If unremunerated blood donors are willing to participate, and if the use of them is economical from the perspective of those collecting blood, I can see no objection to their use. But there seems to me no good reason, moral or practical, why they should be used. The system of paid plasmapheresis as it currently operates in the United States and in Canada would seem perfectly adequate, and while there may always be ways in which the safety and efficiency of (...) supply could be increased, there seems no reason whatever to think that there would be an improvement if the current system changed so as to rely entirely on unpaid donors. Further, given the adequacy of paid plasmapheresis, I could see no problem if the collection of whole blood were to take place on a similar, fully-commercial, basis. Such a view is controversial. To argue for it, this paper offers just one strand in a complex argument: a critique of Richard Titmuss’s Gift Relationship, which holds an iconic position in the critical literature on the paid provision of blood. As I conclude: all told, there seems no good basis for rejecting supply of whole blood for money—let alone the supply of blood plasma. (shrink)

Many liberals believe that government should not base its decisions on any particular conception of the good life. Many believe, further, that this principle of neutrality is best defended through appeal to some normative principle about autonomy. In this essay, I shall discuss the prospects of mounting one such defense. I say only “one such defense” because neutralists can invoke the demands of autonomy in two quite different ways. They can argue, first, that because autonomy itself has such great value, (...) the state can produce the best results by simply allowing each citizen to shape his own life; or they can argue, second, that even if non-neutral policies would produce the most value, the state remains obligated to eschew them out of respect for its citizens' autonomy. Here I shall discuss only the first and more consequentialist of these arguments. (shrink)

ABSTRACT The late Richard Titmuss made a persuasive case against allowing the sale of human blood in his book, The Gift Relationship. His arguments have been developed further by Peter Singer in recent articles. While the issues of quantity and quality of blood under market and non‐market systems have received much attention, the moral and political aspects of the Titmuss‐Singer case have gone relatively unexamined. First, I question their claim that a donation‐only system promotes greater freedom, which rests on a (...) confusion of liberty and opportunity. Next, I consider reasons for doubting their view that altruism is fostered significantly more under the non‐market approach. Finally, I survey recent developments in the quantity‐quality debate and possible implications of the blood controversy for national health care. (shrink)

Order ethicists favour incentives as a means for making moral progress but largely ignore an alternative method, namely, nudging, which has come to prominence through the work of behavioural scientists in recent years. In this paper, we suggest that this is a mistake. Order ethicists have no reason to ignore nudging as an alternative method. Arguments they might press against it include worries about paternalism, manipulation, autonomy, and unintended bad consequences. These are, we argue, largely unfounded insofar as they involve (...) misconceptions or affect incentives as well. In particular, we contend that only some, but not all, nudges are paternalistic, manipulative, and autonomy-reducing. The same is true of incentives. Also, both nudges and incentives can have unintended bad consequences. Therefore, order ethicists cannot endorse arguments against nudges without undermining their favourable view of incentives. In addition, there might be positive reasons to prefer nudges to incentives, for instance, when they are more freedom-preserving, more effective, cheaper, easier to implement, or less inequality-inducing than the latter. (shrink)

DNA databases have significant commercial value. Direct-to-consumer genetic testing companies have built databanks using samples and information voluntarily provided by customers. As the price of genetic analysis falls, there is growing interest in building such databases by paying individuals for their DNA and personal data. This paper maps the ethical issues associated with private companies paying for DNA. We outline the benefits of building better genomic databases and describe possible concerns about crowding out, undue inducement, exploitation, and commodification. While certain (...) objections deserve more empirical and philosophical investigation, we argue that none currently provide decisive reasons against using financial incentives to secure DNA samples. (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)

Article 3.4 of EC directive 89/381 requires member states to take "all necessary measures to promote Community self-sufficiency in human blood or human plasma" and, for this purpose, to "encourage the voluntary unpaid donation of blood and plasma". This paper presents an ethical case in support of the policy of voluntary, unpaid donation.

