“Medical Tourism” is the travel of residents of one country to another country for treatment. In this article I focus on travel abroad to purchase organs for transplant, what I will call “Transplant Tourism.” With the exception of Iran, organ sale is illegal across the globe, but many destination countries have thriving black markets, either due to their willful failure to police the practice or more good faith lack of resources to detect it. I focus on the sale of kidneys, (...) the most common subject of transplant tourism, though much of what I say could be applied to other organs as well. Part I briefly reviews some data on sellers, recipients, and brokers. Part II discusses the bioethical issues posed by the trade, and Part III focuses on potential regulation to deal with these issues. (shrink)

“Medical Tourism” is the travel of residents of one country to another country for treatment. In this article I focus on travel abroad to purchase organs for transplant, what I will call “Transplant Tourism.” With the exception of Iran, organ sale is illegal across the globe, but many destination countries have thriving black markets, either due to their willful failure to police the practice or more good faith lack of resources to detect it. I focus on the sale of kidneys, (...) the most common subject of transplant tourism, though much of what I say could be applied to other organs as well. Part I briefly reviews some data on sellers, recipients, and brokers. Part II discusses the bioethical issues posed by the trade, and Part III focuses on potential regulation to deal with these issues. (shrink)

While people’s lives continue to be put at risk by the dearth of organs available for transplantation, we must give urgent consideration to any option that may make up the shortfall. A market in organs from living donors is one such option. The market should be ethically supportable, and have built into it, for example, safeguards against wrongful exploitation. This can be accomplished by establishing a single purchaser system within a confined marketplace.Statistics can be dehumanising. The following numbers, however, have (...) more impact than most: as of 24th November, during 2002 in the United Kingdom, 667 people have donated organs, 2055 people have received transplants, and 5615 people are still awaiting transplants.1 It is difficult to estimate how many people die prematurely for want of donor organs. “In the world as a whole there are an estimated 700 000 patients on dialysis . . . . In India alone 100 000 new patients present with kidney failure each year”2 . Almost “three million Americans suffer from congestive heart failure . . . deaths related to this condition are estimated at 250 000 each year . . . …. (shrink)

Two recent cases raise the question: Should the body be considered a form of property? Patients generally do not share in the profits derived from the applications of research on their body parts and products. Nor is their consent for research required so long as the body part is unidentified and is removed in the course of treatment. A market in body parts and products would require consent to all categories of research and ensure that patients are protected from coercion (...) and given the chance to be paid fairly for their contributions. Such a market might force us to rethink our policies prohibiting organ sales. Donors, recipients, and society will benefit from a market in body parts so long as owners—and no one else—retain control over their bodies. (shrink)

Should the idea of economic man-the amoral and self-interested Homo economicus-determine how we expect people to respond to monetary rewards, punishments, and other incentives? Samuel Bowles answers with a resounding "no." Policies that follow from this paradigm, he shows, may "crowd out" ethical and generous motives and thus backfire. But incentives per se are not really the culprit. Bowles shows that crowding out occurs when the message conveyed by fines and rewards is that self-interest is expected, that the employer thinks (...) the workforce is lazy, or that the citizen cannot otherwise be trusted to contribute to the public good. Using historical and recent case studies as well as behavioral experiments, Bowles shows how well-designed incentives can crowd in the civic motives on which good governance depends. (shrink)

The benefits of a large organ pool accrue not only to the actual organ recipients themselves, but to others as well due to the insurance it provides against having to wait ‘too long’ for an organ transplant. We argue that this public good character of a large organ pool makes it economically and ethically justifiable to design a market mechanism that boosts the number of donors. Most importantly, such a mechanism has the potential to substantially alleviate the troubling equity and (...) efficiency problems on the demand side while, at the same time, being entirely independent of the allocation algorithm used for the distribution of organs. (shrink)

