This is bioethics bytes with me, David Edmonds and me Nigel Warburton.
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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Every day people die in hospitals because there aren't enough organs available for transplant.
In most countries of the world, though not all, it's illegal to sell organs.
Governments insist that the motive for donating organs has to be altruistic.
It can't be financial reward. The idea of being able to sell body parts makes many people uneasy.
But is it time for policy change? Should we be permitted to flog one of our organs on eBay, say, for $10,000?
If not, why not? Tim Lewin's is a Cambridge philosopher and a member of the Nuffield Council on Bioethics.
Tim Lawrence, welcome to Bioethics Points. It's very nice to be here.
Thank you. The topic we're going to focus on is the donation of body parts.
Could you say something about the kinds of body parts and the kinds of transactions that occur?
Well, the ethical issues around donation are very pressing.
And one of the reasons is that they're obviously essential for health and functioning.
It's estimated that even in the UK alone, three people die every day because they're waiting for organs for transplantation.
So there's a very strong sense that this is something that we need to do something about.
It's a very urgent problem and we need to increase the rate of donation.
At the same time, one can then look at the question of what sorts of incentives are appropriate here.
In general, most international organisations, the World Health Organisation, for example, takes it as a given that donation needs to be altruistic.
And that's particularly when one's talking about the donation of organs, things like kidneys, for example.
So that raises a bunch of ethical questions about why is altruism so important,
whether there are other kinds of incentives that one could use, which are consistent with altruism, those kinds of things.
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.
There are other things which don't just contribute towards one's own health, but they also bring future generations into existence.
So we're also talking about gametes, for example, sperm and eggs.
Most obviously, we can sell our labour.
Our bodies seem to be our own. Why can't we sell our body parts, particularly if we can function very effectively without them?
I think that's a very good question and it's not easy to answer. So some responses that are given look, for example,
towards the alleged quality of supply of materials that you get if you're basing it on altruistic donation.
The argument here, roughly speaking, goes. Suppose you moved away from altruism.
Suppose instead you offered people financial incentives for donating their blood or for donating their kidneys.
Well, then what would happen? The answer, people say, is that poor people, disadvantaged people, would tend to come forward.
And then the worry just is that their organs just wouldn't be as good. They'd be deceased, maybe because of lifestyle issues.
Maybe these people are engaging in all kinds of other dodgy activities, which means that we wouldn't want their blood.
So one set of reasons is just to do with the quality of supply.
And that's, I think, pretty implausible right now in any kind of donation system,
needs extremely rigorous testing and screening procedures, and we could just carry on using those.
So I think those quality arguments don't really stand up. Is that the only argument against taking money for body parts?
There's also a set of arguments that relate to the quantity of supply as well.
And again, these are not deep, principled arguments. The worry relating to quantity of supply goes like this.
Roughly speaking, we currently have an altruistic scheme. Suppose we were to move over to a paid scheme?
Well, maybe some people who really need the money would then donate for remuneration.
But then the thought goes are the people who currently donate tonnes of the altruistic
scheme would feel as though this had been reduced to a mere market transaction.
It was then somebody else's job to do this and they would withdraw their participation.
So some people have claimed, somewhat paradoxically, that the overall rate of donation would actually go down even with this incentivization scheme.
Once again, I think this is a case where the empirical evidence is is fairly flimsy.
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.
Now, there has been some suggestion that although since the scheme has been introduced, certain level of donation has increased.
It looks as though previously altruistic donation has has tailed off there.
But of course it's very, very hard to really extrapolate here some instances which try to show what people would.
Who were you to offer them some incentives based merely on asking them hypothetical questions.
Those hypotheticals suggest that maybe they would indeed be offended by the offer of reward and remove their participation.
But when you look at other countries where people have genuinely been offered small rewards, for example,
for giving blood, it doesn't look as though those rewards actually make any difference to their behaviour in practice.
So far we've just talked about practical arguments about the consequences or alleged consequences of setting up a market in body parts.
But there are people who believe there's something special about the body.
Yeah, that's right. Although it's difficult to really put one's finger on on that.
So sometimes people, when asked why the body is special, will resort to talking about things like dignity in the body, for example.
Well, one of the problems about talking about dignity is it is rather a nebulous concept.
And people often use considerations of dignity to oppose actions that consenting adults are engaging in which they frankly don't like very much.
There is, I think, something, general, that we can say about why we think body parts are important.
And this is something that I think everybody should agree on, and that is simply that health is very important.
So you need a properly functioning body if you want to do almost anything.
It's not a capacity that contributes towards you being able to do just one or two things.
If you're healthy, you can do a very large range of things that you might wish to do.
Being healthy is a kind of precondition for more or less any reasonable life that you might wish to lead.
So that, I think, explains why it is that we view a healthy body with such urgency.
There is also a thought that because we view being healthy as such a general purpose,
good, a kind of entry level good if you like to being able to function at all.
That also explains why it is that we feel many people feel as though justice
demands that everybody should be able to attain some basic state of health.
The question is what that means then?
For incentivisation, it's not clear that what that means is that incentivisation needs to be consistent with altruism.
In fact, you might almost use that to argue in the opposite direction.
So some people would say and what this shows is that health is so important that we should do
more or less anything we can to make sure that everybody can maintain that state of health.
And what that means is that we shouldn't be too prissy about the kinds of
incentivization regimes that we use when we're trying to persuade people to donate.
I think it's important to get clear about exactly what altruism means in this context.
I mean, I think the way to think about altruistic action is in this context,
we're mainly interested in motivation because presumably we're thinking about tourism as some kind of virtue.
So it's something to be understood in terms of what makes people take the kinds of reasons which are prompting action.
And I think we can just take altruistic action as action,
which is motivated by a desire to promote the welfare of whoever is on the receiving end of the action.
