Background Advocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales. Methods This study (...) reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation. Results and discussion According to Islamic law, organ donation is an act of _sadaqatul jariyah,_ and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim _eethaar_, undermining donors of ‘selfless’ or ‘altruistic’ motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran’s unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran’s unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of ‘buyer and seller’, ensuring the philosophy of ‘donor and recipient’ is maintained. Conclusions Offering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors’ health and reducing human suffering without legalizing the human organ trade. (shrink)

Worldwide 1.2 million people are dying from kidney failure each year, and in the USA alone, approximately 100 000 people are currently on the waiting list for a kidney transplant. One possible solution to the kidney shortage is for governments to pay donors for one of their healthy kidneys and distribute these kidneys according to need. There are, however, compelling objections to this government-monopsony model. To avoid these objections, I propose a small adjustment to the model. I suggest we reward (...) kidney sellers with both money and a ceremony that celebrates their noble act. They should, in other words, receive a prize rather than a price. (shrink)

Due to the shortage of organs, it has been proposed that the ban on organ sales is lifted and a market-based procurement system introduced. This paper assesses four prominent proposals for how such a market could be arranged: unregulated current market, regulated current market, payment-for-consent futures market, and the family-reward futures market. These are assessed in terms of how applicable prominent concerns with organ sales are for each model. The concerns evaluated are that organ markets will crowd out altruistic donation, (...) that consent to sell organs is invalid, that sellers will be harmed, and that commodification of organs will affect human relationships in a negative way. The paper concludes that the family-reward futures market fares best in this comparison but also that it provides the weakest incentive to potential buyers. There is an inverse relationship between how applicable prominent critiques are to organ market models and the increase in available organs they can be expected to provide. (shrink)

In The Gift Relationship, Richard Titmuss argued that the practice of altruistic blood donation fosters social solidarity while markets in blood erode it. This paper considers the implications of this line of argument for the organ market debate. I defend Titmuss’ arguments against a number of criticisms and respond to claims that Titmuss’ work is not relevant to the context of live donor organ transplantation. I conclude that Titmuss’ arguments are more resilient than many advocates of organ markets suggest, and (...) more relevant to the debate than is commonly appreciated. (shrink)

This issue of the Journal of Medicine and Philosophy brings together fresh essays addressing three main genres of questions: questions about the nature of bioethical inquiry and the relevance of the humanities to medical practice; questions regarding the ethics of organ donation; questions bearing on the application of fairness to the distribution of medical resources.

Advocates of paid living kidney donation frequently argue that kidney sellers would benefit from paid donation under a properly regulated kidney market. The poor outcomes experienced by participants in existing markets are often entirely attributed to harmful black-market practices. This article reviews the medical and anthropological literature on the physical, psychological, social, and financial harms experienced by vendors under Iran's regulated system of donor compensation and black markets throughout the world and argues that this body of research not only documents (...) significant harms to vendors, but also provides reasons to believe that such harms would persist under a regulated system. This does not settle the question of whether or not a regulated market should be introduced, but it does strengthen the case against markets in kidneys while suggesting that those advocating such a system cannot appeal to the purported benefits to vendors to support their case. (shrink)

Proponents of permitting living kidney sales often argue as follows. Many jobs involve significant risks; people are and should be free to take these risks in exchange for money; the risks involved in giving up a kidney are no greater than the risks involved in acceptable hazardous jobs; so people should be free to give up a kidney for money, too. This paper examines this frequently invoked but rarely analysed analogy. Two objections are raised. First, it is far from clear (...) that kidney sales and dangerous jobs involve comparable risks on an appropriately broad comparison. Second, and more importantly, even if they do involve comparable risks it does not follow that kidney sales must be permitted because dangerous jobs are. The analogy assumes that kidney sales are banned for paternalistic reasons. But there may be other, non-paternalistic reasons for the ban. And paternalists, too, can consistently defend the ban even if kidney sales are no riskier than occupations that they find acceptable. Soft paternalists may want to protect would-be vendors from harms that they have not voluntarily chosen. Egalitarian hard paternalists may want to protect already badly off vendors from further worsening their situation. For neither species of paternalist is the size of the risk prevented decisive. I conclude that the analogy with dangerous jobs, while rhetorically powerful, pulls little real argumentative weight. Future debates on living kidney sales should therefore proceed without it. (shrink)

