Thursday, January 31, 2008

Kidney Theft and A Modest Proposal

The front page of Wednesday’s New York Times reports that police uncovered an illegal kidney-transplant program in India. The program targeted day laborers and other poor people, who were either deceived and then forced to undergo kidney removal or persuaded to sell their kidneys, so that wealthy Indians and foreigners – known sometimes as “organ tourists” – could receive kidneys unavailable to them through ordinary channels. One of the victims of the kidney ring became so ill after his surgery that he could not work anymore to support his destitute family. The story is disturbing and sheds light on the power of wealth to motivate predatory conduct toward the less fortunate.

In this post, however, I want to focus on the other people whose lives are implicated in the kidney story: the wealthy organ recipients. In a story of rich people raiding poor people for their organs, of course, the rich do not tug on our heart strings. It is often largely through the accident of birth that one is able to acquire wealth, and in any event, wealth does not entitle people to pressure or coerce the poor to supply them with organs.

If poverty and wealth are often unearned, however, it is no less true that good and ill health are often unearned. It is not self-evident that people who happen to be born with a kidney defect and/or become ill in adulthood have no right to ask the surrounding society for help. It is out of desperation, indeed the same sort of desperation that might motivate a poor but healthy man to sell one of his kidneys, that wealthy but sick people attempt to use their money to save their own lives. Though hardly praiseworthy, one can easily understand why they do what they do.

One could, in fact, invoke such desperation as evidence that organ sale ought to be permitted but regulated. The law of supply and demand is stronger than the criminal law, and it therefore makes sense for the law to minimize abuse within an inevitable business rather than drive it underground. Such was said (correctly) of alcohol prohibition, and Judge Posner has made this sort of argument in a variety of contexts (including, quite controversially, in condoning a market in babies).

Rather than criticize or defend such arguments, however, I would point out a simple but sad reality in the United States and many other countries: relatively few people consent to donating their organs upon their death. If there is a proper time to require redistribution from the “haves” to the “have nots,” it would seem to be when the “haves” are no longer alive. Rather than honoring the desire to bury or burn people’s earthly remains, the law could instead require that organs be available to others in need. After all, we already violate the wishes of the deceased in requiring autopsies, and there is often much more to be gained from a donated organ than from confirmation that a victim died of gunshot wounds to the head.

This proposal of the ultimate “death tax” probably sounds shocking to many, so let me suggest that a less radical idea could go a long way. At the present time, in the U.S. and elsewhere, the law presumes that we do not consent to donating our organs upon death. Let us change the law to make the default presumption that every person consents to donating his or her organs to save lives at death. To rebut the presumption, one must actively opt out. This has been the approach in Belgium, and they have not suffered the organ shortages plaguing our country and others. Perhaps if the desperate demand for organs could be met more effectively in western countries, their inhabitants would not be driven to act like starving men on a lifeboat who cannibalize those around them.


Posted by Sherry Colb

22 comments:

David C. said...

Re: the opt-in vs. opt-out issue, one can imagine critics of Professor Colb's suggestion arguing that the government should not influence individuals' private choices in this way; that there is something inappropriate and unseemly about the government guiding people's profoundly personal choices.

This recalled to mind a speech (via podcast) I once heard Cass Sunstein give on "libertarian paternalism." (The paper authored by him and Richard Thaler is available at http://papers.ssrn.com/sol3/papers.cfm?abstract_id=405940). The gist, if I remember correctly, is that libertarians should not have knee-jerk reactions to proposals like Professor Colb's, because it is nearly impossible for the government to avoid influencing behavior when it regulates. Rational or not, individuals will often behave and choose differently depending on how options are presented to them, and default positions exert a powerful influence on those choices. When the government regulates by providing people with different options (preferable, the libertarian might think, than leaving people with no choice at all), it can offer those choices randomly, or it can present them in a way that seeks to guide private behavior in a welfare-maximizing way. In other words, the government will necessarily tilt the playing field one way or the other. People who might express a preference for X will still "choose" Y if it is the default, and vice versa. If the government cannot avoid leading people to behave in a way contrary to their would-be preferences, it may as well act paternalistically by channeling people toward the behavior it deems most positive.

With a program like organ donation, this line of thinking is persuasive. If the government must regulate via an opt-in or opt-out program, why would it construct a bias against organ donation? Unless the reasons for an opt-in system are more compelling, the government should pursue the program that will save numerous lives.

Patrick S. O'Donnell said...

Please see Kieran Healy's post at Crooked Timber, "Opt-Out Organ Donation in the U.K.?" http://crookedtimber.org/2008/01/14/opt-out-organ-donation-in-the-uk/#more-6575

Check out his essay, "Do Presumed Consent Laws Raise Organ Procurement Rates?" http://www.kieranhealy.org/files/papers/presumed-consent.pdf

And then there's his book, Last Best Gifts: Altruism and the Market for Human Blood and Organs (Chicago, IL: University of Chicago Press, 2006) http://www.lastbestgifts.com/

Finally, Daniel Goldberg comments at the Medical Humanities Blog:
http://www.medhumanities.org/2008/01/on-presumed-con.html#comments

Michael C. Dorf said...

Okay, so i looked up the sources Patrick O'Donnell cites (some of the links got terminated and so I had to google them, but I got everything but the book). Basically, what they say is that changing the default from opt-in to opt-out won't have that much of an impact unless it is accompanied by a greater commitment of resources to the actual process of organ procurement (transplant teams, public awareness, etc). The entries also make the point that investment in procurement infrastructure alone is likely to be more effective at raising donation rates than changing the default. But this just leads one to the conclusion that the best policy is investment plus a changed default. And a changed default without investment is still likely to be somewhat better than the opt-in default without investment.

Patrick S. O'Donnell said...

Sorry you had the problem with the links: I just tried them again and they worked for me. And thanks for your succinct summary of the points. I happen to think the fact that "investment in procurement infrastructure alone is likely to be more effective at raising donation rates than changing the default," is a politically more realistic and hence viable option than attempting to change the default rule (+ investment). And I don't think the material cited allows one to draw the conclusion that "a changed default without investment is still likely to be somewhat better than the opt-in default without investment," but I could be mistaken.

KipEsquire said...

"If poverty and wealth are often unearned, however, it is no less true that good and ill health are often unearned. ... One could, in fact, invoke such desperation as evidence that organ sale ought to be permitted but regulated."

Of course, a true Rawlsian (or any other utilitarian) could even argue that organ donation should be compulsory. And by that I don't just mean after death, as is being proposed in the U.K.

If society is entitled to seize your unearned wealth, then why is it also not entitled to seize your unearned kidney?

And for those who think kidneys are too extreme, how about compulsory blood donations -- maybe when you report for jury duty or file your tax return?

See also, "military conscription" -- if the state can seize your entire body, then why not just one kidney or pint of blood?

Patrick S. O'Donnell said...

kipesquire,

Re: "or any other utilitarian"

Are you claiming or implying Rawls was a utilitarian? He was not.

You seem to have an inordinate if not overweening fondness for the slippery slope argument (which, admittedly, is not always fallacious).

ahirsch116 said...

And your proposal is better than increasing supply by allowing the market to set a price how?

Carl said...

And your proposal is better than increasing supply by allowing the market to set a price how?

Well, if you want to avoid creating markets for organs and you think that the reason markets for organs exist is that the supply of donor organs is too low, you're probably not going to be particularly sanguine about a strategy for increasing the supply of donor organs that depends on creating the very markets for organs that you are trying to avoid to begin with, are you?

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