Organ trade

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Organ trade is the trade of human organs, tissues or other body parts, usually for transplantation. There is a global need or demand for healthy body parts for transplantation, far exceeding the numbers available.

As of 2018, about 114,000 people were reported to be waiting for a new organ in the United States.[1] On average, an individual will wait three and a half years for an organ to become available for transplant.[2] There is a worldwide shortage of organs available for transplantation,[3] yet commercial trade in human organs is illegal in all countries except Iran. Despite these prohibitions, organ trafficking and transplant tourism remain widespread. The data on the extent of the black market trade in organs is difficult to obtain. The question of whether to legalize and regulate the organ trade to combat illegal trafficking and organ shortage is hotly debated. This discussion typically centers on the sale of kidneys by living donors, since human beings are born with two kidneys but need only one to survive.

Legal organ trade[edit]

Iran is the only nation that allows organs to be bought and sold legally. However, it does place restrictions on the commercial organ trade in an attempt to limit transplant tourism. The market is contained within the country; that is, foreigners are not allowed to buy the organs of Iranian citizens. Additionally, organs can only be transplanted between people of the same nationality – so, for example, an Iranian cannot purchase a kidney from a refugee from another country.[4] The system is largely charity- and volunteer-based, and those tasked with matching donors and patients are not paid for their work.[5]

Proponents of legalized organ trade have hailed the Iranian system as an example of an effective and safe organ trading model. An article in the Clinical Journal of the American Society of Nephrology notes that the Iranian model has avoided many problems associated with organ trade. The article points out that every other solution attempted in other developing countries has failed even to slow down the continual growth of organ transplant wait lists.[6]

All other nations have some form of legislation meant to prevent the illegal trading of organs, whether by an outright ban or through legislation that limits how and by whom donations can be made.

Organ prices[edit]

In Iran's legal markets, the price of a kidney ranges from $2,000 to $4,000.[7][8] On the black market, however, the price may be above $160,000, most of which is taken by middlemen.[9] Additionally, when done through black market-affiliated medical providers, the transplant operation is dangerous to both the donor and recipient, and the recipient often contracts hepatitis or HIV.[7] The typical price paid to donors on the black market is thought to be about US$5,000, but some donors receive as little as $1,000.[10]

Government compensation for donors[edit]

Australia and Singapore recently legalized monetary compensation for living organ donors. Proponents of such initiatives say that these measures do not pay people for their organs; rather, these measures merely compensate donors for the costs associated with donating an organ.[11] For example, Australian donors receive 9 weeks' paid leave at a rate corresponding to the national minimum wage.[12] Kidney disease advocacy organizations in both countries have expressed their support for this new initiative.[13][14]

Although American federal law prohibits the sale of organs, it does permit state governments to compensate donors for travel, medical, and other incidental expenses associated with their donation. In 2004, the state of Wisconsin took advantage of this law to provide tax deductions to living donors to defray the costs of donation.[15]

Iran[edit]

In Iran, it remains legal to sell a kidney for profit. Iran currently has no waitlists for kidney transplantation.[6] Kidney sales are legal and regulated. The Charity Association for the Support of Kidney Patients (CASKP) and the Charity Foundation for Special Diseases (CFSD) control the trade of organs, with the support of the government. These nonprofit organizations match donors to recipients, setting up tests to ensure compatibility. The compensation paid to the donor varies, but an average kidney donor is paid $1,200.[4] Some donors are also offered employment opportunities. Charity organizations support recipients that cannot afford the cost of the organ.[16]

Some critics argue that the Iranian system is in some ways coercive, as over 70% of donors are considered poor by Iranian standards.[5] There is no short-term or long-term follow-up on the health of organ donors.[17] In fact, there is evidence that Iranian donors experience highly negative outcomes, both in terms of health and emotional well-being.[18]

Illegal organ trade[edit]

According to the World Health Organization (WHO), illegal organ trade occurs when organs are removed from the body for the purpose of commercial transactions.[19] The WHO has stated that “Payment for...organs is likely to take unfair advantage of the poorest and most vulnerable groups, undermines altruistic donation and leads to profiteering and human trafficking.”[20] Despite ordinances against organ sales, it was estimated that in 2005, 5% of all organ recipients had engaged in commercial organ transplants.[21] Research indicates that illegal organ trade is on the rise, with a recent report by Global Financial Integrity estimating that the illegal organ trade generates profits between $600 million and $1.2 billion per year, with a span over many countries. These countries include, but are not limited to:

