It is OK to sell your car or your home. Why not your kidney?
In the United States alone, several thousand people die each year while waiting for an organ transplant. The idea of establishing a market in kidneys to increase supply is now attracting unprecedented levels of support. Proponents of organ markets argue that sellers can live with only one kidney, that the risks of surgery are relatively minor, and that—as the philosopher Robert Nozick once put it—it's wrong to interfere with capitalist acts between consenting adults.
But we should pause before sending our little kidneys off to market.
First, while ideal markets involve fully informed participants, real markets do not function on that basis. Some markets involve exchanges whose consequences will only become known in the future. In a study of India's kidney sellers, many developed unforeseen complications. Health risks are likely to be greater in places where people have little access to clean water or adequate nutrition or where sellers are desperately poor. While most of those interviewed sold a kidney to get out of debt, many were still in debt five years later. A majority said that they would not recommend the practice to others.
Second, a kidney market would have the likely consequence that very poor people would disproportionately be the organ sellers of the world. By contrast, a procurement system that relies on donation is much more likely to have suppliers who come from all classes. Sociologist Richard Titmuss found just such a contrast in his study comparing American and British systems of blood donation. Current black markets in kidneys reflect the different socio-economic situations of buyer and seller. Most sellers are desperately poor; most buyers are at least comparatively wealthy. The illicit international trade in organs transfers organs from poor to rich, third world to first world, female to male, and minority to white. There is no reason to think a legal market would be different—except in scale.
Finally, it is important to understand the ways that markets can have effects that reach beyond their participants. While proponents of markets usually focus on exchanges within given environments, the introduction of markets can alter environments and even motivations. For example, in the Tamil countryside where the practice of selling kidneys is widespread, the organs are viewed as loan collateral. In such circumstances, a person who does not want to sell her kidney may find it harder to obtain a loan. Many markets generate what economists call pecuniary externalities—effects of production or exchange on outside parties through prices. But while many markets have such effects, the question here is: Should a person face restricted market opportunities for not wanting to sell her kidney?
Markets also sometimes drive out altruistically minded actions. Researchers found that support for building a noxious nuclear waste facility in a neighborhood actually decreased when monetary compensation to host it was offered. Introducing an organ market might decrease the number of altruistic donors and require a prohibitively high price to increase supply overall.
A defender of organ markets might reply that some of these problems can be addressed through regulation. We can require informed consent, mandate appropriate follow-up care and access to a replacement organ if needed, and have the government subsidize the kidney purchases of the poor so that organs are not distributed according to ability to pay. But these regulations will be difficult to enforce in a world with massive poverty and widespread institutional failures. Nor do they address a core issue. Do we want the organs of the poor to be resources they will need to use to purchase other opportunities?
Weak information, harm, desperation, inequality and pecuniary externalities are all considerations that need to be part of the policy calculus. Not all markets are the same. Some markets are noxious. Consider markets in toxic waste, in international arms and in credit derivatives.
Still, we should not lose sight of the fact that kidney markets might have the potential to extend the life of a person who might otherwise die. Much more could be done to encourage the altruistic donation of organs, including changing the default presumption from one where we have to opt into organ donation to one where we have to opt out of it.
Debra Satz is the Martha Sutton Weeks Professor of Ethics in Society.
