Monday, February 29, 2016

Legalize the sale of organs

Disclaimer: Some of these arguments are paraphrased from a lecture by TCNJ Philosophy Professor James Stacey Taylor last June. All opinions are my own, however.

Today I’m going to defend a very controversial opinion of mine, which I hold very passionately. I believe it should be completely legal to sell one or more of your organs to another person for money via privately negotiated contract. Furthermore, I believe this is such an urgent moral necessity that the legalization should take place immediately, on a massive scale, without proceeding cautiously or gradually at all, and without pausing to create any intricate regulatory bodies that might slow or restrict the emergence of the legal organs market.

I am passionate about this issue because unlike some other parts of philosophy, it has very important real world implications. When we get this wrong, people die. When we get it right, we save lives. The issue is rarely talked about in mainstream politics, but it is not some fringe issue that only matters to tinfoil-hat-wearing libertarian cooks. Experts in the industry endorse it. US presidents have endorsed it. Al Gore said he would consider it. A “rich network of transplant surgeons, nephrologists, legal scholars, economists and bioethicists” are at least willing to test the power of financial incentives for donors. It affects millions of people, and you should care about it. If you haven’t given it any thought until now, you should start thinking about it more. If nothing else, I hope this post will assist you in doing so.

Because this issue is so important, I’m not going to base my argument on any contestable philosophical tenets. As a libertarian, I strongly believe in personal autonomy and self-ownership. I believe people should be able to sell their organs for the same reason women should be able to get an abortion, and the same reason adults should be able to smoke marijuana: it’s their body, and they alone have right to decide what to do with it. But I’m not going to make those arguments today, because they’re polarizing, and because they’re unnecessary to prove why the sale of organs is such a moral imperative. All you need to believe in order to agree with me that the sale of organs should be legal is that human life and wellbeing matters, and it is morally important to maximize both. No mainstream bioethicist would disagree, and neither would the average person walking down the street. Let’s begin.

The facts about legal organ markets

Organs can be categorized based on three important economic characteristics: scarcity, renewability, and vitality. To illustrate, kidneys are not scarce, because most people have two of them, whereas spleens are scarce, since potential sellers only have one. Skin is a renewable organ, since it can grow back once donated, whereas kidneys cannot regenerate. And the heart is a vital organ because it is required to survive, whereas the spleen is not.

In the real world, the most common organs for sale would likely be kidneys, because they are in such high demand, and because individually they are both plentiful and non-vital. Spleens, skin, and other non-vital organs would be the next most common. To be clear, I would even go so far as to legalize the sale of vital organs, for reasons I will explain later. But since that practice is even less likely to be legalized, and would affect far fewer people even if it were legal, for the purposes of this article I’m going to use the sale of kidneys as an example.

For those unfamiliar with the science behind it, normal human beings are born with two working kidneys. The human body only needs one to survive, but for a variety of reasons, some people’s kidneys stop working altogether. Eventually this causes death, through a process called renal failure. However, death by renal failure is not immediate, and can be prolonged even further with the help of a medical procedure called dialysis. Dialysis is sometimes very painful, and always very time consuming, costly, uncomfortable and inconvenient, but it can keep people with failing kidneys alive for several years. Even better, if someone with matching blood type and medical requirements volunteers to donate one of their two working kidneys to the person in need during this window of time, doctors can transplant the kidney from one person to the other with a very high success rate, thereby saving the person’s life entirely.

At present, the practice of selling your organs for profit is illegal in every country except Iran. In every country except Iran, there are lengthy waiting lists of people who need a kidney – soon – or else they are going to die. These people can only get a kidney if a) a suitable biological match volunteers to give them one for free, or b) a suitable match who registered as a posthumous organ donor dies, and his or her organs are preserved in time to transplant them to the person on top of the list. Unfortunately, neither of these things happen as frequently as there are new people who need kidneys. Although 75% of Americans volunteer to donate their organs upon their death, less than 1% of deceased persons are medically eligible to donate their organs anyway. Public health professionals try to increase organ donations by spreading public awareness of the situation, but living donations remain utterly insufficient to save everyone on the list. The result is that every year the kidney waiting list gets longer, and every year more and more people die of renal failure.

