Last night, on the eve of Saint Valentine’s Day, I had the pleasure of attending a colloquium featuring the distinguished professor William LaFleur (University of Pennsylvania). He visited the University of North Florida and gave a guest lecture on the “Desires of the Dying: Japanese Qualms about the Bioethics of our Time”.
The talk raised a plethora of interesting questions about bioethics in a deeply cultural perspective. There were discussions about brain-death, and how to properly define it (or if the concept is altogether logically flawed). There were discussions about the way to think about organ donation (as a form of resurrection, as we might see it in the US (our beloved lives on in the body of another), or a form of cannibalism (ingestion of another’s body parts in order to live), as it is seen in Japan. There were talks about how and why Japan ought to, or ought not, to put more of an emphasis on transplantations, particularly hearts. Furthermore there were talks about the cultural taboos that define how we in the west and the Japanese in the east, think of death, brain-death, and transplantations.
I, who have extremely limited knowledge about bioethics, and is in no way able to take an educated position on any bioethics issues in the field, found myself pondering out loud if the commercialization of organs is to be dismissed outright. (It was clear from the speaker that he very much opposed such a thing). If, as he had claimed, ethical decision making in the US is very much founded on a Utilitarian framework, then would it not be somewhat defensible that we use organs that are purchased? It seems to me, somehow, that a person who will trade millions of Dollars to use for research and community medical service, in return for moving up on the transplant list, may provide a greater good than someone who is on the list but do not have such a great good to provide. I brought up such an extreme example only to begin the discussion, not to say that it was acceptable for a rich person to walk all over a poor person.
I obviously knew of the grave ethical concerns about organ trade when I posed the question, yet I felt it was warranted to attempt the discourse, even if commercialization of organs is potentially a very slippery slope. For good measure I will list some of the many counter arguments that I heard last night from several members of the audience:
– The person who gets pushed back on the list in favor of the rich person is not just some nobody. Regardless of whether the person who got skipped over is a poor kid from the ghetto or a physician, we do not know the many ways in which this person will enrich our society, if he or she is to get a transplant and survive. All people are of equal value. Thus, we should not have one person take precedence over another, regardless of financial circumstances. [I agree. All people are of equal value and so a system of organs trade would have to ensure that this equality is ensured. Of course, come to think of it, isn’t the argument flawed a bit by the fact that we don’t actually know who will provide more, the rich or poor, and, since we philosophers are not fortune tellers then we can’t really base ethics based on ‘maybes’, can we?]
– If we let the rich buy organs as they please, we could end up with a new form of eugenics. The rich gets to live and the poor gets to die. We already see this in egg donations. Eggs from pretty white girls with blue eyes, tall stature, and a high I.Q. fetch a real pretty penny on the egg donation market. [Of course, we are not actually talking about breeding a new master race. We are talking about people from all walks of life, who are going to die due to failing organs. Hardly candidates for procreating from a eugenics point of view]
– If people get wind of the fact that rich people can buy their way to a heart or liver, while the poor get bypassed on the donation wait-list, then the marginalized and poverty stricken groups would further mistrust a medical community, which has a history of preferential treatment of the rich (and white), along with a history of abuse of the poor minorities, and is therefore struggling with a poor image. Something like organ sales could forever end any hope that minority groups will ever trust the medical establishment. We could, of course, as one person suggested, keep it secret, but imagine the uproar if it was to be discovered. [I am not convinced that a properly established program for dealing and trading in organs would necessarily lead to mistrust. Certainly, if the program only benefited the rich, but that is not a presupposition that we necessarily have to hold. If nothing suspect is going on, that is, if the medical community is clear in its statements about intent and mission, I am afraid I fail to see how it could build mistrust.]
– The idea of trading in organs is entirely too ugly for us to even have a discussion about it. [While any guest-lecture always has to be weighed against the constraints of time, I think the notion that something is ‘too ugly to talk about’ is, if anything a statement of bankruptcy of philosophy. It is exactly the ugly and difficult things that we should be most eager to engage in. Why? Because we have the skills to engage in such matters. Certainly, if we choose, in the light of difficulty, not to use them, we have gained nothing at all, nor have we provided anything to our community (academic, local, global). We are then, essentially, just wasting our time playing games when we are pondering brains in vats and little mind exercises like that.]
I can add some more concerns of my own: How about organ harvesting, preying on the poor, exploitation of people in less developed countries, crime/stolen organs, euthanizing family members to pay for college, procreating merely for the sake of getting organs, etc, etc.
While the Japanese prefer not to be engaged in transplantation of organs (as per LaFleur and also check out http://www.lifestudies.org/reconsidering.html), we seem to have decided that in the US, organ transplants are the way we want to proceed. [BTW: Are we ok with the definition of brain-death?] We think of donors with respect and esteem, and recipients as blessed. The only problem, of course is, that there are not enough organs, and the gap is widening every year. With the aging baby-boomer generation (who are used to getting exactly what they want, when they want it) I think the illegal organ trade is an iceberg of which we have only seen the top. Thus, I would claim (again…this is a claim based on my very limited knowledge of bioethics), that rather than continue working with transplants in a failing system based on ‘donation’ (failing because we do not have to organs we need), we should start thinking about building a framework that actually works. I think we may very well find that system in legalizing commercialization. Commercialization does not have to mean black market prices, exploitation, and crime. Business ethics are certainly very much available for us to negotiate rules, price regulation, customer service, and international law.Furthermore, the market does not have to be one that is based on private enterprise or highest bidder. Prices could be regulated globally, to keep profit margins reasonable and keep people from wildly selling of kidneys to pay off credit card debt. Also, the entire enterprise could, much like insurance companies do now, be funneled through the medical community. That is, hospitals can buy the organs through their supply chains, much like they would a respirator, MRI machine, or syringes. After all, commercialization does not have to mean that the rich man trumps the poor man. It could simply mean that organs, that are so wanted, become available to all, which will eliminate the problem of the rich trying to jump up on the list. If there are enough organs, we won’t have to wait at all.Furthermore, even for the poor, if you have insurance (Don’t even get me started on why a country like the US does not have a universal health plan. It is a travesty!), certainly the cost of an organ can be covered there? VA, Medicaid. Etc.
Another thing that commercialization might resolve is the ethical dilemma that befall the Japanese. On one hand, they want to be healthy. On the other, there is not point in health if you have a heart full of ill intent. That is, wishing the death of another, to ensure your own life gives you only one thing; namely a reason not to live. If the organ, however, comes form a person who gladly and freely sells it while still alive (as in the case of kidneys and livers) or wills it for sale for the benefit of heirs (as in the case of all the rest of the body) one does not have to worry about something bad befalling anyone. Selling an organ would be beneficial for both parties and ’intent’ is preserved as pure.
Ultimately my question is this: Is there a just and fair system which would get us the coveted organs we so desire and/or need, while protecting all humans against exploitation and ensure equal rights for all?