The commercial trading of human organs, along withvarious related activities (for example, advertising)was criminalised throughout Great Britain under theHuman Organ Transplants Act 1989.This paper critically assesses one type of argumentfor this, and similar, legal prohibitions:commodification arguments.Firstly, the term `commodification' is analysed. Thiscan be used to refer to either social practices or toattitudes. Commodification arguments rely on thesecond sense and are based on the idea that having acommodifying attitude to certain classes of thing(e.g. bodies or persons) is wrong. The commodifyingattitude consists (...) of three main elements: denial ofsubjectivity, instrumentality, and fungibility.Secondly, in the light of this analysis, the claimthat organ sale involves commodifying the human bodyis examined. This claim is found to be plausible butinsufficient to ground an argument against organ sale,because the very same commodifying attitude is likelyto be present in cases of (unpaid) organ donation. Itis also argued that commodifying bodies per semay not be wrong.Thirdly, the view that organ sale involvescommodifying persons is examined. Although this andthe claim that it is wrong to commodify persons areprobably true, there is – it is argued – littlereason to regard organ sale as worse in this respectthan other widely accepted practices, such as thebuying and selling of labour.The conclusion is that although commodification is auseful ethical concept and although commodificationarguments may sometimes be successful, thecommodification argument against organ sale is notpersuasive. This is not to say, though, that thereare no arguments for prohibition – simply that thisparticular justificatory strategy is flawed. (shrink)

In this book, Alan Wertheimer seeks to identify when a transaction or relationship can be properly regarded as exploitative--and not oppressive, manipulative, or morally deficient in some other way--and explores the moral weight of taking ...

These paperback editions preserve the original texts of these important books while presenting them in durable paperback editions.

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)

An increasingly common objection to kidney sales holds that the introduction of monetary incentives may undermine potential donors’ altruism, discourage donation, and possibly result in a net reduction in the supply of kidneys. To explain why incentives might be counterproductive in this way market opponents marshal evidence from behavioral economics. In particular, they claim that the context of kidney sales is ripe for motivational crowding. This reasoning, if sound, would have a profound influence on the debate over kidney sales. What’s (...) perhaps the principal reason to favor a market – the increase in supply it would bring – would be called into doubt. However, on inspection it becomes apparent that the evidence touted by market opponents not only lends no credence to their claims, but also provides some positive reason to doubt them. The near-ubiquitous references to motivational crowding in the literature on kidney sales are fundamentally misplaced. (shrink)

Erik Malmqvist defends the prohibition on kidney sales as a justifiable measure to protect individuals from harms they have not autonomously chosen. This appeal to ‘group soft paternalism’ requires that three conditions be met. It must be shown that some vendors will be harmed, that some will be subject to undue pressure to vend, and that we cannot feasibly distinguish between the autonomous and the non-autonomous. I argue that Malmqvist fails to demonstrate that any of these conditions are likely to (...) obtain. His argument involves two common errors. First, he, like many, proceeds on a mistaken understanding of how to assess harm. What matters is not the balance of costs and benefits of vending, but a comparison of potential vendors’ welfare across two possible courses of action. Second, Malmqvist's concerns about third-party pressure are predicated on an empirically unrealistic understanding of the operation of a regulated market. A widely underappreciated fact is that kidney sales will be relatively rare, and most who try to vend will be unable to. Because pressure on another to vend will not result in the desired outcome, few will exert it. (shrink)

Erik Malmqvist defends the prohibition on kidney sales as a justifiable measure to protect individuals from harms they have not autonomously chosen. This appeal to ‘group soft paternalism’ requires that three conditions be met. It must be shown that some vendors will be harmed, that some will be subject to undue pressure to vend, and that we cannot feasibly distinguish between the autonomous and the non-autonomous. I argue that Malmqvist fails to demonstrate that any of these conditions are likely to (...) obtain. His argument involves two common errors. First, he, like many, proceeds on a mistaken understanding of how to assess harm. What matters is not the balance of costs and benefits of vending, but a comparison of potential vendors’ welfare across two possible courses of action. Second, Malmqvist's concerns about third-party pressure are predicated on an empirically unrealistic understanding of the operation of a regulated market. A widely underappreciated fact is that kidney sales will be relatively rare, and most who try to vend will be unable to. Because pressure on another to vend will not result in the desired outcome, few will exert it. (shrink)