Looking specifically at donation issues, there are plenty of incentives which are perfectly compatible with altruism.
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.
So called stranger donation in the context of kidneys.
Consider somebody who genuinely wants to make a kidney available to someone else who needs it.
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.
I need that money. I can't lose the money that I'd need to go through surgery and to recover afterwards.
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.
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,
you receive it from the state, but it doesn't follow from that that your action was not altruistic.
Wouldn't an exchange of passive money just lead to exploitation?
Again, I think it's difficult to really make the exploitation argument work, but let me have my best shot at this.
I think in some ways exploitation is a bit of a red herring here.
If you think about exploitative labour, for example,
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.
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,
which would just be to pay people even more money for their organs in this imagined state regulated market.
But that's not what people think would solve the problem. When people say this is exploitative, what they mean.
Is that all? Winters are not the sorts of things that should be traded financially at all.
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
and with it what organs lead to which is health is being somehow mis mis valued.
And the notion of mis evaluation you can make sense of when you look back to, say,
the reports in the newspapers earlier on this year, last year, about paid friends.
Right. So it turns out that you can hire people to be your friend for an evening or for a weekend.
But it looks on reflection as though that's just not what friends are supposed to do.
They're not just meant to be turning up because they're getting paid.
They're not meant to be helping you out because they're being rewarded for it financially.
They're meant to be helping you out because they really care about you.
So one way, I suppose,
of trying to justify why people even think it's important that donation should be altruistic is the thought that we want to live
in the kind of society where efforts to improve the welfare of other people are not just reduced to yet another fee for services,
but instead they're really meant to be expressive of a genuine desire to help out the broader health of the population.
Some kind of solidarity stick notion that we're all in it together.
Health is this kind of basic good and we should be looking out for each other.
Something like that, I think, underlies the general thought that donation should be altruistic.
And what do you think of that argument? I think it's the best effort to justify altruistic donation.
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.
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.
If you are a woman with healthy eggs, but for some reason or another you need IVF treatment,
then private fertility clinics will let you have IVF treatment,
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.
It seems to me that that sort of scheme is not primarily appealing to the altruistic motivation of the donor.
Many women who enter into egg sharing schemes,
they say that they wouldn't have done that had IVF been made available freely to them on the National Health Service.
So in that sense, it looks as though this is a self-regarding action that they're doing.
Now, having said that, it's not clear that there's anything particularly bad about egg sharing schemes, even though they're non altruistic.
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.
They genuinely care about the welfare of mothers who are benefiting from their eggs.
They want to know whether or not pregnancies have been successful.
They seem to gain something from helping other people out.
That suggests to me that we should be critical of the idea that merely by moving away from altruistic incentives,
we're inevitably going to undermine this solid touristic fellow feeling kind of approach
because it looks in the context of egg donation as though there's still plenty of solidarity,
there's still plenty of fellow feeling these kind of benefits in kind schemes are maybe
less likely to undermine solidarity than a scheme where you simply offer somebody payment,
because then it does look a lot more like fee for service.
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,
in the forefront.
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,
people underestimate how important health is long term for their well-being and happiness,
and yet overestimates what they'll be able to do with the money that they get from sacrificing some future healthiness.
If that's true, any incentives where the encouragement of people to take actions which effectively harm their future health seem almost immoral.
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,
as it were, people into donations which will damage the health?
Yeah, I think that's a good point. There's also some some empirical evidence that bears that out from the experience in Iran.
So I mentioned Iran at the moment as a state endorsed scheme for the purchase of organs such as kidneys.
It looks as though people who have sold organs, usually because.
Debt later on come to regret it. They don't manage to clear their debts any way.
They may become depressed. They have domestic dispute write down of marriage.
So some studies really portray the Iranian experience very negatively, even though it's entirely legal.
Now, you might say you don't think there was anything wrong with that if you were a paternalistic,
because of course, there's no coercion involved here. Nobody's forcing these people to sell their kidneys.
The way into the question was a good one, I think.
So you said why would the government want to facilitate this?
It's one thing to say that we shouldn't stop consenting adults from engaging in behaviours that don't harm others.
It's another thing to say that the government should go around actually facilitating and encouraging these kinds of behaviours.
You might say, well, the Government shouldn't prevent people from committing suicide.
It's another thing altogether to say, well,
why shouldn't the government just produce nicely packaged cyanide pills that people can take very easily to help them kill themselves?
So where do you stand on this issue? What do you think about the use of incentives?
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.
So, for example, I mentioned these worries about Iran. It's not clear that the Iranian experience can be generalised outside of that country.
When stigma and shame are attached to the donation of organs for money, then this is likely to have terrible knock on problems.
But it's not a necessary truth that stigma and shame are attached to these things.
And in fact, we can imagine a possible society where it's regarded as a very noble thing to go and give your organs,
even though there's a sizeable financial incentive attached to it.
You can imagine cases where there really may be nothing wrong with this.
However, my view is that it's not the time to institute such a thing.
And that's because in going back to the problem that we started off with.
Organ donation is indeed an urgent problem.
But there are a number of other things that we can do to augment organ donation, some of which are very, very practical,
proper counselling, seeking consent, making sure that there's effective transfer of organs from one centre to another.
Those kinds of sort of nuts and bolts, infrastructural issues may help considerably and for many kinds of donation,
there really isn't too much of a problem at the moment. So blood is not in particularly short supply.
Many organs are, but there are other kinds of tissue that are not in particularly short supply either.
Given worries that there might be similar stigma and shame issues, for example, in the UK,
given worries that financial incentivisation could won't necessarily but could undermine a general solidarity commitment that we have.
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.
Tim Lewis, thank you very much. It's been a pleasure.
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