How many people? In the United States alone, 13-18 people die every day for want of a kidney. As of January 2016, the waiting list for kidneys alone was over 100,000 people long. Someone is added to the end of this line every 14 minutes, for about 3,000 each month. Only about 17,000 of these people will actually get a kidney transplant in a given year – 11,500 from deceased posthumous donors, and 5,500 from living donors. The median wait time is about 3.6 years. For many, that proves too long: by year’s end, about 8,000 people on the list either die or become too sick to receive a transplant. The rest need dialysis 2-3 times a week to stay alive. Perhaps it seems trivial to mention this in light of the above figures, but for what it’s worth, providing dialysis to people with end-state renal failure costs the US Medicare system $34 billion a year.

This used to be the case in Iran, as well. Prior to 1990, it was illegal to sell your organs there just as it was everywhere else in the world. They, too, had lengthy kidney waiting lists. But in 1990, Iran decided to legalize the sale of organs, despite denouncements from the West that this was immoral. The results were astonishing.

Within two years, the waiting list for kidneys completely disappeared.

To this day, there is no list. If you have end-state renal failure in Iran, and you have access to medical care, you WILL get a kidney – no question about it, 100% chance. No other country on earth can claim this.

Iran does have waiting lists of a different kind however: lists of people waiting to sell their kidneys. In fact, the desire to sell a kidney is so strong that public health experts there have found evidence it is causing people to take better care of their health. People are literally going to their doctors and asking to be placed on a diet that makes them a better candidate for kidney donation!

How has the world allowed Iran, of all countries, to be the shining beacon on a hill on this important issue of personal freedom and public health? Iran is a poor, corrupt theocracy with far inferior medical facilities to our own. It’s pretty bad to be less free than Iran in anything.

America is not the same as Iran, but human nature is much the same everywhere, and our national differences would only affect the pace and degree of the effect. Expert Sally Salat opines that while the results of compensating organ donors cannot be known for certain, “if you press me for an answer, I would say that the waiting list would be cleared within five years.” She is too cautious – we can be damn near certain that the number of organ donors would at least increase. That the only country on earth to legalize the sale of organs is also the only country without waiting lists to receive an organ is not a coincidence.

Basic economic theory explains what happened quite clearly. Producers produce in pursuit of profit. If you prohibit the sale of something, the production of that thing will decrease dramatically. With any other desired good, this principle is obvious and self-evident. Imagine that lawmakers were to prohibit the sale of Big Macs. To be clear, they would not be banning Big Macs outright – you’re still allowed to make them, eat them, and even give them away. McDonalds would still be allowed to stay open, to make Big Macs, and to sell other things besides Big Macs – they just couldn’t receive money in exchange for their Big Macs anymore. What would happen to the supply of Big Macs? Of course, it would plummet.

If analogies to Big Macs strike you as too harsh, consider a closer analogy: blood. In an interesting reversal of its stance on organs, the US is one of the very few nations on earth that pays donors for their blood plasma – in places like the UK and New Zealand, they view this as immoral too, and accept pro bono donations only. The result? The same as in Iran. Whereas demand is outstripping supply in the world at large, so many more people donate blood here than do so elsewhere that the US actually supplies blood and plasma to the rest of the world – including 100% of the plasma to the UK, for that matter (see objection #4 for more on this).

Organs are little different. Like the production of any other product, the “production” (in this case, donation) of useable kidneys involves time, cost, and risk, not to mention physical discomfort and forfeited wages as the donor recovers from the procedure. Like most other products, people are usually only willing to bear these costs and inconveniences if they see something in it for them. We are happy to help one another when doing so is easy, or when the person in need is someone close to us. Many people gladly sign up for posthumous organ donation on their driver’s licenses. If an immediate family member or treasured friend were in need of a kidney, or a marrow transplant or a blood transfusion due to some accident, most of us would be happy to go under the knife that they might live. But rarely are people willing to spend several months and several thousands of dollars of medical bills to help a complete stranger, especially when doing so entails risk of a medical complication in their own bodies. The doctor I cited earlier named Sally Satel agrees. She writes:

"Altruism – the “gift of life” narrative – is a beautiful virtue but, clearly, is not enough. Yet, for decades, the transplant establishment has embraced altruism as the only legitimate basis for giving an organ. If we keep thinking of organs solely as gifts, there will never be enough of them. Deaths will mount, needless suffering will continue, and the global black market in organs will continue to flourish."

