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This is bioethics bytes with me, David Edmonds and me Nigel Warburton.

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Bioethics Bytes is made in association with Vox, which we here are Centre for Practical Ethics and made possible by a grant from the Wellcome Trust.

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For more information about Bioethics bytes, go to WW W Doctor Practical Ethics, Dot Oaks Dot AC dot UK or to iTunes u.

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Every day people die in hospitals because there aren't enough organs available for transplant.

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In most countries of the world, though not all, it's illegal to sell organs.

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Governments insist that the motive for donating organs has to be altruistic.

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It can't be financial reward. The idea of being able to sell body parts makes many people uneasy.

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But is it time for policy change? Should we be permitted to flog one of our organs on eBay, say, for $10,000?

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If not, why not? Tim Lewin's is a Cambridge philosopher and a member of the Nuffield Council on Bioethics.

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Tim Lawrence, welcome to Bioethics Points. It's very nice to be here.

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Thank you. The topic we're going to focus on is the donation of body parts.

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Could you say something about the kinds of body parts and the kinds of transactions that occur?

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Well, the ethical issues around donation are very pressing.

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And one of the reasons is that they're obviously essential for health and functioning.

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It's estimated that even in the UK alone, three people die every day because they're waiting for organs for transplantation.

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So there's a very strong sense that this is something that we need to do something about.

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It's a very urgent problem and we need to increase the rate of donation.

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At the same time, one can then look at the question of what sorts of incentives are appropriate here.

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In general, most international organisations, the World Health Organisation, for example, takes it as a given that donation needs to be altruistic.

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And that's particularly when one's talking about the donation of organs, things like kidneys, for example.

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So that raises a bunch of ethical questions about why is altruism so important,

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whether there are other kinds of incentives that one could use, which are consistent with altruism, those kinds of things.

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Just to get clear what sort of organs and tissues we talk about, well, I guess the obvious examples of things like kidneys but also blood is donated.

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There are other things which don't just contribute towards one's own health, but they also bring future generations into existence.

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So we're also talking about gametes, for example, sperm and eggs.

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Most obviously, we can sell our labour.

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Our bodies seem to be our own. Why can't we sell our body parts, particularly if we can function very effectively without them?

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I think that's a very good question and it's not easy to answer. So some responses that are given look, for example,

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towards the alleged quality of supply of materials that you get if you're basing it on altruistic donation.

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The argument here, roughly speaking, goes. Suppose you moved away from altruism.

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Suppose instead you offered people financial incentives for donating their blood or for donating their kidneys.

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Well, then what would happen? The answer, people say, is that poor people, disadvantaged people, would tend to come forward.

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And then the worry just is that their organs just wouldn't be as good. They'd be deceased, maybe because of lifestyle issues.

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Maybe these people are engaging in all kinds of other dodgy activities, which means that we wouldn't want their blood.

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So one set of reasons is just to do with the quality of supply.

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And that's, I think, pretty implausible right now in any kind of donation system,

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needs extremely rigorous testing and screening procedures, and we could just carry on using those.

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So I think those quality arguments don't really stand up. Is that the only argument against taking money for body parts?

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There's also a set of arguments that relate to the quantity of supply as well.

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And again, these are not deep, principled arguments. The worry relating to quantity of supply goes like this.

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Roughly speaking, we currently have an altruistic scheme. Suppose we were to move over to a paid scheme?

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Well, maybe some people who really need the money would then donate for remuneration.

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But then the thought goes are the people who currently donate tonnes of the altruistic

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scheme would feel as though this had been reduced to a mere market transaction.

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It was then somebody else's job to do this and they would withdraw their participation.

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So some people have claimed, somewhat paradoxically, that the overall rate of donation would actually go down even with this incentivization scheme.

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Once again, I think this is a case where the empirical evidence is is fairly flimsy.

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So there is one country in the world where a state endorsed, regulated system of organ donation is currently at work and that country is Iran.

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Now, there has been some suggestion that although since the scheme has been introduced, certain level of donation has increased.

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It looks as though previously altruistic donation has has tailed off there.

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But of course it's very, very hard to really extrapolate here some instances which try to show what people would.

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Who were you to offer them some incentives based merely on asking them hypothetical questions.

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Those hypotheticals suggest that maybe they would indeed be offended by the offer of reward and remove their participation.

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But when you look at other countries where people have genuinely been offered small rewards, for example,

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for giving blood, it doesn't look as though those rewards actually make any difference to their behaviour in practice.

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So far we've just talked about practical arguments about the consequences or alleged consequences of setting up a market in body parts.

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But there are people who believe there's something special about the body.

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Yeah, that's right. Although it's difficult to really put one's finger on on that.