A prominent defence of a market in organs from living donors says that if we truly care about people in poverty, we should allow them to sell their organs. The argument is that if poor vendors would have voluntarily decided to sell their organs in a free market, then prohibiting them from selling makes them even worse off, at least from their own perspective, and that it would be unconscionably paternalistic to substitute our judgements for individuals' own judgements about what (...) would be best for them. The author shows that this ‘Laissez-Choisir Argument’ for organ selling rests on a mistake. This is because the claim that it would be better for people in poverty to sell their organs if given the option is consistent with the claim that it would be even better for them to not have the option at all. The upshot is that objections to an organ market need not be at all paternalistic, since we need not accept that the absence of a market makes those in poverty any worse off, even from their own point of view. The author goes on to argue that there are strong theoretical and empirical reasons for believing that people in poverty would in fact be harmed by the introduction of a market for live donor organs and that the harm constitutes sufficient grounds for prohibiting a market. (shrink)

This paper canvasses recent arguments in favor of commercial markets in human transplant kidneys, raising objections to those arguments on grounds of the role of injustice, exploitation, and coercion in compromising the autonomy of those most likely to sell a kidney, namely, the least well off members of society.

The recent review of the Unrelated Live Transplant Regulatory Authority provides administrative and statistical information regarding living donor kidney transplantation in the United Kingdom.1 However, it leaves much unsaid. For example, although the report does mention the number of live kidney donations from unrelated donors that ULTRA has approved, it fails to mention that the United Kingdom has a low live kidney donation rate compared with other European countries .2 More importantly, the report does not address the fundamental question of (...) whether the legal framework underlying ULTRA is morally justified. The legal regime in the United Kingdom proceeds on the tacit assumption that genetically unrelated donors are much more vulnerable to coercion than are related donors, and hence are more in need of protective regulation. In this article, we argue that the distinction drawn in the United Kingdom between genetically related and unrelated donors is difficult to justify, that it unnecessarily discourages live organ donation, and that the law should be changed.BACKGROUNDThe Unrelated Live Transplant Regulatory Authority is a creature of the Human Organ Transplant Act , which was enacted by parliament in 1989, and which came into force, with regulations, on 1 April 1990.3–5 The Human Organ Transplant Act was enacted hastily after the General Medical Council’s inquiry into the notorious case of a British physician’s involvement in transplants involving Turkish peasants.6 Young men were inveigled by an agent to travel to London, ostensibly to take up new jobs. In fact, they were being recruited as living donors of kidneys transplanted into fee paying foreign patients. The consequent debate in the media attracted an emotional …. (shrink)

This paper argues that a sweatshop worker's choice to accept the conditions of his or her employment is morally significant, both as an exercise of autonomy and as an expression of preference. This fact establishes a moral claim against interference in the conditions of sweatshop labor by third parties such as governments or consumer boycott groups. It should also lead us to doubt those who call for MNEs to voluntarily improve working conditions, at least when their arguments are based on (...) the claim that workers have a moral right to such improvement. These conclusions are defended against three objections: 1) that sweatshop workers' consent to the conditions of their labor is not fully voluntary, 2) that sweatshops' offer of additional labor options is part of an overall package that actually harms workers, 3) that even if sweatshop labor benefits workers, it is nevertheless wrongfully exploitative. (shrink)

This paper offers a positive suggestion for the management of a market in organs for transplant; and in doing so provides a useful opportunity for clarifying the structure of the Great Organ Sales Debate. The issue is in constant need of clarification, because it is usually aired as a political question of the For and Against variety: should organ selling be legal or not? This format usually encourages protagonists to collect into an unsorted heap whatever arguments look as though they (...) might have any persuasive force on their side, and because people may be on the same political side for different moral reasons, or have the same moral principles but reach different political conclusions, the political arguments tend to obscure both the real issues and the logical structure of the controversy. Although attitudes to organ selling seem to have relaxed somewhat since the subject first came to light about a dozen years ago, most professional and political opinion is still against it. But what is the moral basis of this opposition? If you think organ selling should remain illegal, what exactly is your reason? Is it that you regard selling body parts as wrong in itself, irrespective of consequences? Or is it because you think that although it is not wrong in itself, in practice the harms will usually or always outweigh the benefits? Either of these quite different views might support the same political conclusion. In practice, it is not clear that many opponents of organ selling have ever recognised the distinction. Most of …. (shrink)