Criminal networks increasingly engage in kidnappings, especially of children and teenagers, who are then taken to locations with medical equipment. There they are murdered and their organs harvested for the illegal organ trade.[41]

Poverty and loopholes in legislation also contribute to the illegal trade of organs.[42] Poverty is common in all countries with a large black market for organs. As discussed above, legislation containing loopholes, like India's Transplantation of Human Organs Act, allows organ sales to continue.[43] Likewise, India's laws forbid monetary transactions for organs, but do not regulate funds given to a spouse. This provides another loophole for illegal trade; in some cases, an organ donor will marry the recipient to avoid a legal penalty.[44]

History[edit]

The international community and national governments have long attempted to find stable, ethical systems to deal with the high demand for organ transplants. In 1968, the United States implemented the Uniform Anatomical Gift Act of 1968, which gave individuals the right to donate their organs after their death. Later, the U.S. enacted the National Organ Transplant Act of 1984, which established a national online registry for organ donors and prohibited organs from being bought or sold in the U.S. The most recent efforts of the United States to combat high organ demand include the revision of the Uniform Anatomical Gift Act in 2006 and the 2007 Charlie W. Norwood Living Organ Donation Act.[19]

Many other countries have passed laws aimed at ending illegal organ trade. For example, South Africa adopted the Human Tissue Act of 1983, which outlaws the transfer of tissue (including flesh), bone, organ, or bodily fluid in exchange for payment.[43] In May 2007, China adopted the Human Transplantation Act, banning organ commercialism.[45]

Prosecuted cases[edit]

Though claims of organ trafficking are difficult to substantiate due to lack of evidence and reliable data, cases of illegal organ trade have been tried and prosecuted in the past. It is estimated that 42% of transplanted organs come from illegal trafficking in organs.[46]

In 1993, Bombay police exposed a kidney sale and transplantation operation run by a man known as Santosh Raut. Eleven people, including Raut and two nephrologists, were arrested, but Raut managed to escape. Authorities believe that Raut went on to establish similar illegal kidney centers across many Indian cities. In February 2008, another kidney transplant center, run by a man called Amit Kumar, was discovered by police in Delhi and nearby Gurgaon. Due to technological advances in fingerprinting, Kumar and Raut are now believed to be the same perpetrator, having gone by many aliases throughout years of illegal activity. Kumar is facing charges for his decades of involvement in illegal organ trade, which includes over 600 illegal kidney transplants and the involvement of at least two hospitals.[18]

In 2007, a man in the United Kingdom became the first person convicted under the Human Tissue Act 2004 after he attempted to sell his kidney online for £24,000 in order to pay off his gambling debts.[47]

In July 2009, Levy Izhak Rosenbaum of Brooklyn was arrested for conspiring to arrange the sale of an Israeli citizen's kidney to an undercover FBI officer for $160,000 during Operation Bid Rig.[48] According to the charges against him, Rosenbaum said he had been involved in the illegal sale of kidneys for 10 years. Acting US Attorney Ralph Marra said: "His business was to entice vulnerable people to give up a kidney for $10,000 which he would turn around and sell for $160,000." Anthropologist and organ trade expert Nancy Scheper-Hughes stated that she had informed the FBI that Rosenbaum was "a major figure" in international organ smuggling 7 years prior, and that many of Rosenbaum's donors had come from Eastern Europe. She also heard reports that Rosenbaum held donors at gunpoint to ensure they donated their organs.[49] Rosenbaum pleaded guilty to organ trafficking in 2011.

In November 2010, the South African National Direct of Public Prosecution found St. Augustine's Hospital, owned and operated by the private company Netcare Kwa-Zulu (Pty) Limited, guilty of 102 counts of activity relating to illegal kidney transplant operations. Convicted along with the private company were four transplant doctors, a nephrologist, two transplant administrative coordinators, and a translator. The charges against the parent company, Netcare, and its CEO, Richard Friedland, were dropped in order to obtain an admission of guilt from the hospital. The private company pleaded guilty to 109 illegal kidney operations performed on Israeli, Romanian, and Brazilian citizens between June 2001 and November 2003, including five minors. These citizens received cash following their surgeries, while the private company was paid up-front for its involvement in the operations.[50]

In December 2010, Turkish nationals were reported to be involved in organ trafficking in Kosovo.[51][52] In 2013, "an international panel of judges from the European Union Rule of Law Mission in Kosovo"[53] convicted five people for illegal organ trade.

