmarket. and honestly effectively woulddisproportionately thatan organmarket For example,theconcern affect health care for the poor, the uninsured, or the adversely the for numerous underinsured possibilities influencing market. ignores could be utilizedto avoid the need fordirectpayVarious incentives mentsfromrecipientsto donors. Here one mightconsider allowing value for to or families, taketax deductions thefairmarket donors, their of utilizea system taxcredits one In oftheorgans. addition, might against taxesowed fortheorgan'svalue (Monaco 1990). incomeor inheritance for These wouldbe governmentally managedmarkets thepurchaseand of organs.Bothpolicies wouldensurethatdonorswerecompensupply whileactively valueoftheir satedforthemarket encouraging bodyparts, healthcare costs. direct an increasein available organs,without raising whichwould of a consider system organstamps, Here also, one might as create certainwelfareentitlements. Organ stampsmightfunction wherethe state or national healthcare entitlements, straightforward

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tax health insurance wouldpurchase organs utilizing dollarsforthepoor. concreatea systemof entitlements such stampsmight Alternatively, in kind.Forexample,in an English trade tingent uponpersonalor family who was not a good tissue matchto donate to his son, case, a father, offered one of his kidneysto the Britishdonorpool in exchangefor He his son on the nationalcadavericwaitinglist fora kidney. placing a fora tradein kind(Sells 1997, pp. 1392offered cost neutral option to suchas trading market 1393). Other possibilities ought be considered, for livermight exchanged a be redundant organs(e.g., a slice ofhealthy not A of healthy kidney). system incentives unlikethoseutilizedto enor could give organentitlements, higher priority courageblood donation to thosewhodonatedorgans(Perry1980, pp. 63on thewaiting queue, in altruistic mostblooddonation theUnited thana purely act, 71). Rather Statesis situated within such valuable incentives. role could play a significant Churchesand charitableorganizations drives for increating health careresources thepoor.Therecouldbe organ envisionindividumuchon themodel of blood drives.Here one might whichwould in organsdirectly local churches, to als donating rights risks and other healthcare forsurgery minimize guarantee high-quality associatedwithdonation.The organscould thenbe sold to the richto or raisefunds purchase health to care,food,andmedicine, be madeavail"Mother Theresa's able for to thepoor.One couldimagine transplantation forthePoor" generating resources provideorgansfortheimto Organs Organs, Inc." brokering pecunious; or "MotherTheresa's Non-Profit to the organsfrom poor in developingcountries advantagethosepoor. realize thegoal Whichinstitutional would moresuccessfully system a of greater of availability organsfortransplantationthefreemarket, - is an empirical or market, blanket question state-regulated prohibition thatdependsin parton the talentsand goals of individuals.Insofaras it markets create social space for unencumbered humaninteraction, would notprecludetheliberty thealtruistically of inclinedto takecare of others. Market-based liberties include,butare notlimitedto, profitinterests. Unlessthestateprohibits practice, organmarket the an seeking wouldallow private individuals ofcharity sell organsvery out to cheaply to thosein need. Social and politicalinstitutions support rights the that of personsto interact withfreeand consenting others formally are neutralwithregardto theexpressionof charity. short, organmarket In an createsthesocial and politicalspace to exploreadditional opportunities and incentives organprocurement allocation, for and solutions including forthe so-called "crowding-out" without forbidphenomena, thereby other of incentives and opportunities. ding types One might raiseconcerns the on regarding impact thephysicalhealth of organvendorsin termsof mortality morbidity and risks.Although

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life such costs are likelynotsignificant. crucialto consider, Long-term lessenedby theremovalof the fordonorsis notmeasurably expectancy tissue internal redundant organ(e.g., a single kidney)or regenerative healthrisksforlivingdonorsare those (e.g., a liverslice). The primary for associatedwith perioperative procedures organharvesting: operative 3 is fornephrectomy approximately deathsper 10,000 donors mortality in withothermajorcomplications occurring less than2 (0.03 percent), of long-term of risks,such as inmorbidity percent cases. Occurrence creased risk of hypertension or proteinuria, after living-donor such are (Ross et al. 1997). Other operations, nephrectomy controversial a as harvesting liver slice, can be somewhatmore riskyfor donors to does notlimititself thewealthier (Najaranet al. 1992). Organfailure of the population.Yet, donationamong family or healthier segments is members consideredmorallylicit, even if those donatingare poor members society.Provided of and in poorerhealththanmoreaffluent in tissuesare procured suitand regenerative internal redundant organs redundant sterileenvironments, competent surgeons,selling by ably tissues is less riskythanmanyotheroccupaorgansand regenerative risksexist whenever and tions.Such mortality morbidity livingdonors livof are utilized, changeshands.Presuming money regardless whether neutral to ingdonorswill continue be utilized,suchrisksare,therefore, to withregard themarket. be the While minimizing risksof organprocurement might surgery it is notpersuasiveagainst action, an appropriate subjectforregulatory or in As themarket. Reddyet al. acknowledge, India, money, other sigvaluableinterests, changeshandseven amongrelated typically nificantly they argue,is notmereutiliOrganselling, livingdonorsand recipients. it rather, focuses on basic humanvalues, tarianspare partsmedicine; social goals. "We serveonly and connectedness, fundamental community of benefit a transthepatient if and thecorrupt theunscrupulous we deny the becauseofourfearthat paiddonation indicated is that medically plant is too complexto be regulated" (1990, p. 911). Insofaras a disprocess of number poorerindividualswould be exposed to such proportionate harmsof organdonationwould need to be weighed risks,thepotential to attributable increasedinbenefits againstthe short-and long-term the consider sale of a redundant vendors come. In thePhilippines, organ busimeans to raise resourcesto support to be an important fledgling welfare nesses and to further (Alora and Lumitao,forthcoming). family teamsin India docuWhileredundant organsales werelegal, transplant mentedprogramsuccess in termsof graftsurvival, lack of donor of return patientsto productive lives, and assistance in remortality, the greatfinancialneed of donors (Thiagarajan et al. 1990). solving the from developing these for Purchasing organs transplantation, physicians

