biomedical ethics research, internet searching articles, specific topic-based book Ethical Issues in Modern Medicine, Bonnie Steinbock, John D. Arras, Alex J. London 7th ed. The General topic: Part 2 Allocation, Social Justice, health Policy.
Organ donation: Ethics of gift vs. market exchanges
The dramatic difference between the philosophy of deontological, or Kantian ethics and consequential or situational, utilitarian ethics would seem to be crystallized in the issues that arise over the ethics of paid organ donations. From a utilitarian viewpoint, the more people who donate organs, the better. Increased organ donation to preserve more human lives would seem to be a universal 'good.' The more people who donate organs, the more people will live. The ethics of how increased donations arise, barring the untimely termination of the donor's life is of less consequence than the fact that they do arise. Thus allowing individuals to donate organs in exchange for money is not ethically troubling for a utilitarian, given that the consequence is prolonging the lives of more people.
A Kantian deontological ethicist, however, states that for an action to be ethical, it must be true in principle, as if setting guidelines for ethical behavior for all time. It is not enough that a policy may, in the short run, benefit more people. Selling organ parts for money is putting a price upon the body, and upon altruism. This Kantian ethics would only permit a 'gift' exchange for organs, of a person willingly sacrificing his or her body and taking the risk of surgery, but not permit a monetary exchange of funds for organs. If a monetary exchange was allowed, a Kantian might argue, what would happen if the principle in our society was established that human beings could sell parts of their bodies? Where would one draw the line that someone could sell body parts to risk his or her health?
The same, from a Kantian perspective would even be true of enforced organ donation from non-living persons. True, this would seem to be a more ethically defensible position from a utilitarian point-of-view: an individual loses possession of his or her body after death, and there are laws that govern how bodies can be disposed of, within our society. But even here a Kantian would have reservations. If someone has a moral objection to donation because of religious concerns, forcing him or her to donate organs would be a violation of those ideals. A society that allows individual choice regarding religion cannot suddenly state that the government has a material interest in disposing of a person's body for the 'good' of another human being. "It is a sad, true, and often reprised story; the need for solid organ donations egregiously exceeds the supply. The palpable desperation experienced by those who wait, but also frequently die, has led to a variety of proposals aimed at increasing organ supply…efforts targeting an increase in the organs available for transplant -- such as treating donated organs as commodities either in regulated or 'black market' transactions, do not fulfill criteria for just procurement" wrote one deontological medical ethicist (Rutecki 2010). Of course, there are many stories of people needing organ donation who tug upon the listener's heartstrings. But it is precisely because it is so easy to be overly emotional regarding the subject, that a strict, categorical ethical calculus is required, a Kantian would argue.
At present, both an international black market and a legal market (within some select nations) exist that allows for commodity-style trading in organs. However, contrary to what a consequentialist might predict, the result of this has not been a more 'just' society in the nations that allow for organ donations. As "some countries have 'regulated' their commodities market and have paid fees to donors that they determine to be fair and reasonable," the number of volunteer donors has decreased and the number of poor donors has dramatically increased (Rutecki 2010). The deontologist would say that this is what typically happens when simply the immediate situation is focused upon -- the pathos of someone needing an organ -- without regard to how the principle will operate over time. Allowing for paid organ donation effectively allows for the body parts of the poor to be bought by the rich, to serve the needs of the wealthy. "When China began to accept paying recipients from Hong Kong, live 'gift' donations fell by 15%, and in Israel, by 30% when local insurance companies agreed to cover 'Transplant Tourism' (Rutecki 2010).
This creates a fundamentally unjust society, where effectively the life of a poor person is valued as less than that the life and health of a wealthy person's. Iran, a government-regulated commercial commodity exchange for organ donation has existed since 1988. "Regulated transfers have taken over 90% of the entire market, have decreased voluntary donations, have marginalized postoperative donor care, and finally, the policy has again benefited the rich to the detriment of the poor" (Rutecki 2010). And although in theory they might seem to create a more healthy society, such as in the case of kidney donation where theoretically only one kidney is required for an individual to stay alive, they have not. "Poor donors comprise a particularly disadvantaged group: their average family income declined by one-third after donation, three-quarters remained in debt, and 86% had deteriorating health as a result of surgery to donate" (Rutecki 2010). Poor people often receive less high-quality aftercare than rich donors, and they do not always have the ability to evaluate the possible health and occupational consequences that may arise after they donate.
The fact that so many people are willing to pay for organ donation should not be so surprising: from a purely self-interested perspective, to some extent it is only logical that someone would want to do all he or she could to preserve the life of his or her child, or his or her own life. Donors likewise are acting out of what they see as the interests of their families, and themselves, taking a risk that the money they get as a result of the donation will give them a better life. And from a philosophical perspective of egoism, paid donation might be defensible. If the purpose of life is to maximize pleasure, and reduce pain, according to the principles of Epicurus, in an immediate sense, the pleasure of the recipient is increased by extending his or her life and the pleasure of the donor is extended by receiving money (and perhaps, although not necessarily, due to the donor's sense of altruism). But that is why, a deontologist would say, the government must step in and protect people from the bad decisions they make, when they are desperate. It is the government who must step in and administer justice, as defined as giving every person his or her 'due' in an impartial manner, not favoring those with more money.
Social contract egoism states that out of self- interest people cede some of their liberties to the government in exchange for protection provided by the state. One of the protections a government can give to its citizens is protection from themselves when they are making bad decisions under duress. This is the case with 'paid' organ donations, and while a strict libertarian might argue that a citizen should be free to do whatever he or she desires, regardless of consequences, without intervention from the government, so long as it does not have an immediate negative impact, social contract theorists stress that people do not always have the ability to understand the full-ranging consequences of their actions. While individuals do not give up all of their liberties in exchange for the protections provided by society and the state, they must give up some, to live in a functioning community.