In 2014, an alleged member of the Mexican Knights Templar Cartel was arrested for kidnapping and murdering minors. Children were found wrapped in blankets and stuffed in a refrigerated container inside a van. Various accounts have stated the arrested man is part of a network that kidnaps and kills minors, after which their organs are removed. The cartel's other sources of income include drug trafficking, extortion, illegal mining, and, illegal logging.[38][54]

Media portrayal[edit]

There have been various portrayals of illegal organ trade and organ trafficking in the mass media over the past few decades. The 1977 fictional novel Coma by Robin Cook, made into a movie by Michael Crichton, tells of unsuspecting medical patients who are put into a coma in order for their organs to be removed. Similarly, the 1993 book The Baby Train by Jan Brunvand reveals the mythical story of a man who wakes up in his hotel room with a missing kidney the night after flirting with a woman at a bar.[46] In addition to books and films, stories of organ trafficking are often depicted through television, tabloid magazines, emails, and the Internet.[55]

Many of the organ trafficking tales depicted in the media contain unsubstantiated claims. For example, the 1993 British/Canadian TV program The Body Parts Business made a number of claims about organ trafficking that later proved to be false. The program investigated alleged organ and tissue trafficking in Guatemala, Honduras, Argentina, and Russia. One episode discussed a man named Pedro Reggi, reporting that his corneas had been removed without his consent while he was hospitalized in a mental facility. Reggi later disputed this claim, saying that his corneas were still intact, and he had just been suffering from an acute eye infection.[55]

Critics, such as Silke Meyer, argue that this sensationalized view of organ trafficking, often depicted as an urban myth, distracts attention from the illegal organ trade. They call for increased scientific research on illegal organ trade, so that organ trafficking legends can be replaced by scientific fact. Meyer argues: "Only then will [organ trafficking] be taken seriously by all governments affected and will the results constitute a solid ground for the field of policy-making."[46]

The Red Market[edit]

In 2011, Scott Carney coined the term "Red Market" to describe a broad category of economic transactions related to the human body.[56] He argues that advances in science have served to increase the demand for human body parts. He writes that this increased demand has enabled a vast "Red Market," encompassing a wide variety of transactions, from organ sale to organ thievery, 'bone thievery', 'blood farming', and even rented space in women's wombs.[56]

Drawing on the concepts of black markets, white markets, and gray markets, Carney suggests that commerce in body parts is distinct because bodies are not commodities in a strict sense. That is, a body part and its worth cannot be assigned a monetary value. Furthermore, Carney argues, trade in body parts creates a lifelong debt between the provider and the recipient. Straight commerce in human bodies reduces a human life to its 'meat value'. Carney calls for "radical transparency" in the red market supply chain in order to protect its humanness.[56]

Current state[edit]

According to the most recent Bulletin of the World Health Organization on the state of the international organ trade, 66,000 kidney transplants, 21,000 liver transplants, and 6,000 heart transplants were performed globally in 2005.[21] A 2008 article reported that the median waiting time for the United States transplant list was greater than 3 years (with projections to increase in the next few years); at the same time, the United Kingdom reported lacking organs for 8,000 patients, with the rate increasing at 8%.[19]

The high demand for organs and long waitlists have been met with a corresponding expansion of the illegal organ trade. Currently, it is estimated that about 10% of all transplants occur illegally, with the Internet acting as a facilitator.[57] One source estimates that at least 4,000 prisoners were executed in 2006 to supply approximately 8,000 kidneys and 3,000 livers for foreign buyers.[57] In 2007, 2,500 kidney transplants were purchased in Pakistan, with foreign recipients making up two-thirds of the purchasers.[19] As of 2007, the Voluntary Health Association of India estimated that approximately 2,000 Indians sell a kidney every year. In the same year, in Canada and the United Kingdom, experts estimated that about 30 to 50 patients illegally purchased organs abroad.[21]

Transplant tourism[edit]

