In one of recent articles published on the Economist on 12 May 2018 titled: ‘Bans on paying for human blood distort a vital global market’, Barzin Bahardoust expresses his amazement in life (The Economist, 2018). Barzin Bahardoust is the founder of Canadian Plasma Resources (CPR) firm and for considerable years he has been trying to compensate residents of Canada for their blood plasma. However, his pursuit for compensating blood plasma donors has faced huge resistance from human rights activists and groups. For example, when Canadian Plasma Resources attempted to establish clinics in Ontario in 2014, the firm’s efforts were thwarted by local activists’ anti-campaigns (The Economist, 2018). The local activists actually opposed the plans by the firm to pay donors for their blood-plasma and this led to ultimate ban on paid plasma donation by the provincial government of Ontario. Similarly, efforts by Bahardoust’s firm to open clinics in Alberta province never yielded fruits. The provincial government of Alberta banned the practice of paying for blood plasma in 2017 (The Economist, 2018). Nevertheless, the plans to enact legislation in British Columbia seeking to legalize compensation for blood plasma give Bahardoust some hope.
The demand for blood plasma across the globe is growing. Focusing on altruistic donations alone cannot meet the increasing demand for plasma worldwide. In 2016, the value of plasma exports worldwide was estimated to be $126 billion (The Economist, 2018). Paid plasma is permitted in United States, China, Parts of Canada, as well as in some countries in Europe. Countries that allow plasma compensation have proven successful in securing blood plasma supplies. Studies have found that only countries that permit paid plasma have potential of attaining self-sufficient in blood plasma. Although, paid plasma may have capacity to end the chronic blood plasma shortage globally, it is faced numerous challenges. Ethical, medical and social concerns are main challenges that are related to paid plasma. The Economist’s census data analysis reveals that most plasma centers in U.S are situated in postal districts of which 27.4% of inhabitants are poor (The Economist, 2018). Some people fear that allowing global market for paid plasma and other human organs will continue to exploit poor or less privileged communities. Other fears for liberalizing plasma market are spread of health disorders such as hepatitis and HIV, and lowering the supply of ‘’whole’’ blood. It is important to mention here that large proportion of ‘’whole’’ blood is donated voluntarily.
Another contentious issue is legalization of human kidney trade. Gary Becker, a Nobel prize-winning economist, has argued that the ban on voluntary trade and sale of human organs is possibly taking lives of innocent individuals. Approximately, 95,000 American citizens were on waiting queue for new kidneys in 2012 (Yanklowitz, 2015). This figure is shocking considering the fact that just nearly 16,500 kidney transplant operations were undertaken in the same year. Research shows that about 4,000 people in U.S die annually as they wait for the lifesaving organ. The deficiency of kidneys for transplant is a major problem in almost all countries worldwide. According to Yanklowitz (2015), only about 66,000 kidney transplants are carried out each year in the whole world. Luc Noel, the person in charge of monitoring transplantation issues for World Health Organization in Geneva, has reported that healthcare systems across the globe are a distant away from satisfying the needs of people requiring kidney transplant (Yanklowitz, 2015). Despite of ethical or moral issues surrounding liberalization of organ donations market, there are fears that legalizing organ donation trade would lead to exploitation of poor and vulnerable members of society. There are concerns that poor people individuals may be forced to sell their organs or unwilling persons getting their kidneys forcibly removed and then traded (Roth, Sönmez " Ünver, 2007).
Proposal to solve the shortage of human organs for transplant
To address the severe deficiency of human organ for transplant, the relevant institutions should make the trade of human organs/blood legitimate. However, appropriate measures should be taken to ensure the process is implemented in the right manner. For instance, international standards that will track transplantation quality, prohibit commercialization, keep the process transparent, and protect the vulnerable and poor individuals from exploitation should be upheld.
Even though compensating donors for their organs appears to offer a solution for the prevailing situation, the solution raises several concerns. Concerns such as abuse of rights of poor people, as well as reduced supply of ‘’whole’’ blood makes implementation of this solution somehow complex. As a consequence, formulation of research question shown below is important to assist in navigating the emerging issues.