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worldconclude,is in keepingwithethicalvalues as well as fundamental commitments medicalcare. to for Organsellingmayeven lead to positivehealthbenefits vendors. It would increasethe vendor'soverall social and economicprospects, lead to indirect healthbenefits.Individualswith whichmay,in turn, status incur economic, social, and advantages: higher salary, higher jobs care coverhealth functional. example,despiteuniversal For single-tier age, life expectancyin Canada varies accordingto incomeand status II the et (Iglehardt1990, p. 563; Wilkins al. 1989). Similarly, Whitehall an study,in Great Britain,demonstrated inverseassociationbetween evidence of gradeandprevalence angina, electrocardiogram employment and morbronchitis. of ischaemia,and symptoms chronic of Morbidity werebothaffected employment by grade.Reasonscitedto account tality to forthesedifferences include: 1) "different attitudes health"such as "thelowerdegreeofbeliefamongthosewithlowerstatus they jobs that a of could takeactionto prevent heartattack";2) "patterns social activsocial withclear indication less, and less satisfactory, of itydiffered, and 3) "workenvironment thosewith lowerstatus jobs"; support among evidencehas accuis perceiveddifferently betweengrades.Impressive to mulated jobs characterized low control, that pooropportunity learn by workload are associatedwith and developskills,andhighpsychological et increased ofcardiovascular risk disease"(Marmot al. 1991,p. 1392).Low with in theemployment control closelylinked was hierarchy. job position Increase in controlover one's occupation,i.e., increasein statusas well as increasein salary, adleads to economic,social, and functional vantages, which in turnare indirectlyassociated with greaterlife and health,reducedinfant expectancy, morality, increasedadvantages forchildren. For example,within in low-income neighborhoods urban Canada thereare higher ratesof infant low birth and mortality, weight, (Wilkinset al. 1991, pp. 7-8). This circumstance prematurity pointsto indirect healthbenefitsforchildrenassociated withthe incomelevel andjob statusof parents. costs and mortality risksvarywith Morbidity incomelevel and professional status. Measuredsolelyin terms health of care consequences,sellinga redundant be a rational organmay strategy to raiseone's income,increaseone's economicand social prospects, and benefit healthof oneselfand one's family. the Given thereby indirectly thatsocial and personaladvantageis oftentied to educationand business success, such incentives may be significant.However, even short-term welfaremaximization, such as the purchaseof housingor healthcare, mayprovidesome withsufficient incentives sell redunto dantinternal It control overtheir ownlives,which, organs. willgivethem data,shoulditself economic,social, giventheforegoing providefurther

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and healthadvantages.Marketincentivesencouragepersonsto raise and goals. A resourcesto further personalas well as social interests market humanorganswould create opportunities, in whichsome may theirown educato view as attractive, secure resourcesfor pursuing tional,business,political,and welfareinterests. borne vendors primarily are harms Additional They by psychological. frompersonto be difficult measureand may differ to will, therefore, incurpsychological distress as (e.g., feelperson.Insofar organvendors or embarrassment, loss of dignity), adequatefinancial ingsof violation, to be It remuneration compensate. would, however, an error premay harms. While sumethatdonorsare notsubjectto similarpsychological causes increased itself somearguethat harm, psychological compensation to the organ vendormay outweighinthe value of the compensation creased psychological dis-value, therebyobtaining a net benefit 1992, p. 217). Moreover, mayexperiencea organvendors (Wertheimer in for senseofsatisfaction participating a life-saving even, activity, deep It at some riskto themselves. begs the questionto perhapsheroically, motivated organdonorswould presumethatonly unpaidaltruistically as psychologicalharmscan Insofar experiencepersonalsatisfaction.2 or benefits, be adequately recompensed, balancedagainstpsychological at it is implausibleto view organsales as benefiting recipients significantharmto vendors. II. Mutually Advantageous Exploitation a Organ sales may be exploitativeif one partybenefits greatdeal the other.Marxist froman exchangethatonly marginally advantages focuson thewaysin which for of accounts market exploitation, example, than an value from exchange more command they considerably exploiters while for the exploited the reverseis true bringto the transaction, an Joel arguesthat agreement (Roemer1985,p. 30). Similarly, Feinberg or if is exploitative one of thepartiesreceivesexcessive profit disprothe value from exchange(1986, p. 252). On suchan account, portionate less are organvenders exploitediftheyreceivesignificantly value from to of thantheworth thetransplant recipients. thetransaction The concernis thatthepoor will be willingto sell organsforrelawill be advantageous. because even suchan amount tivelylittlemoney, is thiscircumstance rectifiable Insofaras it is morally by problematic, is One possibility statepricecontrols, vendor compensation. increasing for financial standards each organ.Minimum whichset minimum price Such considerations suggest exploitation. help prevent legislationmay Most vendors thatorgansellers mayface a collectiveaction problem.