The United Network for Organ Sharing defines transplant tourism as "the purchase of a transplant organ abroad that includes access to an organ while bypassing laws, rules, or processes of any or all countries involved."[45] The term "transplant tourism" describes the commercialism that drives illegal organ trade, but not all medical tourism for organs is illegal. For example, in some cases, both the donor and the recipient of the organ travel to a country with adequate facilities to perform a legal surgery. In other cases, a recipient travels to receive the organ of a relative living abroad.[45] Transplant tourism raises concerns because it involves the transfer of healthy organs in one direction, depleting the regions where organs are bought. This transfer typically occurs in trends: from South to North, from developing to developed nations, from females to males, and from people of color to whites – trends that experts say "[have] exacerbated old...divisions."[18]

The kidney is the most sought-after organ in transplant tourism, with prices for the organ ranging from as little as $1,300[18] to as much as $150,000.[45] In fact, reports estimate that 75% of all illegal organ trading involves kidneys.[58] The liver trade is also prominent in transplant tourism, with prices ranging from $4,000[59] to $157,000.[60] Though livers are regenerative, making liver donations non-fatal, they are much less common due to an excruciating post-operative recovery period that deters donors. Other high-priced bodily organs commonly sold in the organ trade include corneas ($24,400) and unfertilized eggs ($12,400), while lower-priced bodily commodities include blood ($25–$337), skin ($10 per square inch), and bones/ligaments ($5,465).[60] While there is a high demand, and correspondingly a very high price, for vital organs such as hearts and lungs, transplant tourism and organ trafficking of these parts is very rare due to the sophisticated nature of the transplant surgery and the state-of-the-art facilities required for such transplants.[60]

Global reaction[edit]

The international community has issued many ordinances and declarations against the organ trade. Examples include the World Medical Authority's 1985 denouncement of organs for commercial use; the Council of Europe's Convention on Human Rights and Biomedicine of 1997 and its 2002 Optional Protocol Concerning Transplantation of Organs and Tissues of Human Origin; and the Declaration of Istanbul on organ trafficking and transplant tourism.[43] The World Health Organization (WHO) has played a prominent role in condemning the illegal organ trade. The WHO first declared organ trade illegal in 1987, stating that such a trade violates the Universal Declaration of Human Rights.[20] In 1991, at the 44th World Health Assembly, it approved nine guiding principles for human organ transplant. The principles clearly stated that organs cannot be the subject of financial transactions. On May 22, 2004, these guidelines were slightly amended at the 57th World Health Assembly. They are intended for the use of governments worldwide.[19] These global initiatives have served as a helpful resource for establishing medical professional codes and a legal framework for the issue, but have not provided the sanctions required for enforcement.[45]

Declaration of Istanbul[edit]

The Declaration of Istanbul on organ trafficking and transplant tourism, drafted by the international transplant community, defines transplant commercialism, organ trafficking, and transplant tourism.[20] It denounces these practices based on violations to equity, justice, and human dignity.[57] The declaration aims to promote ethical practices in organ transplantation and donation on an international level.[20] It is nonbinding, but over 100 transplant organizations support its principles, including countries such as China, Israel, the Philippines, and Pakistan, which strengthened their laws against illegal organ trading after the declaration's release.[20]

Illicit organ trade in specific countries[edit]

China[edit]

Since the late 1980s, China relied on executed prisoners to provide the bulk of its transplanted organs.[61] This ready source of organs made it second only to the United States for numbers of transplantations peformed.[62] There is evidence that the government attempted to downplay the scope of organ harvesting through confidentiality agreements[63] and laws, such as the Temporary Rules Concerning the Utilization of Corpses or Organs from the Corpses of Executed Prisoners.[64] Critics further allege that organs were not distributed on the basis of need, but rather allocated through a corrupt system or simply sold to wealthy Chinese and foreign individuals.[62] China was also accused of fueling its transplant industry with organs harvested from living Falun Gong practitioners. The Kilgour–Matas report[65] concluded that China was guilty of this practice; however, the report has come under criticism, by both Chinese and Western sources.[62]