If you think her depiction of human nature is too cynical, I challenge you to put your money where your mouth is: go donate a kidney! Not posthumously, either – the 100,000 people on the waiting list don’t have that long to wait, and there’s a 99% chance your kidneys will be unusable by then anyway. Do it now. And if you haven’t done it already, ask yourself why that is. Even if you are so inspired by this article that you do donate a kidney, how likely it is that most other Americans will behave any differently than you have up to this point in your life?

The morality of selling organs is a matter of opinion, but the effects of allowing it are pretty close to empirically settled. In the few places blood donors are compensated, the theory of what should happen matches the reality of what has happened. In the one place organ sales are legal, the theory of what should happen matches the reality of what has happened. Everywhere else, there is enormous demand for kidneys, and vastly insufficient supply. If you agree it is morally imperative that we entice more people to donate organs than presently are willing to do so, you don’t need a degree in economics to understand how legal organ sales accomplish this. When people with plenty of money but not enough kidneys meet people with plenty of kidneys but not enough money, both of their lives can be drastically improved through a simple transaction. Why on earth would we want to stop this?

The objections to legal organ markets

There are five main objections I hear to the legalization of organ sale. I will refute them in order of their prevalence and strength.

1. The first objection is that selling organs is exploitative. To some people, arguments about personal autonomy are only convincing when the people in question are behaving in accordance with their values and beliefs. If, by contrast, they are only acting in response to their dire circumstances, and doing something they would ordinarily prefer not to do were they to find themselves in happier or more “normal” circumstances, they are sometimes said to be “forced” into that decision. Sweatshop labor is often put forth as an example of this. Nobody truly “wants” to work in such unhappy conditions, the argument goes, and nobody would work there were they not “forced” to by their economic circumstances. Since force compromises autonomy, and we take autonomy as a good thing, the argument goes that we should remove the option these people are being “forced” into. This means closing sweatshops, and if people are only participating in organ markets due to similarly dire living circumstances, it means closing those markets as well.

The World Health Organization opposes kidney sales for this reason. In its Istanbul Declaration, it opines that “[t]ransplant commercialism targets impoverished and otherwise vulnerable donors. It leads inexorably to inequity and injustice and should be prohibited.” Ana Manzano, researcher at the Centre for Health, Technologies & Social Practice at the University of Leeds, calls it “a form of exploitation of the poor”.

The interesting thing about the exploitation argument is that in this context, it is unclear which party to the transaction is the one being exploited, and which is doing the exploiting. In prostitution, the person selling their body is often thought to be the desperate one – surely, detractors misguidedly imagine, such a decision would never be freely made by anyone with “real” alternatives. But in the case of organ donation, the purchaser is surely just as desperate, and just as coerced by their own unhappy situation. By analogy, the practice of “price gouging” – jacking up the cost of scarce goods people need to survive in emergency situations, like generators after a Hurricane, or water in a desert, or a life jacket to a drowning man, a ferry ride to escape a burning city – is also portrayed as exploitative. Kidneys fetch several thousand dollars even in third-world Iran, where the average annual salary is about $400. To collect such a fee is to profit mightily from another’s misfortune. So who is the heartless oppressor, and who is the oppressed?

Just as mutually drunken collegiate hookups cannot reasonably be said to have “raped one another,” mutually beneficial agreements between desperate people cannot be anything but consensual, even if you accept the logic that asymmetrically desperate transactions are nonconsensual. To both the buyer and the seller, the transaction is not a vicious attempt to wield leverage over their fellow man, but rather the best opportunity they sincerely believe they have to elevate their own condition. To take away that opportunity does not help either person involved. Who benefits from prohibition, under such circumstances? Whom are we protecting?