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So sometimes people, when asked why the body is special, will resort to talking about things like dignity in the body, for example.

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Well, one of the problems about talking about dignity is it is rather a nebulous concept.

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And people often use considerations of dignity to oppose actions that consenting adults are engaging in which they frankly don't like very much.

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There is, I think, something, general, that we can say about why we think body parts are important.

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And this is something that I think everybody should agree on, and that is simply that health is very important.

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So you need a properly functioning body if you want to do almost anything.

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It's not a capacity that contributes towards you being able to do just one or two things.

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If you're healthy, you can do a very large range of things that you might wish to do.

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Being healthy is a kind of precondition for more or less any reasonable life that you might wish to lead.

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So that, I think, explains why it is that we view a healthy body with such urgency.

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There is also a thought that because we view being healthy as such a general purpose,

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good, a kind of entry level good if you like to being able to function at all.

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That also explains why it is that we feel many people feel as though justice

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demands that everybody should be able to attain some basic state of health.

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The question is what that means then?

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For incentivisation, it's not clear that what that means is that incentivisation needs to be consistent with altruism.

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In fact, you might almost use that to argue in the opposite direction.

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So some people would say and what this shows is that health is so important that we should do

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more or less anything we can to make sure that everybody can maintain that state of health.

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And what that means is that we shouldn't be too prissy about the kinds of

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incentivization regimes that we use when we're trying to persuade people to donate.

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I think it's important to get clear about exactly what altruism means in this context.

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I mean, I think the way to think about altruistic action is in this context,

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we're mainly interested in motivation because presumably we're thinking about tourism as some kind of virtue.

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So it's something to be understood in terms of what makes people take the kinds of reasons which are prompting action.

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And I think we can just take altruistic action as action,

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which is motivated by a desire to promote the welfare of whoever is on the receiving end of the action.

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Looking specifically at donation issues, there are plenty of incentives which are perfectly compatible with altruism.

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Consider somebody who genuinely wants to give an organ to somebody else, and this is something which is happening in this country rather a lot.

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So called stranger donation in the context of kidneys.

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Consider somebody who genuinely wants to make a kidney available to someone else who needs it.

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Now that person might think. Unfortunately, I'd love to do it, but I can't because I can't afford to take the time off work.

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I need that money. I can't lose the money that I'd need to go through surgery and to recover afterwards.

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Now, suppose the government says, Well, I'll tell you what we'll do. We'll just compensate you for all of your lost earnings.

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Now, that's a financial incentive, but it's entirely compatible with altruism that the mere fact that you recoup what you lost its money,

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you receive it from the state, but it doesn't follow from that that your action was not altruistic.

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Wouldn't an exchange of passive money just lead to exploitation?

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Again, I think it's difficult to really make the exploitation argument work, but let me have my best shot at this.

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I think in some ways exploitation is a bit of a red herring here.

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If you think about exploitative labour, for example,

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usually what's meant by saying that employer is being exploitative is simply that the employer isn't paying his staff what the job is worth.

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Now, if the worry then was that payment for organ donation were exploitative, in that sense there'd be a very simple way to solve it,

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which would just be to pay people even more money for their organs in this imagined state regulated market.

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But that's not what people think would solve the problem. When people say this is exploitative, what they mean.

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Is that all? Winters are not the sorts of things that should be traded financially at all.

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And I think that I mean, roughly speaking, what's going on in the back of people's minds here is that they think that organs

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and with it what organs lead to which is health is being somehow mis mis valued.

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And the notion of mis evaluation you can make sense of when you look back to, say,

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the reports in the newspapers earlier on this year, last year, about paid friends.

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Right. So it turns out that you can hire people to be your friend for an evening or for a weekend.

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But it looks on reflection as though that's just not what friends are supposed to do.

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They're not just meant to be turning up because they're getting paid.

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They're not meant to be helping you out because they're being rewarded for it financially.

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They're meant to be helping you out because they really care about you.

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So one way, I suppose,

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of trying to justify why people even think it's important that donation should be altruistic is the thought that we want to live

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in the kind of society where efforts to improve the welfare of other people are not just reduced to yet another fee for services,

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but instead they're really meant to be expressive of a genuine desire to help out the broader health of the population.

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Some kind of solidarity stick notion that we're all in it together.

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Health is this kind of basic good and we should be looking out for each other.

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Something like that, I think, underlies the general thought that donation should be altruistic.

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And what do you think of that argument? I think it's the best effort to justify altruistic donation.

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Even then, I'm not sure that it works. I've been talking as though all donation of what you might think of as significant body parts is altruistic.

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In fact, it's not. One thing that happens in the UK in the context of a gamete donation is that we allow things called egg sharing schemes.