In ordinary circumstances, human actions have a myriad of unintended and often unforeseen consequences for the lives of other people. Problems of pollution are serious examples, but spillovers and side effects are the rule, not the exception. Who knows what consequences this essay may have? This essay is concerned with the problems of justice created by spillovers. After characterizing such spillovers more precisely and relating the concept to the economist's notion of an externality, I shall then consider the moral conclusions (...) concerning spillovers that issue from a natural rights perspective and from the perspective of welfare economics supplemented with theories of distributive justice. I shall argue that these perspectives go badly awry in taking spillovers to be the exception rather than the rule in human interactions. I. Externalities Economists have discussed spillovers under the heading of “externalities.” To say this is not very helpful, since there is so much disagreement concerning both the definition and significance of externalities. (shrink)

The world is in the early stages of what will be the greatest health crisis since the advent of modern medical technologies. Millions of people—particularly people in many of the world's poor countries—are infected with HIV. The vast majority of these people will go without modern medical intervention or substantial treatment, and will rapidly develop AIDS. The extent of this problem presents profound moral and ethical questions for the world's wealthy people and countries, for it is they who are most (...) able to assist the poor in managing and reversing this human tragedy. (shrink)

Given the current organ shortage, a prevalent alternative to the altruism-based policy is a market-based solution: pay people for their organs. Receiving much popular and scholarly attention, a salient normative argument against neoliberal pressures is the preservation of human dignity. This article examines how advocates of both the altruistic status quo and market challengers reason and weigh the central normative concept of dignity, meant as inherent worth and/or rank. Key rhetorical strategies, including motivations and broader social visions, of the two (...) positions are analyzed and evaluated, and the separation of morally normative understandings of dignity from market encroachment is defended. (shrink)

In the late summer and fall of 1983 articles appeared in such publications as the New York Times, Fortune Magazine, and Science News telling of attempts to set up an agency for the selling of kidneys from living donors. The shortage of organs, especially of kidneys where the transplantation success has increased quite markedly over the past decade, has become something of a crisis. A situation of increased need and inadequate supply is also becoming a problem for such substances as (...) human bone marrow, for use in the treatment of immune and blood diseases, and large quantities of human plasma for use by hemophiliacs. Obtaining a kidney for a patient in renal failure was difficult in the past because adequate matching is likely only between very close relatives. Now with new immunosuppressant drugs such as cyclosporine, close matches have become less important. Cadaver organs or marrow from unrelated living donors can be used with far greater success. The supply problem is still immense and the literature is filled with suggestions for appropriate and efficient means of organ acquisition. One of the latest suggestions involves a system of salvaging based on implied consent of deceased donors. The organs would be taken without asking directly for permission from family. The relatives would have the right to object to the organ removal, but unless they did so, the organ would be taken when needed. (shrink)

A distinctive feature of modern capitalist societies is the tendency of the market to take over the production, maintenance, and distribution of goods that were previously produced, maintained, and distributed by nonmarket means. Yet, there is a wide range of disagreement regarding the proper extent of the market in providing many goods. Labor has been treated as a commodity since the advent of capitalism, but not without significant and continuing challenges to this arrangement. Other goods whose production for and distribution (...) on the market are currently the subject of dispute include sexual intercourse, human blood, and human body parts such as kidneys. How can we determine which goods are properly subjects of market transactions and which are not? The purpose of this article is to propose a theory of what makes economic goods differ from other kinds of goods, which can help to answer this question. (shrink)

Ontario’s Bill 178 proposing a Voluntary Blood Donations Act declares the offer or acceptance of payment for the donation of blood a legal offence and makes it subject to penalty. The bill reinvigorates a fundamental debate about the ethical problems associated with the payment of money for blood. Scarcity of blood donors is a recurring problem in most health systems, and monetary remuneration of the willingness to donate blood is regularly discussed—and sometimes practiced—as a means to overcome scarcity in blood. (...) However, making blood an object of economic exchange has long aroused ethical concerns that often refer to the specific meaning of blood. From the perspective of a modern understanding of money as a metric of economic value, the exchange of money for blood—shed or given—is seen as ethically troubling, because it appears to imply a commensurability of the value of human life and economic wealth. In this paper, we begin with a general taxonomy of the types of arguments that speak in favour or against compensating donors for giving blood. We then describe the context in which the discussion about payment for blood arises, and of the specific aims and concerns that are brought forward in this context. This is used to reconstruct the normative background that supports the rejection of payment for blood as it is envisaged in Bill 178 and the aims of the proposal. We then argue that while a payment indeed changes the nature of a blood donation in an ethically considerable way, we do not believe that decisive arguments against the monetary remuneration of blood donations can be substantiated, at least not independently of assuming specific societal circumstances. Thus it may be possible to establish a stable and safe blood supply through just gratification while at the same time taking strong provisions against social disconnection, injustice, exploitation or heteronomy. (shrink)