It is easy to declare “people shouldn’t have to sell their bodies just to get by!” with much feeling and gusto, but it just doesn’t follow that organ markets should be illegal. First off, there is little evidence that anyone is selling their organs “just to get by”, even in desperately poor nations like Iran. Evidence suggests that most of the donors the WHO is concerned do not view the sale of a kidney as a desperate last resort. On the contrary, the studies indicate donation is merely seen as an enticing economic opportunity – one which people need not seize, but want to anyway. Anecdotal evidence shows people using the proceeds to pay for their children’s education, for example, or to start a business. And personal gain isn’t the only reason someone might choose to sell. Satel explains:

“Surrogate mothers surely welcome the payment they receive but compensation is hardly the only factor in the decision; almost all of them say they are motivated by a strong desire to help another woman fulfill her maternal dream. Financial and humanitarian motives intertwine all the time. Did we honor the heroism of 9/11 firefighters who rushed into the World Trade Center towers any less because they got paid?”

Sincere desire to save dying people is by no means incompatible with receipt of payment for that service. And inversely, receipt of payment for the same act we view as noble without payment is no indication that the donor is now a despairing victim with nowhere to turn.

And if that’s wrong, and most donors really are desperately selling kidneys just to feed their family, prohibition would then be even less likely to dissuade them from selling. If people are genuinely “forced” by their economic situation into selling a kidney, it follows that they would be forced to do so whether or not it is legal. This pushes them onto a black market which is surely far more dangerous and exploitative. Even if we accepted the unsubstantiated claim that much the legal sale comes from people who lack alternatives, making it illegal does not provide them any better alternatives!

It’s easy to understand the heart of this objection on a human level. Selling a part of one’s own body strikes us as desperate, and human desperation makes us uncomfortable. But even in the minority of cases where that seems to be the case, we should object to the situation in which these people find themselves, not to the wholly rational decisions they make to try and elevate themselves from such a plight.

2. The second objection to legal organ markets is that it’s immoral for wealth to be a determinant of who lives and dies. The current waiting list system is income neutral: first come, first serve. Since receiving a donated organ is currently free, poor people are just as likely to receive one in time to survive as rich people are. Attaching a price to organs would change this. Although charitable organ donations would still be legal, the argument goes that many or most of the 5,500 people who currently donate their organs for free each year would instead decide to sell them at market value. Due to both the desperation of people who need a kidney and the inconvenience/cost of donating one, the market value of a kidney would likely be very high (in Iran, it’s about two years’ salary for an average government worker). This would price some people out of the market entirely, supposedly dooming the doubly unfortunate people who are BOTH very poor AND in need of a kidney. One of my friends worried about this point in a recent Facebook conversation on the issue, writing: “does it mean, if there is an organ market, that rich people will get organs whereas poor people who won’t be able to afford it can just pass out?”

There are two reasons this objection fails, one practical and the other moral/theoretical. Morally, the wealth distribution of the people whose lives are saved seems clearly secondary in concern to the aggregate number of lives saved. First come first serve is no less arbitrary a method for deciding who lives and dies than wealth is, so if we have reason to believe that permitting the sale of organs will reduce the number of people who die in a given day from renal failure (and we do), the identity of those people becomes wholly irrelevant. It is one thing to say that we should not favor rich lives over poor lives other things equal, but quite another to say that we should actively bring about thousands of preventable deaths just to balance the income distribution of the deceased!

But the good news is we needn’t worry about this tradeoff anyway, because organ sales are not only compatible with the current waitlist system, but actually complementary to it. Practically speaking, recall that over 2/3 of the people who receive an organ each year in the current system get one not from living donors, but from people who died after volunteering as posthumous donors. Legalizing the sale of organs would not change this existing system at all. People like you and I would still be free to sign up as voluntary organ donors on our driver’s licenses, and when we died, our organs would still be given free of charge to people waiting in line for them.

The only thing that would change about this system is that the line to receive such an organ would become drastically shorter, if it persisted at all, due to the vastly larger number of people who forfeit their place in line to participate in the legal organ market. So even if pro bono donations were crowded out entirely, such that 100% of the people who previously would have donated a kidney instead decided to sell it or keep it (which is extremely unlikely due to the high percentage of those donations which are given to immediate family members or loved ones), it’s likely the waitlist would shorten by an even larger margin than that.