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that wouldbe able to negotiate agreement is less desirablethanwould an as vendors be possibleifpotential collectively a group.Here negotiated thatprohibition one might also raisetheconcern exploitsdonorsby forfrom organs. realizingany value fortheir biddingthem An offer coercive,on the otherhand,if thelure of compensation is vendor'schoice. Finanof the compromises voluntariness thepotential and thatoverwhelms cial gain,forexample,is consideredan influence donors.It is thevoluntary consentof impoverished potential subjugates the vendorsstandto gain so muchfrom sale that because impoverished weak(Wertheimer their 1992, bargaining position appearscomparatively are for 223). Marxists, example,arguethatcapitalistlabor markets p. are coercive because workers limitedto a choice betweenunpalatable at alternatives: (Cohen 1982,p. 3). jobs or starving working low-paying as is donation notregarded altruistic This accounthelpsto explainwhy but it exploitative: is notthatthe exchangeof value is morefair,3 that is the themotivation underlying transaction perceivedas morepure. reducethe financial one might If poverty the difficulty, is though, incentives lowering amountpaid per organ(Radcliffe-Richards the by to in 1996), or restrict participation organmarkets thosewithhighincomes (Epstein 1997, p. 255). Michael Walzer,forexample,holds that an should at least approximate exchange "what goes on in the market betweenequals" (1983, p. 120). While such policies may appear less have counterintuitive First, theyfurther implications. they exploitative, forthe poor, and second, unlikethose betteroff,the restrict options own for the are from utilizing market their fully impoverished prevented advantage.While a poor individualmaydecide thatsellinga kidneyis to moreattractive thanotheroptions,offers purchasean orgando not on make him worse offif he refusesto sell.4 Analogously, the labor or thosewho mustsettleforanyunpleasant morerisky market, occupaor construction, assemblyline tion,such as ditchdigger,oil platform mustmake the same typeof choice; thisdoes not necessarily worker, meanthattheyare beingcoerced.Third,as Margaret Radin notes,it is unclearwhyengagingin market withthe poor constitutes transactions the use of coercivepower,while doing so withthemiddle-classor the is of (1996, p. 47). wealthy an appropriate expression personalfreedom One mustalso distinguish betweencoercionand peaceable manipulation.While coerciveactionsare thosethatplace or threaten place to othersinto a disadvantaged state without justification, peaceable mato nipulativeactionsare those thatplace or offer place othersinto an While coerstateto whichtheyhave no priorentitlement.5 advantaged cion violates the freechoice of persons,peaceable manipulation does not (Rudinow 1978, p. 339). Indeed, peaceable manipulation grounds

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whichindividualsfashioncontheveryprocessof negotiation through As do deliberation sensualagreements. longas offers notmakeindividual choice amongpotential costs and benefits and voluntary impossible,incentivesare,in principle, 1986, p. 308). permissible (Engelhardt have noted,though, line betweencoercion the As Nozick and others is to and peaceable manipulation difficult draw (Nozick 1969). What as peaceable manipulation may undercloser mayprimafacie appear a hiddenformof coercion.If, forexample,a be scrutiny shownto be in the vendor exaggerates qualityof a kidney orderto obtain knowingly benefitsuntilan withholds contractual a higherprice,or an employer to donate,coercion is involved.Each instanceis an employeeagrees intodisadvantaged circumexampleof one individualplacing another orbreach force a form unconsented-to of stancesthrough (e.g., deception of contract). whileaddingto of Opponents organsales mayarguethatsuchoffers, are individualfreedom, one's list of optionsandprimafacie enhancing too good to refuseand in thatsense are coercive.If the impoverished then individual'sstatusquo is highlyunsatisfactory, an offerto purthe because itmanipulates victim's chase an organmayappearcoercive, to evenifit wouldbe rational accept(Zimmerman 1981, p. preferences, the of 130). The intent the offeris to elicit behaviorthatcontradicts to individual'snormaloperativegoals, and in thatsense attempts use himas a meremeans(Rudinow1978, p. 347). Thus,thechoice to sell a is kidneyin orderperhapsto belie theeconomicstatusof one's family to be coera considered decision without scruples.However, typically thansimplypeaceably manipulative, requiresshowingthat cive, rather disadvendorsinto unjustified such an offer places potential making circumstances. vantaged a the is One possibility that lureof financial gain maymotivate deciif he had thought sion thatthe vendorwould have rejected carefully on about its fulleffects his life. The existenceof such miscalculation, is however, an empirical question.If an organvendoragreesto sell bethe cause he believesthat expectedvalue of so doingis positiveand the and,thus,no value is positive,thenthereis no miscalculation resulting exists of The possibility suchmiscalculation coercionon suchgrounds. transactions commercial but commercial withevery transaction; clearly, are notgenerally speakingcoercive. Even if theindividualis so interto thatit would,giventheperson'svalues,be irrational estedin money as the declinetheoffer, choice is stillplausiblyunderstood freeinsofar an offered impoverished the as he affirms outcome.If a richpatient phione two student milliondollarsto sell a kidney, might losophygraduate "Wow! I'm verypleased thathe offered thinking: imaginethe student