In the 2000s, the country came under increasing international and domestic pressure to end the practice of using organs from prisoners. Since then, it has implemented a number of reforms addressing these allegations. It has developed a registry of voluntary, non-incarcerated donors; it is believed that these living and deceased donors supply most of the organs transplanted in the country today.[62] China also standardized its organ collection process, specifying which hospitals can perform operations and establishing the legal definition of brain death. It banned foreign transplant patients.[66] And in 2007, it formally outlawed the sale of organs and collecting a person's organs without their consent.[67]

That said, many non-profit organizations and international jurists are skeptical that China has truly reformed its organ transplant industry.[68] In particular, although the number of organs taken from prisoners has dropped dramatically, there is no prohibition on collecting organs from deceased inmates who sign agreements purporting to donate their organs. There continue to be reports of prison officials offering death row inmates the opportunity to "voluntarily" donate their organs upon death, with the implication that those who decline may get worse treatment from their jailers.[62]

Impact on the poor[edit]

Demographics[edit]

Data from the World Health Organization indicates that impoverished people in developing nations are the primary group targeted by the illegal organ trade. In one study of organ donors in India, 71% of all donors fell below the poverty line.[21] Tales of organ theft usually characterize the victims as unemployed males between the ages of 20 and 40 who were seeking work and were taken out of the country for operations.[19] One such case involved Makbuba Aripova, whose husband left Uzbekistan for a job in Canada. His corpse, and those of family members traveling with him, were found several days later with missing organs and bags of money believed to be the proceeds from an organ sale.[64] While men feature prominently in anecdotes on the organ trade, impoverished women are also frequent victims.[21] However, most data show that women are rarely the recipients of purchased organs.[18]

Reasons for donating[edit]

One of the primary reasons donors articulate for why they sell their organs is to pay off debt.[19] The most impoverished are frequently viewed as more reliable targets for transplant tourists because they are the most in need of money. While some supporters of the organ trade argue that it helps lift some people out of poverty by providing compensation to donors, evidence of this claim is hotly debated.[5] In many cases, people who sell their organs in order to pay off debt do not manage to escape this debt and remain trapped in debt cycles.[69][70] Often, people feel like they have no choice but to donate their kidneys due to extreme poverty.[70][71]

In some cases, organs are sold to family members, either from parents to offspring, or from adult children to parents. This is more frequent in nations where waitlists are less formal, and among families which cannot afford to leave the country for transplants. The trend of younger people donating to their more aged relatives is relatively new, and has been criticized for placing greater value on kidneys from live donors.[72]

Outcomes[edit]

Reports by the World Health Organization show decreased health and economic well-being for those who donate organs through transplant tourism. In Iran, 58% of donors reported negative health consequences. In Egypt, as many as 78% of donors experienced negative health outcomes, and 96% of donors stated that they regretted donating.[21] These findings are relatively consistent across all countries: those who sell their organs on the market tend to have poorer overall health. Substandard conditions during transplant surgeries can also lead to transmission of diseases like hepatitis B, hepatitis C, and HIV. Donors' poor health is further exacerbated by depression and other mental illnesses brought on by the stress of donating and insufficient care after surgery.[19][45]

Impoverished donors' economic outcomes are no better than their health outcomes. A study of Indian donors found that while 96% of donors sold a kidney to pay off debts, 75% still had those operative care that is not provided by the buyer.[73] Donors in all countries often report weakness after surgery that leads to decreased employment opportunities, especially for those who make a living through physical labor.[73]

Issues with enforcement[edit]

Though many statutes regarding organ trade exist, law officials have failed to enforce these mandates successfully. One barrier to enforcement is a lack of communication between medical authorities and law enforcement agencies. Often, enforcement officials' access to information regarding individuals involved in illegal organ transplants is hindered by medical confidentiality regulations. Without the ability to review medical records and histories to build an effective case against perpetrators, officials cannot fully enforce organ trade laws.[46] Many critics state that in order to prohibit illegal organ trading effectively, criminal justice agencies must collaborate with medical authorities to strengthen knowledge and enforcement of organ trade laws. Critics also support other criminal justice actions to meet this goal, such as prioritizing organ trafficking issues among local legislative bodies; multidisciplinary collaboration in cross-border offenses; and further police training in dealing with organ trafficking crimes.[20]

Proposed solutions[edit]

Various solutions have been proposed to increase the number of legally available organs and stanch the flow of illegal trafficking around the globe. Policies of presumed consent have been successful in various countries, including Brazil, the United States, and several European nations. These policies can be either opt-in or opt-out. In a nation with an opt-out policy, consent for organ donation is presumed upon death, although one can choose not to donate by submitting documentation. Research shows a 25–30% increase in the amount of available organs in opt-out countries.[19] In nations with an opt-in policy, like the United States, a person may choose to donate their organs during their lifetime. In opt-in countries, families have on occasion succeeded in overturning the deceased's decision to donate.

