'Anybody Need a Kidney?' or 'What Are the Moral Limits of Markets?'
Daniel Mullin

18 April 2013

I'm in the process of looking for work. In the meantime, I'm a bit low on cash. A friend of mine recently joked that I could always sell a kidney. Well, I'm not that desperate (yet), but the fact remains that I can't sell a kidney, at least not legally. This got me thinking: should I be able to do so?

Most people have intuitions about what it's okay and what it's not okay to do for money. Harvard philosopher Michael Sandel has articulated some of those intuitions in What Money Can't Buy: The Moral Limits of Markets. Although I haven't read the book, I know he takes up the issue of selling organs and rejects it on ethical grounds. The gist of his argument can be found here. I understand these intuitions, but I'm not sure I agree with Sandel entirely. Admittedly, I haven't thought about the issue as long as he has, and my thoughts are still nascent, but I'm going to try to craft an alternative argument and you can judge it for yourself.

To return to our moral intuitions, however, our society tends to frown on people who sell their bodies. This is usually a euphemism for prostitution (which I think should be legal anyways) but we could take it more literally to include the sale of body parts. When it comes to the reproductive system, however, we don't seem to have a problem with it. Men can sell their sperm and women can sell their eggs. A woman can even lease out her uterus as a surrogate mother. But when it comes to the renal system, we as a society draw the line. Why? Granted, there are practical moral issues involved with the sale of organs as Sandel points out. The sellers tend to be poor and the buyers tend to be rich; the movement of organs is usually from the third to the first world. But that might be because these are black market transactions. If they were legal and above ground, a fair market price might emerge. But Sandel is right: the key issue is autonomy. The decision would have to voluntary, not coerced, and determining that in practice isn't easy. Nevertheless, it isn't easy to determine in the case of surrogate mothers or people who are paid to take experimental drugs, yet many of us accept the moral permissibility of these practices.

Perhaps part of our resistance to the sale of organs comes from the fact that we consider it noble to donate organs freely. It is better to give them away than receive compensation for them. Again, most of us acknowledge the difference between giving something freely and exchanging it for monetary gain. Maybe our adherence to that principle is why we consider organ donations good and selling organs bad. But I'm not convinced that principle will work here. The reason being that in the case of most organs, the donation is posthumous. When you think about it, posthumous donation requires no real sacrifice on the part of the donor. (This is why I find it surprising that so few people fill out their organ donor card. I'm even in favor of donation being the default position, i.e. you have to opt out of the program.) After all, the donor is deceased and would remain so with or without their organs. But in the case of a live donor, as is possible in kidney transplants, there is a real sacrifice. The person is actually giving up something. Isn't such a person entitled to some compensation?

To make this a little more clear, let's take a relatively uncontroversial scenario. Let's say that my brother needed a kidney. I would certainly be allowed legally to donate one of mine and I would also feel a sense of moral obligation to do so. But it wouldn't entirely be a selfless act. Yes, I would be making a sacrifice, but I would also be gaining something, namely having my brother around longer, enjoying a better quality of life which, in turn, has implications for my quality of life. So it's not entirely a selfless gesture on my part. In other words, I receive compensation of a kind. In the case of a stranger, with whom I have no familial bond nor have any expectation will improve the quality of my life, is it unreasonable to expect that the compensation be monetary?

Needless to say, this issue is complicated. I haven't even addressed the question of whether or not such compensation would solve the shortage problem and increase the net well-being of patients awaiting transplants. I don't claim to have worked out a full-fledged position on this issue. I've just tried to provide some food for thought and push our moral intuitions in new directions. What do you think?

Comments (4)

Daniel Mullin's picture

Daniel Mullin

Sunday, April 21, 2013 -- 5:00 PM

Yes, the word 'might' is

Yes, the word 'might' is important which is why I chose it. I don't say that it definitely will emerge. But the surrogate mother case provides a good example, I think. As I guy, I'm running a risk commenting on this because obviously I don't speak from experience, but it seems like there is a fair market price in this case. Surrogate mothers arguably make more than they would in a year at a median-paying job. It doesn't prima facie look like a case of exploitation, but I'm open to being corrected.
Speaking of side-stepping, you kind of talked around the concrete argument and examples I gave. You talk a lot about the generalities of markets and slippery slope-type arguments about where such thinking might lead, but you don't respond in any detail, as far as I can tell, to this specific case or how legalizing the sale of kidneys -- with the appropriate regulatory oversight of course -- leads to the deliterious consquences you envision.
I agree with you, however, that economics is not morally value-neutral. I stated up front that we have intuitions about what it's not okay to do for money. My question is simply why does selling a kidney fall under this heading whereas other examples of 'selling one's body' arguably do not? Your answer seems to be that introducing market forces will make the exchange value-neutral. But isn't that just conceding the point to your capitalist interlocutors? Why not talk about the ethics of markets across the board? The kidney case, then, becomes just one more example, albeit a difficult one, of how we assign value, both moral and economic.