To illustrate the mathematics behind this, suppose you are presently the 50,000th person in line for a kidney (out of 100,000), and that you are also too poor to afford to buy one. At present, 17,000 people per year who are ahead of you in line will get one, and another 8,000 per year will die or become to sick to get one. Since you are at the exact midpoint of the line, suppose that exactly half of those 8,000 people will be ahead of you in line, meaning that every year, you move up 21,000 spots. If nothing changes, it would take you about 2.38 years to move to the front.

Now suppose Congress decides to legalize the sale of organs tomorrow, and consequently, half the people on the waiting list decide to buy a privately offered organ instead (of course, it would take time for this market to emerge in real life, but since we’re trying to compare the benefits of the current system with those of a fully established market several years down the line, imagine for the sake of argument that this happened immediately). This strikes me as a conservative estimate – remember that in Iran, the waiting list was completely eradicated as a consequence of legal organ sales in just two years, and that American experts suspect the same would happen here within five years. To give detractors the benefit of the doubt, I’m only supposing that our experiment will be half as successful as that.

Suppose also that the distribution of kidney buyers was even throughout the waiting list, such that you are now the 25,000th person in line out of 50,000. Since we’re supposing each of the 5,500 people who previously donated an organ are now among the 50,000 selling it instead (which, again, is dubious) there are only 11,500 people coming off the list each year – less than the 17,000 that came off previously. But even if we make a third highly dubious presumption that NONE of the 25,000 people in front of you in line will die before you, because ALL of the ones who would have died bought a private market organ instead, this still means that your expected time on the wait list would only be 2.17 years.

TLDR: Even if we make three assumptions that are very generous to the current system, legalizing the sale of organs would be very likely to reduce the time which even the poorest person on the waitlist had to wait to receive an organ for free.

It is true that richer people could pay more to get one sooner. But not only would this cause more lives to be saved overall, it would even save lives among that class of people who are too poor to pay for an organ! Relative to the current system, it’s a boon for all parties. This really puts this objection to bed. To persist in opposing a policy change which would save the lives of both poor people and rich people overall, on the grounds that “it would save rich people’s lives at a higher rate and that’s unfair,” is so outrageously perverse that it doesn’t warrant rebuttal.

3. The third objection to legalizing organ sales is health risk for the donor: some people argue that kidney donation is too dangerous to the health of living humans to be permitted, whether or not the donor is desperate. Just as other occupational hazards can be regulated, the argument goes, medical procedures deemed as too risky can be banned for the protection of potentially ignorant patients. This, too, relies on theoretical presumptions about the right of governments to protect us from ourselves, which libertarians like me reject on face. But you needn’t accept the libertarian position on that issue to reject this objection. For the sake of argument, let’s grant the idea that voluntary but risky behavior can ethically be outlawed to save people from themselves. Would it follow that kidney donation is too risky?

How risky is “too” risky is a somewhat subjective question, but whatever level of risk you find tolerable should at least be consistent across the board. It makes sense, therefore, to compare the risks of organ donation to the risks of other potentially dangerous activities, and see whether comparably risky activities are legal or not. It is currently legal to pay people to go arctic crab fishing, or coal mining, or lumbering, or roofing, or to execute high steel construction. High steel construction, for example, has a statistically demonstrated 0.03% chance of death. Even if we cherry-pick the most outlandishly high estimates for death by organ donation, it’s only a 0.025% risk. For injury, high steel construction is up to about 3%, whereas the highest estimates of organ donation put it about 4.5% - higher, for sure, but still comparable. And again, that’s on the highest estimates. The fairest median estimates for organ donation’s risks suggest that not only construction but also many other industries are far more dangerous.

This means that if you are ideologically consistent, and you want to ban organ sales on the basis that they are too risky, you have no choice but to ban high steel construction as well. Companies would no longer be permitted to build buildings tall enough that people could die from falling off of them during construction. How likely is that to happen?

Organ donation is also far less risky than other activities which people do just for fun, like hang-gliding, or executing dangerous motorcycle stunts for instance. Those activities don’t even have the countervailing factor of saving lives! Surely, we’d have to ban hang-gliding as well. How likely is that to happen?

Furthermore, organ transplant surgery is no more risky when the donor is being paid than it is when the donor is doing it for free. If you want to ban organ sales because they are too risky, you’d have no choice but to ban the free-of-charge organ donations which happen today on the same grounds. This means you believe that the 5,500 people who are donated kidneys voluntarily each year under the current system should be left to die of renal failure, rather than risk the possibility that 0.025% (max) of their 5,500 donors – about 1.4 people – die of complications. How likely is this view to catch on?

