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Autonomy, Inducements and Organ Sales

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Philosophical Reflections on Medical Ethics

Abstract

It is widely known that the number of organs that become available for transplant each year falls far short of the number that are needed. Various methods of alleviating this shortage have been proposed, ranging from increasing public awareness of the organ shortage to encourage donation to introducing a policy of presumed consent, in which organs can be harvested from persons after their death unless they have expressly forbidden this. With one notable exception, all of the proposed methods of alleviating the chronic shortage of available transplant organs enjoy widespread support, even if they might also suffer from similarly widespread opposition. This exception is the proposal that markets should be used to procure additional transplant organs. This proposal has, as Janet Radcliffe Richards has noted, been condemned by almost all who are involved in the discussion of how to increase the number of available transplant organs, irrespective of their political or ethical commitments.1 The arch-conservative Leon Kass, appointed by George W. Bush to be the Chairman of the President’s Council on Bioethics, for example, condemns the use of markets to secure an additional supply of transplant organs with as much venom as its more politically radical opponents, such as Nancy Scheper-Hughes and Lawrence Cohen.2

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Notes

  1. Janet Radcliffe Richards (1996) ‘Nepharious Goings On: Kidney Sales and Moral Arguments’, The Journal of Medicine and Philosophy, 21, p. 375.

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  2. Leon Kass (2002) Life, Liberty and the Defense of Dignity (San Francisco: Encounter Books), pp. 177–98

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  3. Nancy Scheper-Hughes (2003) ‘Keeping an Eye on the Global Traffic in Human Organs’, The Lancet, 361 (10 May), pp. 1645–8

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  4. Lawrence Cohen (1999) ‘Where it Hurts: Indian Material for an Ethics of Organ Transplantation’, Daedalus, 128(4), pp. 135–65.

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  5. See, for example, Mario Morelli (1999) ‘Commerce in Organs: A Kantian Critique’, Journal of Social Philosophy, 30(2), pp. 315–24

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  6. T. L. Zutlevics (2001) ‘Markets and the Needy: Organ Sales or Aid?, Journal of Applied Philosophy, 18(3), pp. 297–302.

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  7. See Janet Smith (1997) ‘The Pre-Eminence of Autonomy in Bioethics’, in David S. Oderberg and Jacqueline A. Laing (eds.) Human Lives: Critical Essays on Consequentialist Bioethics (New York: St. Martin’s Press), pp. 182–95.

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  8. This autonomy-based pro-market argument is offered by Gerald Dworkin (1994) ‘Markets and Morals: The Case for Organ Sales’, in Gerald Dworkin (ed.), Morality, Harm, and the Law (Boulder, CO: Westview Press), pp. 155–61.

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  9. See James Stacey Taylor (2002) ‘Autonomy, Constraining Options, and Organ Sales’, Journal of Applied Philosophy, 19(3), pp. 273–85; and (2004) Stakes and Kidneys: Why Markets in Human Body Parts are Morally Imperative (Aldershot: Ashgate Press), chapter 4.

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  10. The two most prominent proponents of the view that the sale of an organ is an autonomy-compromising constraining option are Paul Hughes (1998) ‘Exploitation, Autonomy, and the Case for Organ Sales’, International Journal of Applied Philosophy, 12.1, pp. 89–95, and Zutlevics, ‘Markets and the Needy’.

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  11. I have previously defended the first of these premises in Stakes and Kidneys, chapters 2 and 3. However, my focus in that volume was different from my focus here, for there I concentrated on determining whether Dworkin’s views on coercion as expressed in Gerald Dworkin (1970) ‘Acting Freely’, Nous, 4(4), pp. 367–85, committed him to holding that the reluctant kidney vendor was coerced into selling.

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  12. Erin and Harris argue that rather than using a market to distribute the organs thus procured, a single buyer such as the NHS should purchase them and distribute them according to non-market criteria. See Charles A. Erin and John Harris (2003) ‘An Ethical Market in Human Organs’, Journal of Medical Ethics, 29(3), pp. 137–8. I argue against this proposal and in favour of a regulated market for the distribution of in human organs in Stakes and Kidneys, chapters 5 and 9.

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  13. Harry G. Frankfurt (1988) ‘Freedom of the Will and the Concept of a Person’, in Harry G. Frankfurt (ed.), The Importance of What We Care About (Cambridge: Cambridge University Press), p. 11.

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  14. For Hobbes, ‘the last appetite, or aversion, immediately adhering to the action, or to the omission thereof, is that we call the will’. Thomas Hobbes (1994) Leviathan, ed. Edwin Curley (Indianapolis, IN: Hackett Publishing), Part 1, chapter 6, para. 21. See Frankfurt, ‘Freedom of the Will’, p. 14.

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  15. For an outline of such criticisms see my Introduction to James Stacey Taylor (ed.) (2005) Personal Autonomy: New Essays in Personal Autonomy and its Role in Contemporary Moral Philosophy (Cambridge: Cambridge University Press), pp. 4–10.