Research Question
To what extent a market for human organs / blood is morally legitimate?
This paper will attempt to explore ethical or moral concerns surrounding making the market for organ donations liberal. Thorough literature review concerning legalization of human organ trade has been conducted to assist in answering the research question. Furthermore, the paper draws a lot from relevant theoretical models.
Theoretical background and Literature Review
In this section, a comprehensive and detailed review of existing literature is conducted to help in answering the research question. The literature review utilizes secondary sources including peer review journals, books, and websites.
The Cost of Queuing
There is a common consensus that the number of persons who are in need of organ transplant exceeds the number of organs existing for transplant by far. Majority of individuals longing for kidney transplant are under dialysis and this poses a great danger to such individuals because life expectancy while on dialysis is short (Becker " Elias, 2014). Studies have found that patients who are between 45 and 49 years can only live for 8 more years when they remain on dialysis. However, they can live for additional 23 years if they receive kidney transplant in time (Becker " Elias, 2014). The inability to substitute the defective kidney with a functional one increases the chances of dying. The burden of queuing for both patients and their care takers is enormous. This includes both decreased life expectancy and numerous challenges of remaining on dialysis. The average cost of dialysis is estimated as $80,000 per year (World Health Organization, 2009). The median period of kidney waiting is 4.5 years and this translates to total cost of $350,000 (World Health Organization, 2009). Taking into account that patients on dialysis are unable to work, this cost places a huge burden to patients and their families.
Supply and Demand for blood imbalances
Managing demand and volunteer supply has been subject to incidents of both additional supply and deficiencies because of the absence of market price for whole blood donations, as well as existence of short storage period for whole blood. Blood donations supply spikes always happen after calamities. This trend can be attributed to altruistic responses of suppliers and lack of sufficient market indications that would have shown minimal or no change in demand. Factors like technical constraints, spikes in donations, collection agency policies, and 6-week shelf-life for whole blood have significantly contributed to destroying blood supply after occurrence of national calamities. For example, according to Slonim, Wang and Garbarino (2014), Red Cross collected extra 570,000 units of blood following the 9/11 terror attack. At the same time approximately 100,000 to 300,000 units of whole blood were finally discarded at a cost of between $21 million and $63 million (American Red Cross, 2013). The burgeoning literature about blood donation reports that the whole blood donation market in affluent nations is currently characterized by volunteer supply inspired by philanthropy (Slonim, Wang " Garbarino, 2014). With no price mechanism to regulate supply and demand, it is ridiculous to believe that a balance between supply and demand will ever be achieved.
There are several avenues of increasing whole blood donation supply as suggested by latest studies. Research by Lacetera and Macis (2010) reveals that social recognition and symbolic rewards like medals have inspired donors to give more blood in Italy. This research is reinforced by studies undertaken by Garbarino, Slonim, and Wang (2013), and Lacetera, Macis, and Slonim (2013). Garbarino, Slonim, and Wang (2013) found that offering unconditional gift increased donations among 6,000 Australian blood donors who for the last 28 months had not donated blood. Likewise, Lacetera, Macis, and Slonim (2013) reported that providing small awards such as gift cards, lottery tickets and t-shirts to individuals who come to donate blood increases supply without necessarily impacting donations in future. According to recent studies, blood safety is not affected by the enticements (Lacetera, Macis, and Slonim, 2013). The main emphasis of the existing studies is that donors prefer getting prizes for presenting themselves to give blood as opposed to being promised to receive incentive after actual blood donation.