The demand for bodily parts such as organs is increasing, and individuals in certain circumstances are responding by offering parts of their bodies for sale. Is there anything wrong in this? Kant had arguments to suggest that there is, namely that we have duties towards our own bodies, among which is the duty not to sell parts of them. Kant's reasons for holding this view are examined, and found to depend on a notion of what is intrinsically degrading. Rom Harré's (...) recent revision of Kant's argument, in terms of an obligation to preserve the body's organic integrity, is considered. Harré's view does not rule out all acts of selling, but he too ultimately depends on a test of what is intrinsically degrading. Both his view and Kant's are rejected in favour of a view which argues that it does make sense to speak of duties towards our own bodies, grounded in the duty to promote the flourishing of human beings, including ourselves. This provides a reason for opposing the sale of bodily parts, and the current trend towards the market ethic in health care provision. (shrink)

Despite stringent and fine tuned laws most jurisdictions are not able to curb organ trafficking. Nor are they able to provide organs to the needy. There are reports of the kidnapping and murder of children and adults to “harvest” their organs. Millions of people are suffering, not because the organs are not available but because “morality” does not allow them to have access to the organs. Arguments against organ sale are grounded in two broad considerations: sale is contrary to human (...) dignity, and sale violates equity. Both these objections are examined in this article and it is concluded that they reflect a state of moral paternalism rather than pragmatism. It is argued that a live human body constitutes a vital source of supply of organs and tissues and that the possibilities of its optimum utilisation should be explored. Commercialisation should be curbed not by depriving a needy person of his genuine requirements but by making the enforcement agencies efficient. (shrink)

In my recent article in the Journal of Medical Ethics, I attacked the Laissez Choisir Argument in defence of letting individuals choose whether to sell kidneys or other organs as living donors, and I argued that such transactions should generally remain prohibited.1 The LC Argument arises as a response to a prohibitionist claim that I endorse: organ sales should be banned to protect potential poverty-stricken vendors, even if a free market could provide great benefits to potential organ recipients. The LC (...) Argument says that this is misplaced paternalism, since banning the market only takes away from willing vendors what they must regard as their best option, thereby leaving them even worse off, at least as they see things. My refutation of the LC Argument pointed out, on the contrary, that giving some people the option to sell their organs may harm them in ways they would reasonably prefer not to be harmed—even though they would reasonably prefer to take the option once it is presented. The upshot is that many potentially willing organ vendors might themselves reasonably prefer prohibition. I argued that the harms of a live donor organ market to this group would in fact be significant and unavoidable, and that it would be morally impermissible to impose these harms. And I suggested that this argument for prohibition best explicates an inchoate but widely shared moral concern about the exploitative nature of live donor organ trading.I thank Gerald Dworkin, Janet Radcliffe Richards and Adrian Walsh for their engaging and often insightful commentaries.2–4 I agree with a lot, but I will …. (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)

Background: It is often claimed that a regulated kidney market would significantly reduce the kidney shortage, thus saving or improving many lives. Data are lacking, however, on how many people would consider selling a kidney in such a market. Methods: A survey instrument, developed to assess behavioural dispositions to and attitudes about a hypothetical regulated kidney market, was given to Swiss third-year medical students. Results: Respondents’ median age was 23 years. Their socioeconomic status was high or middle. 48 considered selling (...) a kidney in a regulated kidney market, of whom 31 would sell only to overcome a particularly difficult financial situation. High social status and male gender was the strongest predictor of a disposition to sell. 32 of all respondents supported legalising a regulated kidney market. This attitude was not associated with a disposition to sell a kidney. 5 respondents endorsed a market and considered providing a kidney to a stranger if and only if paid. 4 of those 5 would sell only under financial duress. Conclusions: Current understanding of a regulated kidney market is insufficient. It is unclear whether a regulated market would result in a net gain of kidneys. Most possible kidney vendors would only sell in a particularly difficult financial situation, raising concerns about the validity of consent and inequities in the provision of organs. Further empirical and normative analysis of these issues is required. Any calls to implement and evaluate a regulated kidney market in pilot studies are therefore premature. (shrink)