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me two milliondollars. I could neverrationally refusesuch an offer, and I wouldneverwantto turn downin anycase. I'm veryglad it was it made." To develop Harry movesthe Frankfurt's if suggestion, theoffer student who is being manipulated thathis first-order volitionscomso as the as pel agreement, actionis stillplausiblyunderstood freeinsofar it is affirmed his second-ordervolitions (Frankfurt 1971, 1973; by Thalberg1978). The generaldifficulty that questionis notwhether poorare is the the financialincenunfreewithrespectto certainobstacles,but whether tivesto purchase redundant internal organsmakefreechoice impossible It and thereby coerce potential vendors intocomplying withtheoffer. is autonomous unclearthatan organmarket would fareworse regarding consentthanotherorganprocurement On strategies. theone hand,surfrom either concern harvesting for gical risksarenota noteworthy organs brain-dead thatvendorsmayfail to bodies or cadavers.Thus,concerns understand risks life-threatening do not defeatautonomous participabear significantly tionin an organfutures nor market, do suchconcerns on familieswho sell organsfrom next deceased or brain-dead recently of kin. On the otherhand,ignoranceas a barrier consentdoes not to the betweendonorsand vendors. respect distinction Unpaiddonorscan be equallyignorant therisksof surgery ofthepotential serious for of or Insofaras ignorancerules out selling,it oughtalso to complications. not However,as withdonors, all vendorswill be igprecludedonation. norant therisks,norwill all be irremediably Adequatecounseling of so. shouldameliorate such concerns.Moreover, thethreat significant if of harmincreasesthestandard proofforconsenttoo greatly, raises of this the concernthatotherimportant freedoms will be ruled out as well. Considerthe circumstance a where,without job, one would starveor need to take a job thatcarriessubstantial risks(e.g., oil-platform conWouldautonomy impossiblein suchcircumstances? be Even struction). if some potential vendorsoughtto be excludedfrom sellingorgansfor reasonsof irremediable disabled),blanket ignorance (e.g., thementally do not servetheinterests liberty. is, therefore, of It prohibitions problematicto describesuch offers coercive,since theydo not deprive as the potentialseller of any preexisting optionsand rationalchoice remainspossible.Whiletheymaybe seductive, suchoffers notsubtle are threats. The poor generally have feweroptionsavailable amongwhich to choose; however,thereis a difference betweenhavinglimitedoptionsandbeingunableto choose rationally one's bestinterests in among theoptionsavailable. Perhaps such offersare coercive relative to a normativemoral baseline. If thereexists a moralobligationto provideassistance,then

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to demanding compensation fulfillone's dutymay be coercive. ConNozick's example:B is drowning. offers rescueB, ifB A to siderRobert agrees to pay him $10,000. Both knowthatA is the only prospective rescuer(1969, pp. 449-450). Nozick concludesthatthisis an example to B's ofcoercion.WhileAprimafacie offers improve situation relative to thestatusquo, A actuallyproposesto makeB worseoffif B does not to A. pay the $10,000 relativeto whatB has a right expect from Alan whilethiscase maybe properly holdsthat described Wertheimer similarly but as coercivethisis notbecause B has no acceptablealternative, bemoralobligationto save B, eitherforno cause A has an independent less (1987, p. 207). Insofaras there or compensation forconsiderably in to existsa right be rescued,or a dutyto help others need,whichsusis tainssuch a moralbaseline,theoffer coercive. thatthisanalysisclarifiesthecase of human It is unclear,however, organsales. Patientsdyingof organfailurewould not usuallybe describedas havingspecial moralobligationsto providepotential organ withfinancialincomewithout vendors askingforsome good or service withend-stage in return. Indeed,it maybe thatit is patients organfailman. Pace theoften cited urewho are analogous to Nozick's drowning will exploitthe poor,this analysissugconcernthatan organmarket the the to in geststhat offering sell organs poormaybe exploiting illness or of the rich forpersonalgain. Yet, absentprioragreements special it moralobligations, is unclearwhythose withhealthyorganshave a In to moralobligation donate.6 short, adequatelyto assess claimsof coone mustalso inquireas to who is in greater ercive offers, need, and of the resources thusin morethreat exploitation: poorwhoneedfinancial or therichwho are dyingof organfailure. it to In general, is difficult counta policyas exploitative as in the if, of case of legitimizing open organsales, it increasesthenumber options as one to individuals.In orderto see such circumstances exploitative, or is holdthat there something must intrinsically wrong debasingin sellone evenifone does thisfreely, has beenbrought so ingone's organs, that to oneself. to do something morally injurious III. Moralistic Exploitation: ImproperCommodification are is beAn additionalpossibility thatorganmarkets exploitative that human For cause moralharm. example,one might cause they argue On organsshouldnotbe exchangedformoney. such an account,a marthatwhich because it commodifies ketin humanorgansis exploitative exInsofaras such a view is sustainable, shouldnotbe commodified. do circumstances not improveif organs are purchasedfor ploitative