If it is unlikely that we ever ban these things, how consistent is opposition to organ sales with society’s risk tolerance in other arenas? Remember, in the status quo, public health experts are pleading the American people to donate their organs more often. Clearly they believe the risks are worth it compared to the good that is done. Why is that any different when we put a price on it?

It’s clear to me that people who make this objection are either uninformed about the risks they decry, or else seriously grasping at straws because they object to organ sales for unrelated reasons they can’t articulate. This article from The Guardian – an anecdote of an organ donation gone wrong in Iran – strikes me as a prime example of this problem. Anecdotes make for bad arguments in any case, but they’re particularly irresponsible when the bulk of the evidence leans in the opposite direction. And even if such stories were common, they would need to be weighed against the far commoner reality of preventable deaths from renal failure – people who would almost certainly have been saved were more kidneys for sale on the market.

Legalization is not a panacea. A select few unlucky individuals will undoubtedly wind up worse off than they were before due to legal organ sales. But that’s true of any legal surgery: sometimes, accidental complications cause death. And like other types of surgery, perhaps even more so, on net it is economically indisputable that more lives will be saved by allowing the legal purchase of organ transplants than would be saved by banning that purchase.

4. The fourth objection to the legal sale of organs is that it will decrease the quality of the organs available, relative to the quality in a voluntary donation system. When somebody donates something out of selfless desire to help others, they have no incentive to lie about the quality of the kidney they offer. Salesmen, on the other hand, have a sleazy reputation of being loose with the truth. This argument posits that organ sales will deplete the quality of the average kidney a recipient can expect to receive because sellers lie about the quality of their product to make money in ways altruistic donors do not.

Practical real world comparisons suggest this isn’t the case, though. Let’s return to blood donations, for instance; recall that Britain permits only voluntary donations, whereas the US allows the commercial sale of blood. Since 1994, the US Red Cross has had 0 cases of transmitted diseases via blood transfusions. The Britain has nowhere near so successful a track record. In fact, the main reason Britain now imports blood from the US is due to a mad-cow disease contamination in its blood supply back in 2002. If for-profit donors were less trustworthy than charitable ones, why would the UK trust the quality of American blood over its own?

As it turns out, the profit incentive can be pretty healthy in a competitive marketplace. For years, for example, Britain permitted gay donors to donate blood, and even published a memo arguing there was no evidence the gay population has more AIDS than others. This was a perfectly rational response to their incentives, which was merely to collect as much blood as possible. The Red Cross, however, adopted the opposite policy, in response to their incentive to please customers by ensuring a high quality product. Today, of course, we know AIDS really is far more prevalent in the homosexual community. Our additional caution was warranted.

So too would competition mitigate the likelihood of deceptive trade practices in the organ market – so long as the market is kept above ground, that is, visible to medical experts with the technology to detect health risks. Just as companies compete for the approval of private consumer protection organizations like Underwriter’s Laboratory, and just as “certified pre-owned” vehicles from dealerships fetch higher prices than un-inspected used cars sold by strangers, sellers and buyers and surgeons alike would be motivated to ensure the kidney is a good biological match before proceeding.

5. The fifth and final objection I’ve encountered to legal organ markets is a compilation of semiotic arguments, which is essentially a fancy term for “it sends the wrong message.” There are those who say that permitting the sale of our bodies demeans what it is to be human; that we shouldn’t look at one another as mere collections of body parts, and encouraging such frank, matter of fact and heartless exchange cheapens the priceless value of human life. There are religious objections, on the grounds that it is unethical to “play God” in deciding who lives and dies. And, arguably as a subset of these religious objections, there are Marxist objections to the “alienation” that results from commodifying everything. My Facebook friend made a version of this complaint during our conversation, writing:

“The human body, for ethical reasons, shouldn't be for sale. That would be the ultimate last step of the commodification of everything. (land, labor, money). I think it is important to establish that certain things are just not commodities and once you sell them that's an extremely difficult fact to establish.”

