Introduction
The Centers for Disease Control and Prevention (CDC) has reported of rare cases where HIV transmission occurred from donors to recipients despite screening, thus emphasizing the importance of using sensitive tests for both chronic and acute HIV infections (serological tests and nucleic acid testing).
This problem of HIV transmission during organ transplantation is more acute in the organ trading and trafficking industry where stringent HIV screening standards are sometimes not imposed.
It is a known fact that the demand for donor organs outstrips supply. As such, there is an ongoing impetus in certain countries to legalize organ trading.
In 2008, a Singapore Medical Association (SMA) Ethics Convention was held on Wednesday, 12th November, to discuss the possibilities of this option. The professional forum was entitled, “Compensation or incentives for donors in organ transplants: possibilities or pitfalls.”
If a legalization of remuneration for organ donations occurs, there is a risk of opening a Pandora’s Box – also known as the transplant tourism market – in Singapore.
Nevertheless, I seriously feel that Singapore might not want to create an image of a place where you can purchase the body parts of another person.
The following discussion highlights the bioethical considerations in organ trading, and how physicians should and must consider the four principles in bioethics as espoused by Professor Raanan E Gillon, namely: autonomy, beneficence, nonmaleficence, and justice.
The Commodification of Humans
In organ trading, there is the problem of commodification of humans and their body parts which, as ethicist Paul Ramsey has aptly stated, ‘will only erode still more an apprehension that man is a sacredness in the biological order’.
Unlike altruistically motivated donations, the sale of organs with the expectation of financial incentives is to commodify humans as mere objects or things, thereby violating the sanctity, dignity and respect due to humans within the living, biological order.
This point is further elaborated by Dr Thomas George, an orthopedic surgeon, in the Indian Journal Of Medical Ethics:
“On a superficial level it does appear that the sale of human organs benefits both the buyer and the seller. The sale of a kidney undoubtedly provides financial relief to a family in abject poverty. I am sure that many poor individuals in India and other Third World countries will exercise their ‘autonomy’ and ‘consent’ to sell their organs. When we oppose the sale of kidneys, we do so in the full realization of this fact but also feel that humankind should not be thus degraded.” – George, “Organs for sale, philosophy for hire,” Indian Journal of Medical Ethics 4 (1996)
Ontological and Metaphysical Concerns
In conjunction with the problem of commodification of humans is the ontological question : how should we view human beings within the biological order, and what about the purported sanctity of human life? I suspect that how we value humans (and their bodies), and whether we perceive them as sanctified beings with meaning and value to life, will somehow determine the way we understand the issue of organ trading.
On a personal note, I am convinced that all humans, and particularly human lives, have intrinsic value and thus should not be degraded by means of their commodification.
Donors: Victims of Circumstances or Recipients of Distributive Justice?
Ceteris paribus, what would be the main reason for the sale of one’s organs? From current statistics and a study of the much-touted Iranian model of organ ‘sharing,’ it seems clear that poverty is the chief motivating factor. I believe that even liberal bioethicists like Janet Radcliffe Richards would agree on this point. Richards considers all current debates concerning organ trading to be “confused noise,” and strongly holds to the laissez-faire approach.
The existence of such financial duress in the procurement of organs as commodities from the poorer communities is a travesty of distributive justice. Surely something can be done by civilized society to avoid this.
Another question we have to address is: should we ration organ availability by clinical need or the ability to pay? This is another key issue in the discussion of organ trading and distributive justice.
Social Justice for the Poor
The argument that money received helps the seller-donor rise above his poverty is gravely flawed. It must be the duty of civilized society to ensure that none of its citizens is in such a dire state of poverty that the poor have to be reduced to selling themselves piecemeal for survival.
A Slippery Slope
If we do permit the sale of body parts piecemeal, what then is the remaining overarching moral or ethical principle that would furnish us with a limitation to such organ sales?
Hypothetically, if we were to respect the autonomy of organ donors-sellers ad infinitum without considering other bioethical principles, should we then permit the sale of a kidney, and subsequently the cornea, a limb, the liver and so on? In other words, if the commodification of human organs is allowed as a legalized practice, what then should be the transcendental moral basis to prevent a slippery slope in the piecemeal sales-cum-disassembly of a fellow human being?
The HIV Connection
The media and medical journals have long documented the fact that organ trafficking has inherent risks of increased HIV and hepatitis C transmission.
It has been argued that the criminalization of organ trading has the unwanted consequence of driving organ sales underground, where screening tests for blood-borne infections like HIV is difficult to monitor and regulate.
Recently, The Lancet reports in its June 2014 edition that, “Although legislation forbidding organ sales exists in most countries, progress has been impeded by weak enforcement and the absence of comprehensive binding international instruments to harmonise regulations and improve cross-national cooperation.” With The Convention against Trafficking in Human Organs soon to be implemented by the Council of Europe, ratifying states are obligated to criminalize that which constitutes “trafficking in human organs.”
But what constitutes organ trafficking? According to The Lancet:
“The central concept is “the illicit removal of organs”, which consists of removal without the free, informed, and specific consent of a living donor; removal from a deceased donor other than as authorised under domestic law; removal when a living donor (or a third party) has been offered or received a financial gain or comparable advantage; or removal from a deceased donor when a third party has been offered or received a financial gain or comparable advantage.”
It is interesting to note that, according to this definition, organ trading is considered trafficking and therefore, illicit. The scope of the Convention is international, open to any nation and “not restricted to the 47 Council of Europe member states.”
Conclusion
It is important for physicians to take a holistic, yet ethical, view that encompasses fundamental ethical principles and relevant legislative considerations. In the process of debate and discussion, physicians are encouraged not to abandon the first principles of compassion and care, all the while seeking a progressive resolution to this bioethical problem.
It must be admitted that bioethical discussions concerning organ trading can be complex and perhaps, confusing at times. But in view of the aforementioned points, I seriously suspect that human organ trading and sales could easily be misconstrued as an unethical vestige of human exploitation if not dealt with delicately and wisely in our policies and legislation.