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moremoney. This capturesthe intuition thatwhile some significantly are appropriately distributed the market, others not. are goods through If organsales improperly humanbody parts,it is argued, commodify such transactions shouldbe prohibited. are As Radin maps the conceptualgeography, commodities marked of statusas a thingin the Kantian (i.e., "ascription by objectification at sense of something thatis manipulable the will of persons"),fungias "fullyinterchangeable with no effecton value to the bility (i.e., can be arrayed (i.e., holder"),commensurability that"values of things as a function one continuous of variable"),and monetary equivalence (i.e., "the continuousvariablein termsof whichthingsare rankedis dollarvalue") (1996, p. 118). Opponents organsales mustarguethat of human suchtransactions 1) organsby treating inappropriately objectify human them objectsrather as thanas partsof subjectsor agents, treat 2) thatthevalue of items,as exchangeable, presume 3) organsas fungible the organto the vendoris commensurable the value of the organto to thepurchaser, 4) that valuecan be givena monetary and this expression. farebetter worse or The question,though, whether is organmarkets An commodification thanotherstrategies. initialchallenge regarding and of foropponents the market thatorgansare infact manipulable is withothersof the same kind.This is the veryreason interchangeable thattransplantation medicallyviable. Both market and non-market is based strategies procurement transplantation similardiffiand face for culties.All treat humanorgansas exchangeableobjects. valPerhapsorgansales involve an exchangeof incommensurable ues. Incommensurability a represents concernthatthe values at stake cannotbe relevantly incomsummed and compared.By itself, though, will not establish that organ sales are illicit. The mensurability of transactions does not requirethatthe goods permissibility market be precisely transbut that commensurable, rather theparties exchanged act voluntarily, that deception or other formsof coercion are not and thateach is satisfied withthevalue to be received.This employed, meansthatwhatis receivedin return worth least as muchto the is as as thatwhichwas given.For example,one can buyor sell "priceparty less" Montswithout value of the or claimingthattheaesthetic historic is "commensurate" withthe moneythatis paid (Wertheimer painting 1992, p. 218). ElizabethAndersonsuggestsanother Thereis a kindof possibility. she to is exploitation, argues,thatoccurs"whenone party a transaction oriented toward exchangeof 'giftvalues', whiletheother the opparty erates in accordance with the norms of the marketexchange of commodities. values,whichincludelove,gratitude, appreciation Gift and

IS A MARKET IN HUMAN ORGANS EXPLOITATIVE?

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or cannotbe bought obtainedthrough of others, piecemealcalculations of individualadvantage"(1990, p. 89). However,this oversimplifies. often of The pursuit self-interest requiresthatone advancethebest inbenefits ways other in thandisinterested of terests others providing by to At commitments civic dutyor generalizedsolidarity. timesone party sell value as to an exchangemaydeliberately goods forless thanmarket that valuescan be brought Such considerations a subtlegift. suggest gift Even if Andersonis correct, the intoplay in the market. though, diffiof exists. cultyis relevantif and only if such a dichotomy intentions the value of humanorgans Personswho negotiate regarding fairmarket such conceptualdissonance. will notlikelyexperience one cultivate virtues the In orderto do well in themarket, mustoften and personalrecognition theother. of The goal of giftgiving, kindness, of of customer satisfaction, independently thegoal to maximizeprofit, realization of profits. is typicallynecessaryto maintainlong-term concurrent commitbusinessgenerally a successful requires Achieving and of satisfaction to theprovision qualitygoods and ment customer to notesthiscirand services(Engelhardt Rie 1992). ElsewhereAnderson withauction markets, customermarkets cumstancewhile comparing are like whereauctionmarkets structured one-shot dilemmas, prisoners' like are markets structured indefinitely whilecustomer prisonrepeated forfuture Where ers' dilemmas. parties cooperation provide opportunities incentives respecteach to withmarket-generated markets in customer of others effects treating the other'sinterests, reputational poorlyproin duces thesame incentives auctionmarkets (1997, p. 103). Similarly, meetonlyonce, neceswherevendors and recipients in "spot markets," involvementprovides considerable incentives for sary third-party virtuous behavior.For example,it is in the titlecompany'sbest interof and skilledtransfer real estateownership. an ests to effectuate honest from others The reputational hospipoorlyon surgeons, treating impact who perform teams,and others tals,transplant specializedservices,will in tendencies an organmarket, incentives virtuous for significant provide and as wellas vendor recipiand service medical suchas quality follow-up, can Virtue be seenas a profit-maximizing entsatisfaction. strategy. is One might expression an inapgivingorgansa monetary arguethat propriateway to value humanbody parts. Here the concern is that to discourseand market exchangeswill encourageindividuals property ineconomic terms as valuethosegoodsregarded "property" (Gold solely underlie ideals of 1996, p.17). Conceptions human flourishing typically shouldbe valued.Cultivating how certain thatsupport things capacities to appreciateaestheticand historicvalues enrichesand elevates life. in is "To failto valuethings appropriatelyto embody one's lifean inferior