There are a lot of things wrong with this, starting with the fact that no single person or organization gets to decide what is or is not a commodity. If somebody somewhere is willing to pay for it, and somebody else is willing to sell it, it’s already a commodity. A government’s decision to punish people for that transaction doesn’t somehow un-commodify the desired item. Drugs are a commodity, whether or not they are legal. Prostitution is a commodity, whether or not it is legal. Ivory is a commodity. Even hired murder is a commodity! Wherever there is a demand that can be profitably supplied, someone will try to supply it. No ethical theory of what we ought to buy or sell can change this. Whether or not the government makes it legal to do so, sick and dying people will continue to desire healthy organs, and continue to treat them as commodities, on the black market if they must.

Similar arguments were given in the past for that menacing commodity called life insurance. In the late 19th century, a standard objection to this emerging market was that it cheapens the value of human life to put a dollar value on their death payout. Plus, if we allowed people to sell life insurance, people fretted, it would send a message that human bodies were just commodities to be used up, expended, and gambled with. Those fears were unfounded. We don’t look at human life much differently today than we did in the 19th century, and there’s no reason to believe that people will start looking at one another as collections of parts if we make the sale of organs legal in the 21st century. Such arguments were emotional and implausible then, and they are equally so today.

But the most glaring problem with semiotic objections is that your personal discomfort with the ethics of selling organs is a rather flimsy justification for DELIBERATELY CAUSING PEOPLE TO DIE! That is what you are doing if you oppose my position, for all the reasons I described above. Legalizing the sale of organs WILL – indisputably among sane economists – cause more people to willingly offer their organs to those who need them. More organs offered WILL – indisputably among those familiar with our waitlist situation – save lives. It is true in theory, and it is true in reality, which makes it as close to fact as we can get in the world of policy: legalizing organ markets will prevent people from needlessly dying. Say it with me! All together now: IT SAVES LIVES! If you didn’t know before, now you know. To deliberately prevent these transactions anyway is to deliberately and knowingly bring about the death of innocent people.

And why, again? Because the “commodification of their bodies” makes you uncomfortable? Fuck off!

To arrest someone for offering to sell their kidney to a dying man in need of it is a hair’s breadth shy of murder. It’s like refusing starving children access to a grocery store, because it strikes you as more humane to direct them towards a soup kitchen THAT’S OUT OF SOUP!!! Libertarians sometimes catch flack for defending the ethical permissibility selling a life-jacket to a drowning man at inflated cost. But the same people who levy those critiques are now endorsing something far worse: that once such a sale is already agreed to, we should tackle the man with the vest and prevent him from tossing it out, as if the child’s death were morally preferable to the bystander’s profit. Marx’s theory of alienation is cute and all, but if you are unwilling to save lives in the real world because it’s “too capitalist,” you deserve to reap what you sow.

While we’re talking about “the message it sends,” let’s talk about signaling on the issue of personal autonomy. My Facebook opponent continued: “I don't think it would be a good thing to have poor people selling their kidney just to get money. Especially since these people have already hard living conditions and physical work that makes their life expectancy lower (and they need their 2 kidneys)”

She is certainly entitled to that opinion. But as it turns out, there’s an important group of people who disagree with her: namely, poor people themselves. Their vote should trump hers for the same reason women’s votes should trump those of people who don’t think abortion is a good idea: it is their body! What sort of “message” does it convey to tell would-be donors that they can make decisions for themselves in every other sphere of social interaction – who to marry, what to buy, etc. – but that when it comes to their own body, we know better than you?

From abortion to prostitution to drug use to sin taxes, it’s the same bullshit every time. Your body is your most obvious and important form of property. If you don’t own your own body, you don’t have a single right in the world. No matter which side of the political spectrum you fall under, the right to your own body is the starting point and building block for every other right. Are you a conservative who supports strong property rights, and thinks you have a right to keep what you earn through your own time and labor because John Locke said so? Own it. Are you a liberal who wants unquestioned bodily autonomy on abortion because “woman’s body, woman’s choice”? Own it.