The Four Principles
Beauchamp and Childress in their book titled ‘’the Principles of Bioethics’’ explain four important principle of bioethics namely; autonomy, beneficence, nonmaleficence, and justice (Beauchamp " Childress, 2001). The principle of autonomy generally implies the right of self-determination (Beauchamp " Childress, 2001). From the perspective of medical ethics, a competent patient has the choice to accept or deny medical care even when in lifesaving medical care (Childress " Liverman, 2006). A competent patient here is defined as a person who can make informed decision. The principle of beneficence requires physicians to act in the best interest of the patient. According to the tenet of nonmaleficence, the medical practitioner should where possible avoid harming a patient (Cherry, 2015). Considering medical procedures such as cancer chemotherapy, it can be argued that none of these three tenets is absolute because at certain instances physicians cause some harm to patient with their treatment. Nonetheless, these principles are interpreted to imply that the accrued medical benefits should be higher than the related risks of harm.
Since the principle of justice refers to obligations that stretch beyond the relationship between the physician and the patient, it has been cited as the most challenging or complicated one. Jonsen, Siegler and Winslade (2006) assert that justice is critical in policy decisions (Jonsen, Siegler " Winslade, 2006). However, they issued a warning that the principle of justice should not be applied to make decisions at the bedside decisions (Jonsen, Siegler " Winslade, 2006). Deontological justice and utilitarian justice are the two major competing notions of justice in the field of medical ethics. The focus of utilitarian justice is on the efficiency or utility (Hippen, Ross " Sade, 2009). According to utilitarian justice, a transplantation scheme of organs is considered fair if it maximizes the number of life-years obtained (Hippen, Ross " Sade, 2009). Generally, the emphasis is maximizing the wellness or health of the highest number. On the other hand, deontological justice places emphasis on equity and a just dissemination of resources regardless of the efficiency cost. The practice in organ transplantation is founded on regulations and standards that seek to balance efficiency and equity. The existing deceased donor distribution system that places emphasis on queuing time (equity), as well as on the ABO blood type matching (efficiency) provides a good example of this practice (Hippen, Ross " Sade, 2009).
The Misery of Black Markets
The implausibility of arguments surrounding the buying and selling of organs implies that the moral permissibility of organ trade is a contentious and complex issue. World Health Organization reports that about 10,000 black market operations dealing with human kidney selling takes place each year (Hippen, Ross " Sade, 2009). Vendors in black market are basically poor and experience serious physical and psychological traumas. Recent study conducted in Bangladesh found that kidney vendors suffer from crying spells, grave sadness and haplessness (Hippen, Ross " Sade, 2009). In addition, the study reported that kidney sellers undergo social isolation, shame and stigma for trading their body organs. Another research in Chennai, India has revealed that more than 85% of kidney vendors experienced reduction in health after donating their kidney redress (Hippen, 2005). The same study reported that 80% of kidney donors would not advice that other people in similar conditions trade a kidney redress (Hippen, 2005).
The present market of underground organ trafficking may be deliberately created to use suppliers whose economic position would reduce, as well as sellers whose health will worsen (Hippen, 2005). Considering that suppliers from the least class of society are more probable to perform worst, less likely to be aware of involved risks and less likely to possess effective means of compensation when cheated via use of a promulgated and transparent rule of law (Hippen, 2005), it is prudent to conclude that such individuals are the least adept of acting at liberty when making choices regarding becoming vendors. As it stands, the modern organ trafficking is morally impermissible and the imposed ban is justifiable. Currently, the success of organ trafficking operation relies on deceiving suppliers and recipients by routinely breaching contractual treaties without ways for redress (Hippen, 2005). In addition, vendors and recipients are defrauded about the associated risks to their well-being.
Analysis
This section tries to critically analyze and evaluate arguments held by both proponents and opponents of organ market. Through evaluation of the available assertions about opening liberal market for human organs, a better understanding of the extent to which a market for human organs / blood is morally legitimate can be established.