From all points of the political compass, from widely different groups, have come indignant outcries against the trade in human organs from live vendors. Opponents contend that such practices constitute a morally outrageous and gross exploitation of the poor, inherently coercive and obviously intolerable in any civilized society. This article examines the arguments typically offered in defense of these claims, and finds serious problems with all of them. The prohibition of organ sales is derived not from the principles and argument (...) usually invoked in support of prohibition, but rather, from strong feelings of repugnance which exert an invisible but powerful influence on the debate, distorting the arguments [and working] to the detriment of the [very] people most in need of protection. (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)

The target article challenges the increasingly popular portrayal of living kidney sale as potentially a mutually beneficial arrangement, capable not only of saving or improving the lives of patients in need of transplants but also of significantly benefiting poor vendors. Carefully reviewing the literature on harms to vendors in illegal kidney markets and in Iran’s legal market, Koplin argues that many of these harms would persist in the sort of legal regulated system that kidney sale advocates envision. This is an (...) important argument. The kidney sales debate has been skewed in favor of permitting sales by a simplified view of the potential harms involved and excessive optimism about the capacity of regulation to prevent these harms. The article counterbalances these tendencies and thus considerably weakens the case for allowing sales. Nonetheless, some market proponents might remain unconvinced. I shall suggest that in addition to the lessons that Koplin draws from existing kidney markets, there is yet another one, which casts further doubt on the advisability of allowing kidney sales. (shrink)

This paper challenges the view that bans on kidney sales are unjustifiably paternalistic, that is, that they unduly deny people the freedom to make decisions about their own bodies in order to protect them from harm. I argue that not even principled anti-paternalists need to reject such bans. This is because their rationale is not hard paternalism, which anti-paternalists repudiate, but soft paternalism, which they in principle accept. More precisely, I suggest that their rationale is what Franklin Miller and Alan (...) Wertheimer call ‘group soft paternalism’. Group soft paternalistic policies restrict the freedom of autonomous individuals, not for their own good (hard paternalism), but as an unavoidable consequence of seeking to protect other, non-autonomous individuals from harms that they have not voluntarily chosen (soft paternalism). Group soft paternalism supports prohibiting kidney sales on three conditions: (1) that such sales are potentially harmful to vendors, (2) that many vendors would suffer impaired autonomy, and (3) that distinguishing between autonomous and non-autonomous vendors and interfering only with the latter is unfeasible. I provide reasons for thinking that these conditions will often hold. (shrink)

I argue that women in traditional marriages are a vulnerable source for kidneys and this vulnerability gives rise to exploitative donation arrangements made within families. In so doing, I critique Alan Wertheimer’s account of the impact that emotional closeness between participants in an agreement has on the wrongfulness of exploitation. I propose a regulated market scheme that is not only less exploitative than our current donation scheme, but also resolves a variety of other moral problems that typically arise in real (...) and imagined kidney sale scenarios, problems that render markets “noxious,” according to Debra Satz. (shrink)

Countries throughout Asia promote themselves as leading destinations for international travelers seeking inexpensive healthcare. India, Indonesia, Malaysia, Singapore, the Philippines, and Thailand are all trying to attract greater numbers of what their promotional campaigns call “medical tourists.” Government tourism initiatives, hospital associations, medical tourism companies, and individual hospitals advertise hip and knee replacements, spinal surgery, cosmetic surgery, and other medical procedures. In contrast to most nations marketing treatments to international patients, the Philippines differentiates itself by selling “all inclusive” kidney transplant (...) packages. Patients from other countries travel to the Philippines and receive kidneys purchased from poor individuals. (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)

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)

One common objection to establishing regulated live donor organ markets is that such markets would be exploitative. Perhaps surprisingly, exploitation arguments against organ markets have been widely rejected in the philosophical literature on the subject. It is often argued that concerns about exploitation should be addressed by increasing the price paid to organ sellers, not by banning the trade outright. I argue that this analysis rests on a particular conception of exploitation, and outline two additional ways that the charge of (...) exploitation can be understood. I argue that while increasing payments to organ sellers may mitigate or eliminate fair benefits exploitation, such measures will not necessarily address fair process exploitation or complicity in injustice. I further argue that each of these three forms of wrongdoing is relevant to the ethics of paid living organ donation, as well as the design of public policy more generally. (shrink)

This article concerns the morality of establishing regulated kidney markets in an effort to reduce the chronic shortage of kidneys for transplant. The article tries to rebut the view, recently defended by James Taylor, that if we hold autonomy to be intrinsically valuable, then we should be in favor of such markets. The article then argues that, under current conditions, the buying and selling of organs in regulated markets would sometimes violate two Kantian principles that are seen as moral constraints. (...) One principle forbids expressing disrespect for the dignity of humanity; the other forbids treating others merely as means. In light of the moral danger posed by regulated markets, the article advocates an alternative way of diminishing the current organ shortage, namely opt-out systems of cadaveric organ donation. (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.