Personal autonomy isn’t the only principle worth considering, but there isn’t even a competing value in this case. It’s an important enough value to people of all political persuasions that if you’re going to tell other people what they can or cannot do with their own bodies, you’d better have a damn good reason. Opponents of legal organ sales don’t. As Reason’s Ronald Bailey notes, “Paternalism is bad enough, but banning organ markets is ineffective and counterproductive paternalism at its worst.”

Miscellaneous notes:

1. It should go without saying that I also want to legalize the sale of non-organ biological agents like semen, eggs, ova, blood, blood plasma, cells, etc. This is already legal in the US, but not in many other countries, for reasons I really can’t fathom.

2. Although I prefer a completely free market in these things, I’m willing to accept any number of government-centered programs designed to incentivize organ donation in the interim. This could include income tax credits, a third party contribution to the donor’s retirement fund, a gift to a charity designated by the donor, guaranteed follow-up medical care for any complications, or at least allowing the recipient to cover the costs of the transplant surgery and recovery itself.

3. Some argue that a mandatory six-month waiting period would “screen out financially desperate individuals who might otherwise rush to donate for a large sum of instant cash and later regret it.” I would counter that it would also screen out buyers who have less than six months to live, and that the presumption of impulsiveness is cruel and condescending. But if that’s what it takes to get it legal, I’d also take it.

4. Perhaps the most cogent version of the “coerced choice” objection raises the scepter of family members who pressure other family members into doing it. This is problematic even in Western families (where things can get a bit awkward for elderly recipients unlikely to last long anyway) but it’s especially so in highly patriarchal Islamic societies like Pakistan, where there is evidence women (who don’t get much say in anything) are being pressured into selling on the black market to support the family.

5. Threatening violence on family members is clearly wrong, and strong social approbation can be a huge disincentive to doing what you otherwise would have preferred. Whether these decisions count as “free” or not is a subject for another day, but I concede they are more heavily pressured than our Western sensibilities feel comfortable with. This is a perfectly legitimate claim we should address. But…a) all the ways to address it in the organ market specifically have serious tradeoffs in terms of lives saved, b) the fact that it’s already happening on the black market only proves my point about how ineffective and counterproductive banning organ sales is, and c) the decisions which family members can pressure/coerce their wives and daughters into making are hardly limited to this issue, such that a true solution involves challenging the patriarchy in those societies more so than prohibiting each and every single one of the innumerable choices women may be pressured into making.

6. Sometimes the risk argument is fused with the exploitation argument by saying that the risks are highest for poor donors. Manzano argues that “the poorer the donor, the higher the possibility that he or she loses the functionality of the remaining kidney because of demanding work or inadequate healthcare.” Maybe so, but there are easy ways to get around that problem shy of making organ sales illegal. Even while organ markets are still illegal, for instance, I would favor a law which states that anyone who donates a kidney and then loses functionality in their remaining kidney gets to cut to the front of the line for voluntary organ donation. This would increase donations by reducing the risk which donating poses.

7. I promised at the start of this post to explain why even vital organs should be allowed to be sold. It seems counter-intuitive that it could ever be in the rational interest of anyone to donate an organ they need to survive. So imagine the following scenario: a lower class, middle-aged father with a perfectly healthy heart is on his deathbed due to pancreatic cancer. There is nothing doctors can do to save him. If left untreated, he will die within a month. Advanced chemo procedures can keep him alive for much longer – perhaps 6 months to a year – but his quality of life would be miserable, and such procedures are expensive. In fact, these procedures are so expensive that they would deplete the life savings he had hoped to would help pay for his children’s college tuition. 

The father does not want to be a financial and emotional burden on his family just so he can live in pain, immobile and bedridden, for a few more months. So instead, as a form of assisted suicide, he decides to sell his heart to a man in need of a heart transplant. The needy recipient is desperate for this heart, since he is near the back of the waiting list and unlikely to receive one in time to save his own life. As such, he is willing to pay a large fee for it – perhaps a million dollars or more. In one fell swoop, therefore, the sale of this heart would a) save the life of a man who would otherwise die, b) spare the family the financial and emotional burden of caring for their father/husband as he lingered on unhappy, c) remove the pressure to blow the man’s life savings on chemotherapy, d) spare the father the pain and indignity of slowly withering away, while honoring his last wishes, and e) transform the surviving family members into millionaires. Everybody wins, nobody loses. Why should this be illegal?

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