Is legalizing commercial kidney donation medically-ethically justifiable?
It is estimated that in the United States, seventeen people die each day while waiting for kidney transplants that cannot take place due to a shortage of donated organs. Owing to a rising prevalence in kidney disease and extending treatment possibilities such as dialysis, the entire Western world struggles with a demand for kidneys which abundantly exceeds supply.
Despite efforts by national governments, public strategies to expand the kidney donor pool have mostly been unsuccessful. The despair of people with end-stage renal failure has led to so-called transplantation tourism, with rich patients paying up to $87 000 for a kidney in countries such as China. Commercial kidney trade now accounts for five to ten percent of worldwide performed kidney transplants. Previously regarded unethically, an increasing number of professionals call for the establishment of a regulated kidney market to meet the urgent need for kidneys. This has led to a heated discussion between opponents and supporters of commercializing kidney trade.
The World Health Organization (WHO) is strongly against payment for any type of organ donation. Organ trade is illegal in all countries, except for Iran. The Istanbul Declaration of 2008 condemns commercial transplants on the grounds of principles of equity, justice and respect for human dignity. In addition, organ trade is prohibited by article 3 of the Declaration of the Fundamental Rights of the European Union. China, the country with the second highest transplantation rate has recently introduced stronger restrictions on organ trade as well.
Transplant commercialism as a moral imperative
Feelings of aversion are common when the rich and healthy of the Western world are confronted with organ trade. The discussion of commercial organ donation is overshadowed by horrendous stories about exploitation and murder in countries like Pakistan and China. Nonetheless, it is essential to have strong arguments against organ trade before banning it.
First, it is unethical itself to let patients die of a treatable disease. Besides, many poor people might benefit from it. With the fight against poverty still far from reaching its goal, they should be provided with alternatives to ameliorate their financial situation. A regulated market in kidneys is an example of such an alternative.
Moreover, the fact that people are poor does not exclude them from the right to autonomy. The poor should have the freedom to sell a kidney and to forbid this would be paternalism at its worst form. Therefore, numerous experts on medical ethics are in favor of commercial kidney donation. Janet Radcliffe-Richards, professor of practical philosophy at Oxford Uehiro Centre, stated that we desperately need organs, some people desperately need money; there is going to be an exchange and I would rather it were a legal exchange that we could control than a black market exchange that we can not.
From a strictly medical point of view, kidney trading should be stimulated since transplants from living donors have better medical outcomes than cadaveric ones. Additionally, in a regulated system it is possible to ensure that all surgeries are performed according to Western medical standards. By doing this, the medical risk of kidney donation for the donor is generally low. There is no long-time increased mortality risk for the donor after the initial risks related to surgery.
Opponents of the establishment of a kidney market often state that poor donors are generally uninformed and thus incapable of giving informed consent. This is debatable since the decision to sell a kidney is often taken after serious consideration in order to create a better life for one’s family. To ensure informed consent, competent guardians should be appointed.
Finally, commercial kidney transplantation is cost-effective so that claims on health insurance budgets will decrease. The price for a commercial kidney might be impressive, but the costs are acceptable when considering the annual costs of dialysis (between $30 000 and $60 000 in the USA).
The poor as spare body parts
Despite all the apparent advantages of the sale of kidneys, this practice is a violation of human rights. There are several reasons why transplant commercialism is medically-ethically unacceptable.
First, safety standards are likely to be seriously compromised in developing countries due to corruption, weak infrastructure and a lack of resources. Thus, the regulatory mechanisms of a commercial market will be ineffectively enforced.
Moreover, kidney trade will lead to medical and psychological complications. Several studies report that the health status of vendors worsens after commercial donation, for example because of a lack of follow up care. In addition, vendors suffer from social stigmatization leading to social exclusion and depression. Besides, patients receiving a commercial transplant are worse off compared to those who receive an organ from an altruistic donor due to a lack of screening and unsafe surgery resulting in high infection rates. This results in inferior patient and graft survival. So, for both donors and vendors it is medically irresponsible to allow kidney sale.
Furthermore, legalized organ trading can be regarded unethical and unfair, since wealthy recipients have an advantage over the poor who do not have the financial resources to buy an organ. Instead, medical care should depart from the principle of egalitarianism.
Finally, commercial organ trade will lead to exploitation of the poor as it can be questioned whether selling a kidney is a truly autonomous choice. People who vend their kidney act out of despair: they are compelled by poverty under the pretence of a decision out of free will. In addition, most donors are young men with no or little education. This complicates ensuring informed consent, making it all the more unlikely that vendors have made a conscious choice.
Exploitation of the poor is also encouraged because most vendors receive only a fraction of the eventual price for a kidney. Apart from the fact that it is not a long-term solution, it has not been proven that kidney sale improves poor people’s lives. Several studies confirm that the financial status of kidney vendors even deteriorate after the donation. Besides, it can be questioned whether this way of alleviating poverty is the right one: it forms a resignation with respect to the existence of poverty without any prospect of eliminating the structural causes.
Whether or not one is in favor of commercial kidney donation, alternatives should be examined in order to solve the problem of organ shortage. Examples are the implementation of a ‘presumed-consent’ system – automatic registration as organ donor unless one has opted out – or the extension of crossover kidney transplantation programmes, in which transplants between otherwise incompatible donor-recipient couples are exchanged.
Pakistan: a flourishing kidney bazaar
According to the Sindhi Institute of Urology, approximately 2 000 kidneys are transplanted in Pakistan every year, of which about two-thirds are bought by foreigners from Saudi Arabia, the United Arab Emirates, Britain and Canada. Although legislation has been implemented in 2008 to prevent transplant tourism, the organ market in Pakistan in still thriving with transactions being arranged by intermediaries who recruit donors and bring in recipients by offering ‘transplant packages’ on the internet. Vendors are often inhabitants of rural villages, who have to pay off their debts to the landowner. A study done in Punjab points out that even in the rare case that kidney vendors are able to pay off their loan, they express remorse with regard to selling their organ. As a vendor explained, they find themselves in a situation over which they don’t have control: apna kuch nahin hay – there is nothing that is ours.
- Bakdash T et al. Is it ethical for patients with renal disease to purchase kidneys from the world’s poor? PLoS Med 2006.
- Radcliffe-Richards J et al. The case for allowing kidney sales. International Forum for Transplant Ethics. Lancet 1998.
Moazam F et al. Conversations with Kidney Vendors in Pakistan: An Ethnographic Study. Hastings Center Report 39, no.3 (2009)