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of (Anderson1990,p. 89). For example, conception human flourishing" in Moore v. Regents the University California, Justice Arabianarof of gued that treatingcertain things as commodities may be morally "Plaintiff asked us to recognizeandenforce right to has a inappropriate: sell one's bodytissue profit. entreats to regard humanvesHe the us for sel ... as equal withthebasest commercial He commodity. urgesus to the sacred withthe profane. asks much"(Moore v. ReHe commingle gentsof theUniv.of Cal., 51 3d at 148). Arabianconcludedthatmarket in normsinherent property discourseare incompatible withopen discussion of non-market, values (Gold 1996, p. 36). non-monetary, surSara Ketchem arguedin thecontext commercial has of Similarly, that ofthemarket use of recaststhemeaning nature women's and rogacy ... bodies. "Sexual or reproductive the enter market as comprostitutes modities.. . . once thereis a market women'sbodies, all women's for bodies will have a price,and the womanwho does not sell her body becomes a hoarderof something thatis usefulto otherpeople and is valuable" (1992, p. 290). It treats cawomen'sreproductive financially as commodities. analogousclaimfororgan The once sales is that pacities there a market human is in all organs, organswill havea price,and those who do not sell theirredundant organswill be viewed as hoardersof that valuable. something is bothusefuland financially Such considerations, of hold equallyagainstsystems donahowever, tion.As organtransplantation became thestandard care,organswere of recastas merethings (Fox and Swazey 1992, p. 207). Personswho do not donate while living,or fortheirloved ones at death,are seen as scarcelife-sustaining medicalresources. Concerns avoid to withholding as collectionsof sparepartsmustbe addressedunder recasting persons of and any system organprocurement transplantation. because it wouldhave a deeply Perhapsorgansellingis exploitative effecton altruism, or One beneficence, social solidarity. debilitating would be corrupted the veryexistenceof might arguethataltruism by themarket, philanthropy that wouldbe sulliedby greed.The concernis thatthemarket would so affect altruistic impulsesthatit would starkly limittheexpression altruism thereby of and lead to far-reaching moral costs to community and (Titmuss1971, p. solidarity social beneficence to values,it is argued, 198). Monetary oughtnotto be attached thepresence of a spirit altruism. of The contention thatmarket is relationships minimize moraland social dimensions, whiledonations gifts more as are and as such defysuch minimization. donationsupopen-ended, Organ and posedlyaffirms community solidarity expressesthebeliefthatit is to to humanneeds. Donation,withits important minister fundamental of and is set symbolism love, friendship, fellow-feeling, thereby over

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forcesof mass socialienating depersonalizing, againstthesupposedly and impersonal bureaucracies. market relations, largeorganizations, ety, of goods and principles foran alternate This is a search interpretation that the by whichgoods are to be distributed "capturesmorefaithfully of our mostdeeplyheld ideas about the meaningsof those complexity justice" (Murray1996, p. 117). At stake goods and about distributive of are the ways in whichindividualfreechoice shapes the character a will altruism benefiand and whichstrategy lead to greater community to or the cence, as well as a sense of community: market commitments In to civil dutyand social solidarity. addition reducing organavailabilof and social solidarity a society of weakening theverymoralfabric ity, such If to is argued be theprobablecost of an organmarket. sustainable, moralcosts might thescale againstthemarket. tip one To assess such criticisms adequately, mustconsidertwo interrelated issues. First, whethercurrent practices of organ procurement and donation beneficence, personalrealtruism, community encourage of and societymore lationships, staveoffthedepersonalization modern and second,the ways in whichthe free thanthe market; successfully with choicesofindividuals, shape thecharacter interacting one another, of thecommunity. describescurIt is unclear,forexample,that"altruism" accurately With the documentedsuccess of rent organ procurement policies. of and drugs procedures theadvent immuno-suppressive transplantation and survivalrates,physicians, thegeneralpubthatincreaselong-term lic quickly changed their view of organ transplantationfrom an successfultherapy to (Fox surgicalprocedure a medically experimental to alteredmedicalsocial reality and Swazey 1992, pp. 8-30). This shift as has thatorgantransplantation come to be regarded a treattheextent are Humanorgans often indicated. whenever to ment be offered medically in Thismedicalshift language, as construed a "scarcemedicalresource." and practiceplaced a greater perceivedmoralburdenon expectation, to and even strangers make theirorgansavailable to members family the othersif needed.However,by bringing considerablelegal forceof of to bear againsttheverypossibility sellingone's orthegovernment of the"donation," calling into thereby gans one legislatesthenecessity than Rather of character suchtransactions. the binding question "altruistic" in as and donors recipients, wellas their physicians, thesolidarity potential are human social valuesand caring of shared dying patients relationships, and recastas "sources"of neededmedicalresources, their disinterestedly it It to as families "accessbarriers" be overcome. maybe that is the grieving that rather themarket, than on blanket current prohibition selling, system's and reduces altruism, socialbeneficence. organ availability,