Following an earlier paper in the journal in which Evans argued that it was commercial exploitation, not mere payment, that was morally objectionable about certain sorts of organ donation, this paper looks at the moral issues when commercial exploitation is eliminated from systems of paid organ donation. It argues that there are no conclusive moral arguments against such schemes for non-exploitative paid kidney donation.

ABSTRACT Largely as a result of public outcry, legislation has recently been passed in the UK prohibiting the sale of bodily parts. This topic was the focus of a recent article in Journal of Applied Philosophy by Ruth Chadwick, which acknowledged that difficulties might exist in trying to distinguish between the selling of one's bodily organs and the selling of one's labour. The position argued for, in the ensuing discussion, is that there is no relevant moral difference between the two (...) acts. Furthermore it contests the view that the sale of bodily organs should necessarily be prohibited. The assertion is made that the legislation does little to prevent the general exploitation of the type of person likely to be involved in such transactions, places unnecessary restrictions on the autonomy of individuals, and does nothing to promote an enhanced moral attitude by health professionals. (shrink)

Transplantation is a medically successful and cost-effective way to treat people whose organs have failed--but not enough organs are available to meet demand. T. M. Wilkinson explores the major ethical problems raised by policies for acquiring organs. Key topics include the rights of the dead, the role of the family, and the sale of organs.

In Why Some Things Should Not Be for Sale, philosopher Debra Satz takes a penetrating look at those commodity exchanges that strike most of us as problematic. What considerations, she asks, ought to guide the debates about such markets? What is it about a market involving prostitution or the sale of kidneys that makes it morally objectionable? How is a market in weapons or pollution different than a market in soybeans or automobiles? Are laws and social policies banning the more (...) noxious markets necessarily the best responses to them? Satz contends that categories previously used by philosophers and economists are of limited utility in addressing such questions because they have assumed markets to be homogenous. Accordingly, she offers a broader and more nuanced view of markets--one that goes beyond the usual discussions of efficiency and distributional equality--to show how markets shape our culture, foster or thwart human development, and create and support structures of power. (shrink)

In recent years, the free market position has been gaining strength. In this book, Radin provides a nuanced response to its sweeping generalization.

_Bodies for Sale: Ethics and Exploitation in the Human Body Trade _explores the philosophical and practical issues raised by activities such as surrogacy and organ trafficking. Stephen Wilkinson asks what is it that makes some commercial uses of the body controversial, whether the arguments against commercial exploitation stand up, and whether legislation outlawing such practices is really justified. In Part One Wilkinson explains and analyses some of the notoriously slippery concepts used in the body commodification debate, including exploitation, harm and (...) consent. In Part Two he focuses on three controversial issues outlining contemporary regulation and investigating both the moral issues and the arguments for legal prohibition. (shrink)

Philosophers have given sustained attention to the controversial possibility of (legal) markets in transplantable human organs. Most of this discussion has focused on whether such markets would enhance or diminish autonomy, understood in either the personal sense or the Kantian moral sense. What this discussion has lacked is any consideration of the relationship between self-ownership and such markets. This paper examines the implications of the most prominent and defensible conception of self-ownership--control self-ownership (CSO)--for both market and nonmarket organ-allocation mechanisms. The (...) paper contends that CSO rules out a large set of nonmarket mechanisms, including escheatage ("presumed consent"), compensated takings of organs, and restricted gifting. It also argues that CSO, if accompanied by an economistic concern for welfare, can underwrite varying types of markets in human organs, ranging from mutual-insurance pools to inter vivos (i.e., live donor) organ sales. (shrink)