Presumed consent programs cut down on organ trafficking in many ways. These laws help increase the amount of available organs, decreasing patients' reliance on the black market. At the same time, the increased supply of organs decreases the financial cost of a transplant, lessening the need for medical tourism.[64]

Another proposed method is to enact laws that would hold doctors accountable for not reporting suspected organ trafficking. Scheper-Hughes has written extensively on the issue of doctors knowingly performing illegal operations with illicit organs.[18] She argues that though doctors would be violating doctor-patient privilege, their legal obligation to the patient is superseded by public interest in ending alleged medical violations of human rights. If accountability measures were imposed, doctors would be liable as accomplices if they knowingly performed operations with black market organs.[64]

Many people in the United States believe that adopting a system for regulating organ trading similar to Iran's will help to decrease the national shortage of kidneys. They argue that the U.S. could adopt similar policies to promote accountability, ensure safety in surgical practices, employ vendor registries, and provide donors with lifetime care. They further argue that private insurance companies would be invested in providing such care for donors, and that laws could be enacted to make long-term care an inviolable condition of any donation agreement.[5]

Debate over legalization[edit]

Although there has been a widespread international consensus against the sale of human organs for decades, individual physicians, jurists, and philosophers have become more willing to criticize the status quo. So far, these proponents of legalized organ trade have yet to persuade a state to permit the practice. However, they have succeeded in starting a lively debate over the prohibition.

Models for organ markets[edit]

Proponents of legalized organ sales offer a number of designs for a market in human organs. Some argue that individuals ought to be free to contract for the sale and purchase of organs as if they were like any other commodity.[74] Ethicists Charles A. Erin and John Harris have proposed a much more heavily regulated model for organ transactions.[75] Under this scheme, would-be sellers of organs do not contract with would-be recipients. Instead, a government agency would be the sole buyer of organs, paying a standard price set by law and then distributing the organs to its citizens. This safeguard is designed to prevent unscrupulous buyers from taking advantage of potential donors and to ensure that the benefits of the increased organ supply are not limited to the rich. Moreover, participation in the market would be confined to citizens of the state where the market is located, to prevent the unilateral movement of organs from developing nations to the developed world. Erin and Harris's model has been endorsed by a number of prominent advocates of organ markets.[76][77]

Arguments for legalization[edit]

Increased organ supply[edit]

The main argument made in favor of legalized organ sales is that it would increase the number of organs available for transplantation.[78] Although governments have implemented other initiatives to increase organ donation – such as public awareness campaigns, presumed consent laws, and the legal definition of brain death – the waitlist for vital organs continues to grow. Even those patients who get off the waitlist often do so after receiving an organ from a cadaver; such transplantations have worse results than when the donor is a living person.[79] Legalizing payments for organs would encourage more people to donate their organs. Each organ sold on a market could potentially save the life (and improve the quality of life) of its recipient.[80] For example, patients with kidney disease who receive a kidney transplant from a living donor typically live 7 to 15 years longer than those who depend on dialysis.[79]

Critics of legalization argue that proponents exaggerate the impact that a market would have on the supply of organs. In particular, they note that legalized organ sales may “crowd out” altruistic donations.[81] In other words, people who would otherwise give their organs to relatives may decline to do so, opting instead to purchase the organ (or rely on the government to buy one) for their relatives. Proponents of markets counter that while altruistic donations might decrease slightly if organ sales were legalized, this decrease would be more than offset by the influx of organs.