Proponents of market for human organs argue that the principle of autonomy implies that persons have the right to what they deem appropriate with their own bodies (Hippen, Ross " Sade, 2009). Provided the vendor trades his or her kidney willingly and without coercion, the supporters believe that the vendor is at liberty to do so. Proponents also use beneficence tenet to support their claims. Several individuals lose lives while queuing to receive kidney transplant (Taylor, 2017). According to beneficence principle, medical practitioners are obligated to act in the best interests of patients. Therefore, when physicians permit the sale of kidneys to save lives of sick persons they are acting in the best interests of patients as demanded by beneficence principle (Childress " Liverman, 2006). Furthermore, supporters claim that utilitarian idea of justice would promote any approach that seeks to increase organ supply and protect lives. In light of this claim, it can be argued that if the market can lower the deficiency of organs and there justifiable reasons to have faith it will do so, then the market can be considered moral (Satz, 2008). Although supporters acknowledge existence of inequalities, they suggest that the market will permit people with little resources to try to make their conditions better through selling their kidneys vial liberal market.
Nonetheless, there exists a fallacy in the arguments of supporters as it pertains to autonomy. According to bioethics principles, the tenet of autonomy is not absolute. Autonomy is faced with moral limitations. Harm to others has been identified as one major constraint facing autonomy principle (Hippen, Ross " Sade, 2009). However, it is important to note that the harm to the vendor of organ is to himself or herself and this excludes the notion maintaining that a society is worse off when it permits its members to trade their body organs on basis of commodification (Hippen, Ross " Sade, 2009). According to the claim of commodification, the marketing valuation has a declining effect on particular practices and products if they are sold and purchased regardless of whether a just bargaining position is available (Goodwin, 2006). Constraints are placed on autonomy to safeguard people from themselves. For instance, the society bans people from trading themselves into slavery with an intention of protecting them.
Opponents of organ market claim that the act of individuals to sell their own body organs is permanently wrong. One prominent philosopher supporting this argument is Immanuel Kant. Kant believes that it is an obligation of humans to act in a manner that portrays respects for mankind dignity (Childress " Liverman, 2006). According to Kant, people have a value beyond price irrespective of where they are placed on the spectrum of happiness, affluence or talent (Childress " Liverman, 2006). Kant holds the proposition that the action of an individual to trade his/her own body part is always wrong due to obvious reason that the act itself fails to demonstrate accepted respect for the vendor’s own dignity (Childress " Liverman, 2006). He believes that the action always portrays an untruthful message. In contrast to Kant’s believe, it is implausible to hold that each moment an individual vends one of his or her internal body organs, he or she is portraying such a message. Notably, kidney cannot be equated to a person. Therefore, when individuals sell their kidneys do not imply that they have an ordinary price.
According to antagonists of organ markets, allowing the trade of body organs would nurture group distinctions and violate the inalienable morals of life and freedom (Taylor, 2017). Ostensibly speaking, class or group distinctions are nurtured more blatantly by the supposition that a whole group of individuals is irresistibly separated from freedom and life if adequate money is included. In fact, reliance on the distortion of ‘’economic man’’ propelled completely by materials desires remains a supposition for opponents of organ markets (Hippen, 2005). On the other hand, the advocates of organ markets maintain that the justification for decisions formed by liberal ethical agents are insufficiently described by economic determinism and are less transparent to the audience than is generally believed. Supporters unanimously accept that the worth of permitting market exchanges is paramount. Actually, they assert that markets are essentially valuable in allowing people with diverse and opposing moral commitments to meet and mingle on the foundation of shared agreement and peaceful negotiation (Hippen, 2005). Similarly, advocates believe that avoiding certain market associations can demonstrate moral commitments of a certain individual.
Conclusion
The existing system of procuring organs for transplant is inconsistent and is destined to fail. Claims of opponents for organ market depend on demonstrably incorrect comparisons (Goodwin, 2006), entail circular ethical reasoning like commodity fetishism (Hippen, 2005), human slavery and organ trafficking (Cherry, 2015), and fail when the analogized system is analyzed in broader scope (Satz, 2008). Engaging in an organ market is subject to side-limitations of transparency, rule of law, safety and institutional ethics.