Daniel Mullin's picture

Daniel Mullin

Sunday, April 21, 2013 -- 5:00 PM

Grue, thanks for the link. I

Grue, thanks for the link. I may have listened to that episode in the past, but I'll refresh my memory when I get the chance.
With respect to Richard's comment, it probably warrants more by way of response than I gave it the first time around. In retrospect, my response seems a bit terse. I was writing in a hurry, but I wouldn't want that to be mistaken for dismissiveness on my part. 
Obviously, I haven't worked out the logistics of my tentative proposal in any detail. That wasn't the purpose of the post. I just wanted to stir the pot. If sale 'to the highest bidder' were the only option, of course, the proposal would be problematic. But sale to the hightest bidder -- which I agree is the least desirable arrangement and most likely to be abused -- is not the only way the sale and distribution of kidneys could be organized. What about a gov't organ bank that set the market price and incentivized the sale only in cases where scarcity demanded it? Again, I'm just throwing out some ideas.
I'm also sensitive to the concern about viewing persons as commodities. Most morally sensitive people share the intuition that it's wrong to view persons as mere commodities or means to an end. But I'm not entirely sure how this principle applies here. Is the act of 'selling one's body' itself somehow demeaning of the person? Is this so in all cases? In this case specifically? If the person does so autonomously is it still so demeaning that the state has an overriding interest in preventing it? These are the questions in the neighborhood of this issue. It becomes an exercise in what, to my mind, looks like arbitrary line-drawing. Are the general principles we rely on elsewhere useful in these cases?
Also, are there cases in which compensation can actually affirm personhood? Whether we like it or not, the way our society assigns value is through money. Perhaps I'm sensitive to this because over the past five years I gave a lot of myself to a job for which I wasn't fairly compensated. This has a profound effect on one's sense of value and can rightly be described (I think) as a denigration of one's personhood. I don't know if this principle applies here, but there's a fine line between volunteerism that's noble and volunteerism that exploitative. I can envision scenarios in which 'giving out of the goodness of one's heart' or out of a perceived sense of obligation, are more exploitative than setting up mechanisms of fair compensation. Again, whether this applies in the kidney case is debatable.
P.S. I hope that, ultimately, this will be a moot issue, as medicine advances and we can clone replacement parts in the lab. But, still, the process would likely be expensive and may still cost the recepient some money. Would this be less morally objectionable, however?

Daniel Mullin's picture

Daniel Mullin

Monday, April 22, 2013 -- 5:00 PM

I suppose I'm curious about

I suppose I'm curious about what makes the surrogacy case dissimilar to the kidney case for you? Why is a woman's womb a legitimate domain for markets and not someone's kidney?
I think we might also be in danger of talking about "something called 'the market'" in too abstract a way. Markets can be very complicated entities, but the basis for markets is relatively simple: property rights plus contracts. We generally think this is fine when the arrangement is voluntary and we generally acknowledge that individuals have a high degree of sovereignty over their own bodies. Again, people already sell blood, sperm, eggs, wombs, etc. This at least sets the stage for extending markets to cover kidneys.
The only real issue that I can see -- and I think that this *is* central to both Sandel's and Satz' position -- is the problem of weak agency. In other words, are the persons giving up their kidneys doing so in an informed, voluntary way and not being coerced by some external agency or circumstance. I acknowledged in the original post that these are practical worries. But there are at least two responses available: 1) these worries may be overcome by regulatory oversight (we shouldn't generalize from black markets to regulated markets); 2) the problem of weak agency applies also to donation (as opposed to sale).
But these are all arguments on the individual autonomy side. You rightly bring up the issue of our collective concerns. Well, how about the argument that allowing a market in kidneys would increase supply and reduce the suffering and death of 75,000 Americans on waiting lists? This is a social welfare argument and I think it ought to give us pause. We can talk idealistically about some things being too precious to be reduced to market forces, but in the meantime there are a lot of concrete cases of suffering that go unanswered. It's an exercise in utilitarian calculus, I know, but it speaks to the 'greater good' aspect of the argument.
In any case, it's good to bear in mind the bigger picture, because our moral intuitions may lead us astray. The idea of using someone, even if they are fairly compensated, for spare parts rightly causes a twinge of conscience. However, we typically don't feel that same twinge of conscience in the case of the tens of thousands per year who die awaiting a transplant. This is the problem of silent suffering and it looks suspicously like a cognitive bias in our moral reasoning.
At the end of the day, I suspect that one's position on this issue comes down to how much weight they place on individual autonomy and how much weight they place on the aggregate suffering of those on wait lists. Clearly, kidney markets aren't ideal and aren't without their problematic moral consequences, but we're seldom given the luxury of choosing between ideals. The pragmatic question, then, is "are kidney markets better (or at least no worse) than the alternative?" Tentatively, I still find myself saying 'yes.'

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