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  16. The most recent of these modifications and clarifications can be found in Frankfurt’s replies to his critics, in Sarah Buss and Lee Overton (eds.) (2002) The Contours of Agency: Essays on Themes from Harry Frankfurt (Cambridge, MA: MIT Press).

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  17. See, for example, John Christman, Introduction to John Christman (ed.) (1988) The Inner Citadel: Essays on Individual Autonomy (Oxford: Oxford University Press), pp. 8–9. See also James Stacey Taylor, Introduction,” in Taylor (ed.), Personal Autonomy, p. 4.

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  18. The first of these mistakes can be found in Ann Cunningham (2003) ‘Autonomous Consumption: Buying into the Ideology of Capitalism’, Journal of Business Ethics, 48(3), pp. 229–36. Here, Cunningham draws on Noggle’s analysis of what it is for a person to identify with a desire (i.e. of what it is for a person to fail to be alienated from a desire) to defend advertising from the change that it undermines personal autonomy. In fairness to Cunningham, however, Noggle also believes that autonomy and identification are coextensive. See Robert Noggle (1995) ‘Autonomy, Value and Conditioned Desire’, American Philosophical Quarterly, 32(1), pp. 57–69. The second of these mistakes is made by Nomy Arpaly, ‘Responsibility, Applied Ethics, and Complex Autonomy Theories’,” in Taylor (ed.), Personal Autonomy, pp. 173–5.

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  19. Versions of this argument have been offered by Pranlal Manga (1987) ‘A Commercial Market for Organs? Why Not’, Bioethics, 1(4), p. 327

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  20. John B. Dossetor and V. Manickavel (1992) ‘Commercialization: The Buying and Selling of Kidneys’, in C. M. Kjellstrand and J. B. Dossetor (eds.), Ethical Problems in Dialysis and Transplantation (Dordrecht: Kluwer Academic Publishers), p. 63

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  21. Patricia A. Marshall, David C. Thomasma and A. S. Daar (1996) ‘Marketing Human Organs: The Autonomy Paradox’, Theoretical Medicine, 17, p. 13. I have addressed this argument at length in Stakes and Kidneys, chapter 3.

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  22. Sells writes that since ‘the financial benefits [of selling a kidney] [would] have such an impact on the life of the donor … as to be irresistible: the element of voluntariness … must be … in extreme cases, abolished’. R. A. Sells (1991) ‘Voluntarism of Consent’, in W. Land and J. Dossestor (eds.), Organ Replacement Therapy: Ethics, Justice, Commerce (New York: Springer-Verlag), p. 20. I address Sells’ argument more fully and directly in Stakes and Kidneys, 67–9.

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  23. See Paul Hughes, ‘Autonomy, Ambivalence, and Organ Sales’, unpublished MS. A version of this argument is also developed in Ruth Grant and Jeremy Sugarman (2004) ‘Ethics in Human Subjects Research: Do Incentives Matter?’, Journal of Medicine and Philosophy, 29, pp. 717–38.

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  24. Stephen Wilkinson (2003), Bodies for Sale: Ethics and Exploitation in the Human Body Trade (London: Routledge), p. 131. In fairness to Wilkinson it should be noted that he is not here directly addressing the third antimarket argument from irresistibility, but instead the related charge that markets for human organs are exploitative. Dworkin, ‘Markets and Morals’, p. 157.

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  25. Indeed, if the course of action that a person should take is clear to him, owing either to the unthinkability of the alternatives, or to this course of action being required by his volitional nature, then it is plausible to claim that the person concerned will exercise his autonomy most fully when he pursues it. See Harry G. Frankfurt (1999) ‘Autonomy, Necessity, and Love’, in Harry G. Frankfurt, Necessity, Volition, and Love (Cambridge: Cambridge University Press), pp. 129–41.

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  26. Gerald Dworkin (1988) The Theory and Practice of Autonomy (Cambridge: Cambridge University Press), p. 80.

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  27. Madhav Goyal et al. (2002) ‘Economic and Health Consequences of Selling a Kidney in India’, Journal of the American Medical Association, 288(13), pp. 1589–93. The findings of Goyal et al. are also outlined in Taylor, Stakes and Kidneys, pp. 77–8, 84–5.

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  28. Praveen Swami (2003) ‘Punjab’s Kidney Industry’, Frontline, 20(3), 1–4 February.

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  29. Such medical care for persons who undergo nephrectomies is suggested by Working Party of the British Transplantation Society and the Renal Association, United Kingdom Guidelines for Living Kidney Donor Transplantation (2000). See also Taylor, Stakes and Kidneys, pp. 87–8, where I develop this pro-market argument further.

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Authors
  1. James Stacey Taylor
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Editors and Affiliations

  1. Centre for Professional Ethics, Keele University, UK

    Nafsika Athanassoulis (Lecturer in Ethics) (Lecturer in Ethics)

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© 2005 James Stacey Taylor

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Taylor, J.S. (2005). Autonomy, Inducements and Organ Sales. In: Athanassoulis, N. (eds) Philosophical Reflections on Medical Ethics. Palgrave Macmillan, London. https://doi.org/10.1057/9780230273931_7

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