Besides adoption of a regulated market in body organs creating moral arguments, it also raises concerns of whether the actual supply increase will be realized. According to current systematic review of research, providing financial incentives for blood donation does not necessarily increase supply of whole blood (Lacetera, Macis, and Slonim, 2013). However, it is important to state that effects of compensation might be different for blood and kidneys (Taylor, 2017). It is still unclear the extent to which a regulated market would in reality increase supply of body organs like kidney. A deontological justice is the most suitable notion of justice for public society in a democratic society which values human dignity, as well as human rights. Deontological approach of justice ought to ban the sale of human organs on basis of exploitation or commodification.
Although I personally recommend that the trade of human organs/blood legitimate, a number of issues need to be addressed. Consequently, there is need to focus future research on maximizing voluntary deceased donation, prevention, and developing alternative organ sources like therapeutic organ cloning. In addition, future research should focus on investigation of xenotransplantation.
References
American Red Cross. 2013. “Eligibility Criteria by Alphabetical Listing.” http://www.redcrossblood .org/donating-blood/eligibility-requirements /eligibility-criteria-alphabetic
Beauchamp, T. L., " Childress, J. F. (2001). Principles of biomedical ethics. Oxford University Press, USA.
Becker, G. S., " Elias, J. J. (2014). Cash for kidneys: the case for a market for organs. The Wall Street Journal, 18.
Cherry, M. J. (2015). Kidney for sale by owner: human organs, transplantation, and the market. Georgetown University Press.
Childress, J. F., " Liverman, C. T. (2006). Report of the Institute of Medicine Committee on Increasing Rates of Organ Donation. Organ donation: Opportunities for action.
Garbarino, E., Slonim, R., " Wang, C. (2013). The multidimensional effects of a small gift: Evidence from a natural field experiment. Economics Letters, 120(1), 83-86.
Goodwin, M. (2006). Black markets: the supply and demand of body parts. Cambridge University Press.
Hippen, B. E. (2005). In defense of a regulated market in kidneys from living vendors. Journal of Medicine and Philosophy, 30(6), 593-626.
Hippen, B., Ross, L. F., " Sade, R. M. (2009). Saving lives is more important than abstract moral concerns: financial incentives should be used to increase organ donation. The Annals of thoracic surgery, 88(4), 1053-1061.
Jonsen A, Siegler M, " Winslade, W. (2006). Clinical ethics. a practical approach to ethical decisions in clinical medicine. 6. New York: McGraw-Hill Companies Inc
Lacetera, N., " Macis, M. (2010). Social image concerns and prosocial behavior: Field evidence from a nonlinear incentive scheme. Journal of Economic Behavior " Organization, 76(2), 225-237.
Lacetera, N., Macis, M., " Slonim, R. (2013). Economic rewards to motivate blood donations. Science, 340(6135), 927-928.
Roth, A. E., Sönmez, T., " Ünver, M. U. (2007). Efficient kidney exchange: Coincidence of wants in markets with compatibility-based preferences. American Economic Review, 97(3), 828-851.
Satz, D. (2008, October). XIV—The Moral Limits of Markets: The Case of Human Kidneys. In Proceedings of the Aristotelian Society (Vol. 108, No. 1_pt_3, pp. 269-288). Oxford, UK: Oxford University Press.
Slonim, R., Wang, C., " Garbarino, E. (2014). The market for blood. Journal of Economic Perspectives, 28(2), 177-96.
(The Economist, 2018). Bans on paying for human blood distort a vital global market. Print edition, International.
Taylor, J. S. (2017). Stakes and kidneys: why markets in human body parts are morally imperative. Routledge.
World Health Organization. (2009). WHO Global Consultation: 100% Voluntary Nonremunerated Donation of Blood and Blood components. June. http://www. who. int/blood safety/events/consultation_vnrbd/en.
Yanklowitz, S. (2015). Give a Kidney, Get a Check. The Atlantic. Retrieved from https://www.theatlantic.com/business/archive/2015/10/give-a-kidney-get-a-check/412609/