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If you are a woman with healthy eggs, but for some reason or another you need IVF treatment,

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then private fertility clinics will let you have IVF treatment,

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maybe at a greatly reduced price, or maybe for free if you are willing to donate some of those eggs to another woman who needs donated eggs.

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It seems to me that that sort of scheme is not primarily appealing to the altruistic motivation of the donor.

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Many women who enter into egg sharing schemes,

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they say that they wouldn't have done that had IVF been made available freely to them on the National Health Service.

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So in that sense, it looks as though this is a self-regarding action that they're doing.

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Now, having said that, it's not clear that there's anything particularly bad about egg sharing schemes, even though they're non altruistic.

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When you ask people who are donors involved in egg sharing schemes, they seem to genuinely care at least once they've entered into the scheme.

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They genuinely care about the welfare of mothers who are benefiting from their eggs.

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They want to know whether or not pregnancies have been successful.

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They seem to gain something from helping other people out.

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That suggests to me that we should be critical of the idea that merely by moving away from altruistic incentives,

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we're inevitably going to undermine this solid touristic fellow feeling kind of approach

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because it looks in the context of egg donation as though there's still plenty of solidarity,

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there's still plenty of fellow feeling these kind of benefits in kind schemes are maybe

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less likely to undermine solidarity than a scheme where you simply offer somebody payment,

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because then it does look a lot more like fee for service.

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It's much less clear that this generally important empathy when it comes to the health and health needs of others will be placed in the foot,

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in the forefront.

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Potentially, there's a problem if we're bad at calculating the consequences for our own health of certain sorts of actions, say on average,

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people underestimate how important health is long term for their well-being and happiness,

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and yet overestimates what they'll be able to do with the money that they get from sacrificing some future healthiness.

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If that's true, any incentives where the encouragement of people to take actions which effectively harm their future health seem almost immoral.

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I mean, why would a government or a health organisation want to set up a pattern of behaviour which is actually going to encourage nudges,

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as it were, people into donations which will damage the health?

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Yeah, I think that's a good point. There's also some some empirical evidence that bears that out from the experience in Iran.

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So I mentioned Iran at the moment as a state endorsed scheme for the purchase of organs such as kidneys.

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It looks as though people who have sold organs, usually because.

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Debt later on come to regret it. They don't manage to clear their debts any way.

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They may become depressed. They have domestic dispute write down of marriage.

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So some studies really portray the Iranian experience very negatively, even though it's entirely legal.

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Now, you might say you don't think there was anything wrong with that if you were a paternalistic,

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because of course, there's no coercion involved here. Nobody's forcing these people to sell their kidneys.

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The way into the question was a good one, I think.

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So you said why would the government want to facilitate this?

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It's one thing to say that we shouldn't stop consenting adults from engaging in behaviours that don't harm others.

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It's another thing to say that the government should go around actually facilitating and encouraging these kinds of behaviours.

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You might say, well, the Government shouldn't prevent people from committing suicide.

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It's another thing altogether to say, well,

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why shouldn't the government just produce nicely packaged cyanide pills that people can take very easily to help them kill themselves?

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So where do you stand on this issue? What do you think about the use of incentives?

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I'm not convinced by any of the in principle arguments that try to show that nothing but an altruistic donation scheme could possibly work here.

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So, for example, I mentioned these worries about Iran. It's not clear that the Iranian experience can be generalised outside of that country.

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When stigma and shame are attached to the donation of organs for money, then this is likely to have terrible knock on problems.

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But it's not a necessary truth that stigma and shame are attached to these things.

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And in fact, we can imagine a possible society where it's regarded as a very noble thing to go and give your organs,

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even though there's a sizeable financial incentive attached to it.

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You can imagine cases where there really may be nothing wrong with this.

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However, my view is that it's not the time to institute such a thing.

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And that's because in going back to the problem that we started off with.

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Organ donation is indeed an urgent problem.

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But there are a number of other things that we can do to augment organ donation, some of which are very, very practical,

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proper counselling, seeking consent, making sure that there's effective transfer of organs from one centre to another.

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Those kinds of sort of nuts and bolts, infrastructural issues may help considerably and for many kinds of donation,

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there really isn't too much of a problem at the moment. So blood is not in particularly short supply.

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Many organs are, but there are other kinds of tissue that are not in particularly short supply either.

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Given worries that there might be similar stigma and shame issues, for example, in the UK,

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given worries that financial incentivisation could won't necessarily but could undermine a general solidarity commitment that we have.

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We shouldn't mess around with that system in those respects. We should mess around with the system in other respects, it seems to me.

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Tim Lewis, thank you very much. It's been a pleasure.

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