Drawing on a social construction theory of ownership in biological material this paper discusses which differences in biological material might motivate differences in treatment and ownership rights. The analysis covers both the perspective of the person from whom the material originates and that of the potential recipient. Seven components of bundles of rights, drawing on the analytical tradition of Tony Honoré, and their relationship to various types of biological material are investigated. To exemplify these categories the cases of a heart, (...) a kidney, stem cells and hair are used. (shrink)

Whereas previous discussions on ownership of biological material have been much informed by the natural rights tradition, insufficient attention has been paid to the strand in liberal political theory represented by Felix Cohen, Tony Honoré, and others, which treats property relations as socially constructed bundles of rights. In accordance with that tradition, we propose that the primary normative issue is what combination of rights a person should have to a particular item of biological material. Whether that bundle qualifies to be (...) called “property” or “ownership” is a secondary, terminological issue. We suggest five principles of bodily rights and show how they can be applied to the construction of ethically appropriate bundles of rights to biological material. (shrink)

Since the early 1970s, Marcel Mauss’s Essai sur le Don, translated into English as The Gift in 1954, has been a standard reference in the social science and bioethical literature on the use of human body parts and substances for medical and research purposes. At that time, three social scientists—political scientist Richard Titmuss in the United Kingdom and sociologist Renée C. Fox working with historian Judith Swazey in the United States—had the idea of using this concept to highlight the fundamental (...) structure of the biomedical practices they were studying, respectively, blood donation, and hemodialysis and organ transplantation. The fact that these first applications of Mauss’s essay should emerge in English- rather than in French-speaking countries raises the question of what the translation of the essay, and notably of the word don as gift, may have to do with this fact. Reading Mauss in translation undoubtedly inspired a seminal approach to interpreting medical and research practices based on bodily giving. This article posits that something may have also been lost: a much broader concept of giving with unquestionable links to the Durkheimian concept of solidarity, which Mauss conceptualizes not only as an obligation but also as a liberty to give. (shrink)

Are socialists best regarded as those who are most truly and consistently committed to democracy, under modern industrial conditions? Is the underlying issue that divides liberals from socialists the degree of their wholeheartedness in affirming the ideal of a democratic society? On the liberal side, Friedrich Hayek has remarked: “It is possible for a dictator to govern in a liberal way. And it is also possible that a democracy governs with a total lack of liberalism. My personal preference is for (...) a liberal dictator and not for a democratic government lacking in liberalism.” No doubt many socialists would wish to quibble with Hayek's free-market oriented conception of liberalism. But I am wondering whether the conceptual map implicit in Hayek's remark is apt. Hayek appears to assume that there are two independent lines of division, one marking greater and lesser commitment to liberal values, the other marking greater and lesser commitment to democratic procedures. According to the conception of socialism as democracy that I wish to examine, a better picture of the political landscape would show one line of division with gradations indicating greater and lesser commitment to democracy. On this continuum, socialists are located at the extreme pro-democratic end, those who favor autocracy at the other end, and liberals somewhere in the middle. The analyst who finds this latter conceptual picture the more illuminating of the two will say that Hayek reveals his rejection of socialism by being less than wholehearted in his support of democracy. (shrink)

In his widely-discussed book, Real Freedom for All, Philippe Van Parijs argues that justice requires the provision of a universal, unconditional basic income. Some critics reject that conclusion on the grounds that it violates requirements of reciprocity or prohibitions on exploitation, free-riding and parasitism. This paper explores a less familiar critique, which operates within the same resource egalitarian parameters as Van Parijs's argument, and leaves unchallenged his conviction that justice requires a basic income. Instead the paper suggests two reasons to (...) doubt his ambitious claims about its magnitude. First, the paper argues that if envy elimination is the fundamental egalitarian aim then Van Parijs's argument for boosting basic income by including jobs within the class of external assets to be equalized is unsuccessful. Second, it argues that Van Parijs fails to show that the provision of basic income should not be constrained by a more restrictive principle for correcting inequalities in personal resources than his favored compensatory norm. Before defending these criticisms, two preliminary sections describe Van Parijs's distributive principles and his central argument for basic income. (shrink)