Minimal negative consequences for donors[edit]

Proponents also assert that organ sales ought to be legal because the procedure is relatively safe for donors.[82] The short-term risk of donation is low – patients have a mortality rate of 0.03%,[83] similar to that of certain elective cosmetic procedures such as liposuction.[84] Moreover, they argue, the long-term risks are also relatively minimal. A 2018 systematic review found that kidney donors did not die earlier than non-donors.[85] Donors did have a slightly increased risk of chronic kidney disease and pre-eclampsia (a condition sometimes seen in pregnancy). The review found no difference in the rates of diabetes, heart disease, high blood pressure, or mental illness. Multiple studies of American and Japanese donors found that they reported a higher quality of life than the average non-donor.[83] Proponents of organ markets argue that, given the comparative safety of donating a kidney, individuals should be permitted to undergo this operation in exchange for payment.

Critics challenge this view of transplantation as being overly optimistic. Specifically, they cite research suggesting that individuals who sell their organs fare worse after the procedure than those who freely donate their organs. Kidney sellers are more likely to have renal problems after the operation (such as hypertension and chronic kidney disease), to report reduced overall health, and to suffer from psychological side effects such as depression.[86] Opponents of markets usually ascribe these worse outcomes to the fact that kidney sellers are drawn from the ranks of the poor; if organ sales are permitted, most sellers will be poor and can expect the same dangerous consequences. Proponents of organ markets respond by blaming these bad outcomes on the fact that kidney sellers have been forced into the black market, with minimal oversight, follow-up care, or legal protections from abuse; thus in a regulated market in the developed world, kidney sellers could expect to see outcomes more akin to those of kidney donors

Respect for autonomy[edit]

Many proponents argue for legalized organ sales on the grounds of autonomy. Individuals are generally free to buy or sell their possessions and their labor. Advocates of organ markets say that, likewise, people ought to be free to buy or sell organs as well.[87] According to this perspective, prohibitions against selling organs are a paternalistic or moralistic intrusion upon individuals' freedom. Proponents acknowledge that, unlike selling a material possession such as a car, selling a kidney does carry some risk of harm. However, they note that people are able to undertake dangerous occupations (such as logging, soldiering, or surrogacy) which carry significant chance of bodily harm.[88] If individuals are allowed to take on that risk in exchange for money, then they ought to be able to take on the risks of selling a kidney as well.

Harm reduction[edit]

Other physicians and philosophers argue that legalization will remedy the abuses of the illicit trade in organs.[89][90] The current ban on the sale of organs has driven both sellers and buyers into the black market, out of sight of the law.[91] Criminal middlemen often take a large cut of the payment for the organ, leaving comparatively little money left for the donor.[92] Because the mainstream medical establishment is barred from participating in the transplantation, the procedure typically occurs in substandard facilities and not according to best practices.[93] Afterwards, the donors often do not receive important medical follow-up because they are afraid that their role in the crime will be discovered. There have also been reports of criminal gangs kidnapping people and illegally harvesting their organs for sale on the black market.[92] Proponents of legalization argue that it will result in better medical care for donors and recipients alike, as well as larger payments to the donors.

Some critics challenge the proponents' assumptions that legalization will completely eliminate the black market for organs or its problems. For example, one scholar argues that once the organ trade became legalized in Iran, it did not end the under-the-table sales in organs.[94] Instead, people made deals outside the government-sanctioned system to acquire organs from more desirable (i.e., healthier) donors.

Arguments against legalization[edit]

Coercion by poverty[edit]

Critics often argue that organ sales should remain prohibited because any market solution will take advantage of the poor. Specifically, they fear that a large financial incentive for donating organs will prove irresistible to individuals in extreme poverty: such individuals may feel like they have no choice but to agree to sell a kidney. Under these circumstances, the decision to sell cannot be regarded as truly voluntary.[95] Consequently, it is appropriate for the government to protect poor people by prohibiting the sale of organs.

Proponents of organ markets counter that, by this reasoning, poor people could not be trusted to make any significant economic decision since it would inevitably be influenced by their need to earn money to escape (or survive in) poverty. If impoverished people cannot consent to sell a kidney because of their economic circumstances, they ask, why is their consent valid for other unpleasant choices, such as undertaking an undesirable jobs or selling a treasured family heirloom?