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if that be motivated, taken Requirements organdonation altruistically or wouldruleoutanyschemeofpresumed consent mandatory seriously, consentlegalizes simply choice, as well as manydonations.Presumed deniespermission, one's organsat death,unlessone specifically taking forceof thestateto choice implements significant the whilemandatory or coerce one intochoosingwhether notto "donate."Neither policyis of altruistic with"giftgiving"as a voluntary, consistent expression beindividualswho standto be financially neficence. Moreover, supported than"kindhave other motivations by a personneedingan organmight on be to ness" fordonating a relative.Otherdonations might premised for not or concern to be stigmatized love, friendship, guilt, reciprocated be one's intentions to failing donate(OTA 1987,p. 117). How puremust as an altruistic act? Even if it is truethataltruso as to transfer organs social moral blockofbeneficent ismis a necessary communities, building even of and relationships, personal solidarity, thedevelopment significant of if such altruism reduces the depersonalization the modernbureauto cratic society,and ministers basic humanneeds, it is unclearwhy for national "altruism" a depersonalized or either bureaucracy legislated wouldpossess or foster ofthese and distribution any organprocurement thanthe rather legislation, goods. Indeed,it is oftenstatebureaucratic in For altruistic behavior. example, theUnitedStates, that market, limits to forbidden waive are whoacceptMedicarepatients generally physicians even if the physician as of thepatient'sco-payment a matter kindness, is himself the sole bearerof such costs (see U.S. Medicare statute 42, U.S.C. 1320a-7b(b)). in individualaltruism Moreover, legislated"giftgiving"constrains an otherwise commercial wheresurgeons, nurses, pharmaceutisetting, and between cal companies, hospitals highly inequality profit, increasing et al. and thepoorwho donateorgans.This cirsurgeons compensated cumstance raisestheadditionalquestionof who shouldbear theburden of fostering altruism: thosein need of transplants requirecare and support;yet,so too do the familiesof the dying,braindead, or recently deceased potential than organdonors.Rather beingseen as thosein need of kindnessand support, specterof organdonationrecaststhebethe reaved familyas gatekeepers of a scarce medical resource. Organ donationappearsto invert of those who would otherwise recipients be beneficence intothosewho mustagain sacrifice (Epstein 1997, p. 260). Those who shouldbe recipients charity confronted of withtheaddiare tionalburden organprocurement of in The commercial market, policies. wouldallowforaltruism fororgan both donation allocation. and contrast, Ratherthanerodinga sense of community, market the mayenhance anddrawtogether moral a for communities, opening opportunities building

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for sense of social solidarity, developing and personalrelationships, for altruistic as well as forcharitably for sentiments, expressing providing thefundamental needsof others. Expressionsof altruism mayexistside in markets humanorgans.For example,if it is by side withfor-profit to altruistic a parent donatea kidney a childto save his life,it is for to to for altruistic a parent sell a kidney pay fora life-saving to operation a in 1996, p. 392). Forbidding market humanor(Radcliffe-Richards from withothers pool financial to persons joiningtogether gansrestricts It resourcesto purchaseorgansfortheimpecunious. prevents altruistic donationof organsto non-profit groups,who could thensell such parts or to raise fundsto purchasefood,shelter, healthcare forthepoor.Instead of encouraginga hostile relationshipbetween physiciansand would meet who are potential donors,vendorsand physicians patients, A in on a moreequal footing. market human organswouldlikelybe more thancurrent nationalized bureaucratic successful each ofthesegrounds on suchas presumed consent manand or other proposed policies, procedures and in encouraging altruism community choice, solidarity. datory of Another maybe depossibility moralharmis thatsuch a market violate theirdignity. Compare organ gradingto vendorsand thereby "In now values the sex, each party selling to prostitution: commercial .. a surrenders certain other merely instrumentally. . The customer only is cedes herbody:theprostitute degraded of amount cash; theprostitute Satz arto the statusof a thing"(Satz 1995, p. 73). This degradation, and to i.e., a failureto respectin theory gues, is also objectification; makespace in practiceforthehumansubjectas a person(Radin 1996, in donors,surgeons, p. 155). As alreadynoted,though, transplantation oralike objectify and allocationagencies,and recipients procurement we someone Moregenerally, do nottreat as them fungible. andtreat gans of Commodification as merely a means if he consentsto be so treated. humanorgansis notan obvious violationof theKantianmaximto treat that absentadditional showing arguments personsas ends in themselves The organmareven consensualsellingof organsis morally injurious. in as and vendors persons moralagents. ketrespects Prohibition, contrast, themunable to makemoraldecidemeanthepoor by considering may sions abouttheirown fates. social exploitaraise additionalconcernsregarding Such arguments secureandable-bodied tion.By forbidding sales,arethefinancially organ the exploiting poor to assuage theirown feelingof guilt,so thatthey have saved thepoorfrom that themwell at night can sleep thinking they would selves? Thatis, therichand able-bodiedunderthiscircumstance the be exploiting poor so as to be able to have the poor not challenge theirview of propermoralconduct.As alreadynoted,some may find