As we look to the future in a world with porous borders and boundaries transgressed by technologies, an inevitable question is:Can there be a single, global bioethics? Intimately intertwined with this question is a second one: How might a global bioethics account for profound - and constantly transforming - sources of cultural difference? Can a uniform, global bioethics be relevant cross-culturally? These are not simple questions, rather, a multi-dimensional answer is required. It is important to distinguish between two meanings of (...) bioethics: the academic discipline of bioethics as opposed to bioethics as a set of practices governing clinical care and scientific research. There is growing evidence to support the notion of a shared global understanding of bioethics as a field of inquiry focused on the moral dimensions of science and biomedicine. (shrink)

As we look to the future in a world with porous borders and boundaries transgressed by technologies, an inevitable question is:Can there be a single, global bioethics? Intimately intertwined with this question is a second one: How might a global bioethics account for profound - and constantly transforming - sources of cultural difference? Can a uniform, global bioethics be relevant cross-culturally? These are not simple questions, rather, a multi-dimensional answer is required. It is important to distinguish between two meanings of (...) bioethics: the academic discipline of bioethics as opposed to bioethics as a set of practices governing clinical care and scientific research. There is growing evidence to support the notion of a shared global understanding of bioethics as a field of inquiry focused on the moral dimensions of science and biomedicine. (shrink)

In 1997, a Scottish surgeon by the name of Robert Smith was approached by a man with an unusual request: he wanted his apparently healthy lower left leg amputated. Although details about the case are sketchy, the would-be amputee appears to have desired the amputation on the grounds that his left foot wasn’t part of him – it felt alien. After consultation with psychiatrists, Smith performed the amputation. Two and a half years later, the patient reported that his life had (...) been transformed for the better by the operation [1]. A second patient was also reported as having been satisfied with his amputation [2]. (shrink)

ABSTRACT Should surgeons be permitted to amputate healthy limbs if patients request such operations? We argue that if such patients are experiencing significant distress as a consequence of the rare psychological disorder named Body Integrity Identity Disorder (BIID), such operations might be permissible. We examine rival accounts of the origins of the desire for healthy limb amputations and argue that none are as plausible as the BIID hypothesis. We then turn to the moral arguments against such operations, and argue that (...) on the evidence available, none is compelling. BIID sufferers meet reasonable standards for rationality and autonomy: so as long as no other effective treatment for their disorder is available, surgeons ought to be allowed to accede to their requests. (shrink)

Many still oppose legalizing markets in human organs on the grounds that they are morally repugnant. I will argue in this paper that the repugnance felt by some persons towards sales of human organs is insufficient to justify their prohibition. Yet this rejection of the view that markets in human organs should be prohibited because some persons find them to be morally repugnant does not imply that persons’ feelings of distress at the possibility of organ sales are irrational. Eduardo Rivera-Lopez (...) argues that such instinctive distress is an appropriate response to the perception that certain kinds of arguments that are offered in favor of legalizing organ sales are “in an important sense, illegitimate.” Having argued that repugnance should not ground the prohibition of markets in human organs, I will also argue that the moral distress that some feel towards certain arguments that favor such markets is not rationally defensible, either. (shrink)

This article focuses on ethical issues surrounding the selling and buying of human organs. The author argues that most people who sell their organs in India do so in order to pay already existing debts. The transaction is only temporarily an exchange of “life for life,” and most “donors” are back in debt soon after the operation. The author discusses the flexible ethics that reduce reality to dyadic transactions and the purgatorial ethics that collapse real and imaginary exploitation in the (...) service of complex interests. He also offers a sophisticated discussion of the ethics of publicity and public ethics. He emphasizes the lack of factual information, intentional manipulation of information, and the dissemination of kidney panics and kidney scandals, especially by the new developing bioauthorities and bioethical brokers. (shrink)

An important argument against prohibiting organ sales is that it removes the best option available to individuals in dire circumstances. However, this line of reasoning fails to recognise that selling a kidney on a regulated market is only the best option in a very narrow comparison, where a regulated organ market is compared with banning organ sales. Once we acknowledge this narrowness, selling a kidney is not the best option. This paves the way for a distributive justice-based critique of the (...) ‘best option’ argument for organ markets, which illuminates that organ markets should be compared with a broader set of alternatives. If providing the option of selling a kidney is not the best option, but rather the best option we are willing to provide, and one which means that many people will remain in poverty and unjust circumstances, then this reflects poorly on those societies willing to offer only this option and not a better one. (shrink)