Direct harms of organ selling[edit]

Some opponents of markets adopt a paternalistic stance that prohibits organ sales on the grounds that the government has a duty to prevent harm to its citizens. Unlike the "coercion by poverty" line of argumentation discussed above, these critics do not necessarily question the validity of the donors' consent. Rather, they say that the dangers posed by donating an organ are too great to allow a person to voluntarily undertake them in exchange for money. As noted previously, critics of organ sales cite research suggesting that kidney sellers suffer serious consequences of the operation, faring far worse than altruistic kidney donors. Even if one assumes that kidney sellers will have similar outcomes to donors in a regulated market, one cannot ignore the fact that a nephrectomy is an invasive procedure that - by definition - inflicts some injury upon the patient.[96] These critics argue that the government has a duty to prevent these harms, even if the would-be seller is willing to undertake them.

A similar argument focuses on the fact that selling a kidney involves the loss of something unique and essentially irreplaceable on the part of the donor.[97] Given the special value placed on bodily integrity in society, it is appropriate to outlaw the sale of body parts to protect that value.

Objectification[edit]

Another criticism of legalized organ sales is that it objectifies human beings. This argument typically starts with the Kantian assumption that every human being is creatures of innate dignity, who must always be regarded as an end to itself and never just a means to an end. A market for organs would reduce body parts to commodities to be bought and sold. Critics argue that, by permitting such transactions, society would reduce the seller of the organ to an object of commerce - a mere means to an ends.[98] Assigning a monetary value to a key organ is essentially assigning a value to its bearer, and putting a price on a human being violates his or her intrinsic dignity.

Proponents of organ sales claim that this line of argument confuses the kidney with the whole person;[99] so long as the transaction is conducted in a way that minimizes risks to the donor and fairly compensates him or her, that person is not reduced to a means to an end.

Unwanted pressure to sell an organ[edit]

Another argument against organ markets is that they will give rise to a pressure to sell organs which would harm all people (even those who did not participate directly in the market).[100] Under the current ban on the organ trade, debtors and heads of families in the developed world face little pressure to sell their organs. If a person's creditors or dependents suggest that she sell her kidney to raise money, she could refuse on the grounds that it is illegal. In contrast, if organ sales were legalized, a destitute individual could face pressure from family and creditors to sell a kidney – and possibly endure social consequences such as scorn or guilt if she declined. Legalizing organ sales would create this unwanted pressure (and attendant disapproval) for all poor individuals, regardless of whether or not they wished to sell their kidneys. Thus a legal prohibition on selling organs is warranted to protect poor people from this undesirable pressure.

Academic perspectives on legalization[edit]

Economic perspective[edit]

Economists generally lean in favor of legalizing organ markets. The consensus of American Economic Association members is that organ trade should be allowed, with 70% in favor and 16% opposed.[101] Another literature review, looking at the publications of 72 economic researchers who have studied organ trade, reached a similar conclusion: 68% supported legalization of the organ trade, while 21% opposed it.[102]

Many scholars advocate the implementation of a free market system to combat the organ shortage that helps drive illegal organ trade.[103] The organ trade's illegal status creates a price ceiling for organs at zero dollars. This price ceiling affects supply and demand, creating a shortage of organs in the face of a growing demand.[104][105] According to a report published by the Cato Institute, a US-based libertarian think tank, eliminating the price ceiling would eliminate the organ shortage.[5] In the Journal of Economic Perspectives, Nobel laureate Gary Becker and Julio Elias estimated that a $15,000 compensation would provide enough kidneys for everyone on the waitlist. The government could pay the compensation to guarantee equality. This would save public money, as dialysis for kidney failure patients is far more expensive.[16]

However, other critics state that a free market for organs would only increase already high prices for organs, creating an imbalance: only wealthy individuals would be able to purchase these organs. They also argue that such a free market system for organ trade would encourage organ theft through murder and neglect of sick individuals for financial gain. Advocates for the free market of organs counter these claims by saying that murder for financial gain already happens; sanctions against such acts exist to minimize their occurrence; and with proper regulation and law enforcement, such incidents in a legal organ trade could be minimized as well.[103]

Human rights perspectives[edit]

Legalization of human organ trading has been opposed by a variety of human rights groups. One such group is Organs Watch, which was established by Nancy Scheper-Hughes – a medical anthropologist who was instrumental in exposing illegal international organ-selling rings. Scheper-Hughes is famous for her investigations, which have led to several arrests due to people from developing countries being forced or fooled into organ donations.[106] Like the World Health Organization, Organs Watch seeks to protect and benefit the poverty-stricken individuals who participate in the illegal organ trade out of necessity.[107]

See also[edit]

References[edit]

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