Abstract
The idea of paying donors in order to make more human bodily material available for therapy, assisted reproduction, and biomedical research is notoriously controversial. However, while national and international donation policies largely oppose financial incentives they do not treat all parts of the body equally: incentives are allowed in connection to the provision of some parts but not others. Taking off from this observation, I discuss whether body parts differ as regards the ethical legitimacy of incentives and, if so, why. I distinguish two approaches to this issue. On a “principled” approach, some but not all body parts are inherently special in a way that proscribes payment. On a “pragmatic” approach, the appropriateness of payment in relation to a specific part must be determined through an overall assessment of e.g. the implications of payment for the health and welfare of providers, recipients, and third parties, and the quality of providers’ consent. I argue that the first approach raises deep and potentially divisive questions about the good life, whereas the second approach invokes currently unsupported empirical assumptions and requires difficult balancing between different values and the interests of different people. This does not mean that any attempt to distinguish between body parts in regard to the appropriateness of payment necessarily fails. However, I conclude, any plausible such attempt should either articulate and defend a specific view of the good life, or gather relevant empirical evidence and apply defensible principles for weighing goods and interests.
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Notes
I will henceforth use the term ‘provider’ rather than ‘donor’, which has connotations to altruism that may be misleading when money is offered in exchange for what is provided.
Thus, while scholarly debates about paid donation revolve around something like what Eyal calls “body exceptionalism”, i.e. “the view that we should treat the body…differently than we do material resources” (Eyal 2009: 234), there has been little attention in this context to what we might call “body parts exceptionalism”, i.e. the view that certain (but not all) parts of the body warrant such treatment.
These include Spain, Greece, and Ukraine (eggs), Germany (blood), and several states in the US (eggs, sperm, plasma, and bone marrow) (Almeling 2011; NCoB 2011; Williams 2011; Pennings et al. 2014; Harvey 2015). By ‘reward’ I mean payment that (de facto or de jure) “goes beyond ‘recompensing’ the person for the losses incurred in donating” (NCoB 2011: 70).
Thus, my argument is located at a somewhat higher level of abstraction than analyses of the ethics of payment in relation to specific body parts typically are. But it is less abstracted than Fabre’s (2006) excellent exploration of the status of the body in “ideal theory”, where it is assumed that agents fully comply with the demands of justice. By contrast, my discussion explores ethical quandaries arising in our current, decidedly non-ideal world.
Kant is sometimes attributed the first of these views because of his condemnation of all bodily commodification (including of hair and teeth) in his Lectures on Ethics (Kant 1997a), but it is debatable whether this condemnation reflects his philosophy or the prejudices of his time. Andrews (1986) provides a robust defence of the view of the body as personal property, but stops short of endorsing the commodification of all its parts.
Almeling’s (2011) finding that US egg donors explicitly dissociate themselves from their eggs may seem to contradict this assumption, but this dissociation is more reflective of the interests and rhetoric of egg agencies than of some general cultural pattern of identification.
Some such idea underlies the familiar”four principles” approach to bioethics (Beauchamp and Childress 2012), for instance. Largely on the basis of what I here call pragmatic considerations, this approach seeks to articulate ethical principles that people can in principle agree on despite deep normative and metaphysical disagreements.
Since all potentially relevant pragmatic considerations cannot be covered in one paper my discussion will be selective. I will leave out concerns about exploitation, for instance. Although such concerns loom large in this context, they partly overlap with principled concerns of the kind discussed above and/or with the concerns about harm and consent discussed below, and when they do not overlap with such concerns it is unclear whether they support policies against payment (Wilkinson 2003). Also, my discussion of societal consequences will be limited to “crowding out” effects. There may well be other such consequences that matter to the legitimacy of payment, e.g. social and legal pressures on providers that the normalization of payment may create (Andrews 1986; Rippon 2014). But these effects are likely to vary between institutional and cultural contexts at least as much as between body parts, making them difficult to consider on the level of abstraction where my argument proceeds.
There seem to be no studies that directly compare socioeconomic profiles of paid providers across several different body parts and risk/payment levels, and available information on providers of specific parts does not admit of the generalizations and comparisons needed to support this assumption. While poor populations seem to be overrepresented among paid providers in certain settings (Naqvi et al. 2007; Cooper and Waldby 2014), it is unclear that they are (or would be) more overrepresented when the risk/payment is higher.
Some believe that the real worry about inducement is not that it threatens consent but that it might encourage people to overcome their deeply held values. On this account, it is disrespectful to pay people to do things that they have strong objections against, even if the money does not impair their judgment or the voluntariness of their decision (Dickert and Grady 2008). This account is plausible, but it cannot be invoked in support of the argument considered here because it has nothing to do with the level of payment. It seems no less disrespectful to offer somebody a small sum for a pint of blood than a large sum for a kidney if that person has strong objections against donating both.
This support would be strengthened if higher payment could be assumed to attract a larger proportion of poor providers than lower payment because the poor are likely to be especially vulnerable to such pressure (Malmqvist 2015). However, as we have already seen, this is an empirical assumption that has to be backed up by evidence that currently seems unavailable.
I cannot here defend Titmuss’ argument but only explore its implications for the question at hand. For a compelling explication and defence of this argument, see Archard (2002).
In principle any general such conception—utilitarianism, egalitarianism, prioritarianism, etc.—is applicable here. Determining which one is preferable in this context is beyond the scope of this paper.
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Acknowledgments
I thank Erica Haimes and Ken Taylor for the opportunity to present an early version of this paper at the 16th PEALS International Symposium in Newcastle, UK, September 22–23, 2015, and other participants in the symposium for valuable feedback. I am also grateful to Lisa Guntram, Hanna Van Parys, András Szigeti, Martin Andersson, and two anonymous reviewers for this journal for helpful comments on later versions.
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Malmqvist, E. Does the ethical appropriateness of paying donors depend on what body parts they donate?. Med Health Care and Philos 19, 463–473 (2016). https://doi.org/10.1007/s11019-016-9705-6
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DOI: https://doi.org/10.1007/s11019-016-9705-6