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sale of a redundant organto be an acceptable,indeedvaluable,meansof The their circumstances opportunities. richand ablelife and improving bodied by forbidding organ sales exploit the poor to supporttheir or views on moralpropriety, commodification, huimproper particular on to mandignity, thepoor thisopportunity choose freely the denying how best to advantagethembasis of theirown judgments regarding in selves. While "at leastthesepeople will despairand die quietly, ways and the poor will not force to and less offensive the affluent healthy, busiin on their by repulsive misery ourattention engaging thestrikingly or ness of sellingpartsof themselves repairthedeficiencies therich" to is 1996, (Radcliffe-Richards p. 406), theoutcome robustly paternalistic. IV. Some Final Reflections on Exploitation In part,language regarding exploitation appears to be parasiticon choices. If one and heteronomous the distinction betweenautonomous this oftenmeans thatpersonsare being thatX is exploitative, argues is so to giveninducements act in a waythat heteronomous that1) though a claim,3) theyare offered good, 2) to whichtheyhad no independent for existsindepento theyare required engagein activities whichthere dentgroundsforholdingthatit is immoral(e.g., such actionsviolate humandignity, the commodify humanbody,etc.). In that improperly a choice. Therefore, justifiedinthe act involvesheteronomous sense, of an is vocation a viewthat offer exploitative dependson an independent to argument show thatthe action would 1) illicitlyviolate the natural the good of maintaining bodyas a whole,2) involvea violationof human dignity,3) improperlycommodifythe human body, or 4) is the to justifiably morally repugnant; thereby, returning matter considerationsotherthanexploitation. Which is to say thatif thereare not independent moralgroundsto show thatthe sale of organsis immoral, thenthe purchaseof organs from poor will be exploitative and onlyif either1) suchindepenthe if dentgrounds impropriety be established 2) thepolicyon balance of can or will cause moreharmthanbenefit thepoor.However, for assessingthis latter condition will require that recognizing allowingthepoorto choose on theirown view of the good both protects poor from the being demeanedby being considered unable to make moralchoices abouttheir ownfuture helpsto educateindividuals their and in faculties freeand of choice. responsible Saint Edward's University

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1. The categories of "harmful,""mutually advantageous," and "moralistic" (1992, 1996). exploitationare borrowedfromWertheimer 2. Helena Ragon reports thatmanycommercialsurrogates view theirworkas a vocation or calling, a means by which to fulfillthemselves(1994, p. 55). Similarly, where Titmuss argued that the social conditions of blood vending conduced to among vendors,recentempiricalstudiesreveal feelingsofduressand dissatisfaction satisfaction among both paid and volunteer donors (Puig et al. 1995). The effects payingblood donorsmaynotbe as appreciable as Titmuss of "crowding-out" asserted. 3. Given state-legislateddonation, it is more likely less fair since the donor for receives no compensationin return thevalue of his organ,in a way analogous to thieves and theirvictims(Steiner 1984, p. 225). 4. Gerald Dworkin (1982) has argued thatin some contextsit is false thatbeing providedwithmoreoptionsleaves one at least as well offas whentheindividualhad set. a smalleropportunity For example, one' s bargaining powermaybe strengthened the ifone cannotmake certainconcessions. Withregardto an organmarket, concern is thatonce the floodgates are open, poor individuals may find thatothersbegin demandingtheirorgans as a condition for access to certain goods. Will creditors demand theredundant organs of the poor as collateral formakingloans? Yet, such difficultiesare independent of the existence of a market. Once became a successful procedure, demand on family members to transplantation donate organs to each otherbecame perceived as partof one's obligations. Many not may have preferred to have had to make thischoice. Psychological, emotional, and medical needs, as well as a desire to please othersmay influenceone to donate organs (OTA 1987, p. 96). Family membersmay agree to donate organs to avoid or confrontations to satisfy some personal, family,or social objective. This is to especially thecase ifthealternative theproposedprocedureis thedeathof a loved the one. Paternalistically only closes a protecting poor froma humanorgan market of To miserable range of options still further. the dreadfuldifficulties povertyis added state coercion thatremoves an option thatpotentialvendors may see as the best theyhave to bettertheirlives. For example, in India researchersdocumented and thatself-respect social respectincreasedbothbecause of thesaving of another's life and of theabilityof one's familyto prosper(Reddy 1991, p. 176). As RadcliffeRichards argues, "if some of the unemployedcould get a large sum of money and theirfamilies instead of living on the dole, would therebe startagain, supporting and therespectof others?"(1996, but anything a huge increase in theirself-respect internal Some mayfindsale of a redundant organto be an acceptable, indeed p. 389). In valuable, means to improveone's life circumstancesand opportunities. short, Dworkin's concernsmay suggestthe need forcaution,but theydo not appreciably supportprohibition. 5. Consider the ways in which "I was coerced" providesone withan excuse for behavior, while "I was manipulated" generallydoes not (Rudinow inappropriate 1978, p. 339).

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a Hillel Steiner, person'smonopoly 6. To extend analysisfrom an ownership of different monopoly from overhis healthy is ownership natural organs crucially is the a of secured resources. While secondis often the throughviolation rights, first in of whileintervening thecommerce thesecondcan prevent not.Significantly, It aboutexploitation. in of brings intervening thecommerce thefirst exploitation, as as the of others from paying owner theorgan much itis worth forcibly prevents (1984, p. 239).

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