Can taxation and the redistribution of wealth through the welfare state be conceived as a modern system of circulation of the gift? But once such a gift is institutionalized, regulated and sanctioned through legal mechanisms, does it not risk being perverted or corrupted, and/or not leaving room for genuinely altruistic motives? What is more: if the market’s utilitarian logic can corrupt or ‘crowd out’ altruistic feelings or motivations, what makes us think that the welfare state cannot also be a source (...) of corruption? To explain the standard answers to the abovementioned questions as well as their implications I will first re-examine two opposing positions assumed here as paradigmatic examples of other similar positions: on the one hand, Titmuss’s work and the never-ending debate about it; on the other, Godbout’s position, in-so-far as it shows how Titmuss’s arguments can easily be turned upside down. I will then introduce and reinterpret Einaudi’s “critical point” theory as a more complex and richer anthropological explanation of the problems and answers considered herein. Through the analysis of these paradigmatic positions I will develop two interrelated arguments. 1) The way these problems are posed as well as the standard answers to them are: a) subject to fallacies: the dichotomy fallacy and the fallacy of composition; b) too reductive and simplistic: we should at least try to clarify what kind of ‘gift’ or ‘corruption’ we are thinking about, and who or what the ‘giver’, the ‘corrupter’, the ‘receiver’ and/or the ‘corrupted’ party are. 2) The answers to these problems cannot be found by merely following a theoretical approach, nor can they be merely based on empirical evidence; instead, they need to take into account the forever troublesome, ambiguous and unpredictable matter of human freedom. (shrink)

Critics of investment citizenship often appeal to the idea that citizenship should not be commodified. This chapter clarifies how the different arguments in support of this Commodification Objection are best understood as versions of wider claims in the literature on the moral limits of markets (MLM). Through an analysis of the three main objections – The Wrong Distribution Argument, The Value Degradation Argument, and the Motivational Corruption Argument – it claims that these objections rely on flawed and partial interpretations of (...) the broader debates. As such, they do not in fact support the conclusions critics of investment citizenship wish to draw from them. The paper concludes that the commodification objection to investment citizenship should therefore be abandoned, and that normative resistance to the practice should be made on other grounds. (shrink)

Drawing on empirical evidence in medicine, economics, law, and anthropology, I argue that a market is uniquely capable of meeting the demand for transplantable kidneys, and that it may be arranged so as to operate safely. The welfare gains, expected to accrue to both vendors and recipients, are sufficient to justify sales. Having spelled out the considerations recommending a kidney market, I address the most forceful objections facing the proposal. Despite its currency, the claim that incentives will crowd out altruistic (...) donors and result in a decrease in supply is empirically unsupported and predicated on an implausible view of donorsâ motives. A host of objections claim vendorsâ will not give informed consent. Many such objections identify easily remediable problems, or impose unreasonable standards â standards that would rule out morally permissible kidney donation. And all presuppose a model of morally transformative consent that, I argue, is deficient. Two further challenges point to harms inflicted on those who do not participate in the market. Some claim that those in poverty will be subject to harmful social and legal pressure to vend. This objection fails to distinguish between being pressured to perform a specific act, and being under general economic pressure and having the option to perform an act. It, moreover, presupposes vending more common than is possible. Others worry that the market will give rise to unfair pecuniary externalities. This objection also presupposes that kidney sales will occur more often than is possible. But more importantly, the normative consideration that is supposed to make such externalities especially objectionable, in fact, recommends allowing sales. I also make a political case for kidney sales. I offer an account of the stateâs proper role in the market. I begin with a conception of democratic equality according to which the state is responsible to secure for its citizens the preconditions for democratic participation. I then show that this end would be promoted were the state to end the current prohibition on sales. (shrink)

Semiotic objections to market exchange of a good or service maintain that such exchanges signal an inappropriate attitude to the good or to associated individuals, and that this provides a weighty reason against having or participating in such markets. This style of argument has recently come under withering attack from Jason Brennan and Peter Jaworski (2015a, 2015b). They point out that the significance of any market exchange is explained by a contingent semiotic norm. Given the tremendous value that could be (...) realised by markets in, for instance, bone marrow, or kidneys, deferring to such norms across the board would have very significant opportunity costs. In the absence of any rationale for these norms, they should be ignored completely. We provide one important rationale. Unlike many semiotic objections to markets, we provide a broadly consequentialist semiotic argument. We argue that a range of behaviours play important signalling roles in interpersonal social practices; in particular, in practices involving caring, esteem, and testimony. Markets in these behaviours would distort these signals. Moreover, many of the productive advantages yielded by markets rely in turn on positive market norms that also inhibit the signalling behaviours associated with these nonmarket behaviours. We conclude that there will inevitably be trade-offs between the distributive advantages of new markets and these interpersonal social practices. (shrink)