Anti-commodification theorists condemn liberal political philosophers for not being able to justify restricting a market transaction on the basis of what is sold, but only on the basis of how it is sold. The anti-commodification theorist is correct that if this were all the liberal had to say in the face of noxious markets, it would be inadequate: even if everyone has equal bargaining power and no one is misled, there are some goods that should not go to the highest (...) bidder. In this paper, I respond to the anti-commodification critique of liberalism by arguing that the political liberal has the wherewithal to account not only for the conditions under which goods should not be sold, but also for what kinds of goods should not be for sale in a market economy. The political liberal can appeal to a principle of equal basic rights, and to one of sufficiency in basic needs and the social bases of self-respect, I argue, to account for what’s problematic about markets in civic goods, necessary goods, and physical goods including body parts and intimate services. (shrink)

Julian Koplin, drawing extensively on empirical data, has argued that vendors, even in well-regulated kidney markets, are likely to be significantly harmed. I contend that his reasoning to this conclusion is dangerously mistaken. I highlight two failures. First, Koplin is insufficiently attentive to the differences between existing markets and the regulated markets proposed by advocates. On the basis of this error, he wrongly concludes that many harms will persist even in a well-regulated system. Second, Koplin misunderstands the utilitarian assessment of (...) the market. He focuses on the costs and benefits of the transaction for the vendor. But, the relevant comparison is between an individual’s welfare across different courses of action, namely, vending and the nonvending alternative. Although Koplin’s empirically informed contribution is a welcome addition to this literature, the mistakes that pervade his interpretation of the data demand correction. (shrink)

It is widely agreed that living kidney donation is permitted but living kidney sales are not. Call this the Received View. One way to support the Received View is to appeal to a particular understanding of the conditions under which living kidney transplantation is permissible. It is often claimed that donors must act altruistically, without the expectation of payment and for the sake of another. Call this the Altruism Requirement. On the conventional interpretation, the Altruism Requirement is a moral fact. (...) It states a legitimate constraint on permissible transplantation and is accepted on the basis of cogent argument. The present paper offers an alternative interpretation. I suggest the Altruism Requirement is a moral fiction—a kind of motivated falsehood. It is false that transplantation requires altruism. But the Requirement serves a purpose. Accepting it allows kidney donation but not kidney sale. It, in short, rationalizes the Received View. (shrink)

Kidney markets are prohibited in principle because they are assumed to undermine the seller’s dignity. Considering the trade-off between saving more lives by introducing regulated kidney markets and preserving the seller’s dignity, we argue that it is advisable to demand that citizens restrain their own moral judgements and not interfere with the judgements of those who are willing to sell a kidney. We also argue that it is advisable not only to limit the political implications of the moral argument of (...) dignity concerns toward a market-based solution but also to re-evaluate the dignity argument itself. First, if the dignity argument is to be given normative force, it must also consider the dignity violation of the potential transplant recipient. Second, there seems to be no compelling notion of dignity that demonstrates why it is morally permissible to donate but not to sell a kidney. (shrink)

Globally there is a shortage of organs available for transplant resulting in thousands of lives lost as a result. Recently in the United Kingdom 457 people died as a result of organ shortage in just 1 year. 1 NHS Blood and Transplant suggest national debates to test public attitudes to radical actions to increase organ donation should be considered in addressing organ shortage. The selling of organs for transplant in the United Kingdom is prohibited under the Human Tissue Act 2004. (...) This discussion paper considers five ethical objections raised in the United Kingdom to paid donation and discusses how these objections are addressed within the only legal and regulated paid living unrelated renal donation programme in the world in Iran, where its kidney transplant list was eliminated within 2 years of its commencement. This article discusses whether paid living unrelated donation in Iran increases riskier donations and reduced altruistic donation as opponents of paid donation claim. The paper debates whether objections to paid donation based upon commodification arguments only oppose enabling financial ends, even if these ends enable beneficent acts. Discussions in relation to whether valid consent can be given by the donor will take place and will also debate the objection that donors will be coerced and exploited by a paid model. This article suggests that exploitation of the paid donor within the Iranian model exists within the legally permitted framework. However, paid living kidney donation should be discussed further and other models of paid donation considered in the United Kingdom as a radical means of increasing donation. (shrink)

Has not the time fully come to lift the prohibition on a regulated market in organs for transplantation? Is there a price for such a market that would be too high to pay? The author revisits the cases for and against organ markets in the light of cultural shifts in society and asks whether the traditional insistence on altruism represents a hindrance to much needed developments or a safeguard for much valued public goods.