NON-CONSENSUAL HARVEST FROM THE DEAD
If we believe that medicine and society are deeply committed to saving lives, we must not only object to immoral schemes of organ procurement but also search for acceptable ones.
One reason why interest in incentives to live donations is rising is the low rate of cadaveric donations. It is a commonplace tenet that compulsory harvest from the dead might erode public trust in medicine. I am not sure. I am deeply worried about the possibility that society cares to respect the dead, and people’s sentiments regarding “their” dead, more than the health and lives of those still living.
One unexplored scheme is payment to next of kin for consent to donate. This will be expensive, because it will create expectation to be paid for every donation from the dead. But it might still be worthwhile to pay more money and save more lives overall. We know that many objections to donations from the dead are rooted in the wishes and values of the deceased persons and their families. Problems of trust in medicine might also stymie consents to donation. Precisely because payment for consent might work, this would be inappropriate, as society does not try to bribe people against their values and judgment. In this light the use of money to push people to harm their own bodies against their values and judgment seems even more out of place. Even if the harm to the seller is very minor, it is certainly more significant than the harm incurred by harvest from a dead relative.
It is reasonable to increase the price offered when somebody is unwilling to sell a coveted property. But coveted kidneys are not property in waiting for the optimal opportunity for consumption or liquidation. This is why they have no price tag in the first place, and this is why offering money in exchange of kidneys will not make it worthwhile to sell, even though many might consent to sell when prices are high enough (e.g. millions, tens of millions). It is amazing to find ethicists who are confident about the moral duty to set limits on public expenditure on health care but at the same time do not find the expenditure on live organs excessive. They would allow patients to die when treatment for their conditions is too expensive, protecting public funds more than they care to protect desperate people.
Because we do not want society to maim the living and leave the dead intact, it may be argued that no efforts should be made to encourage live donations/sales at all. One possible response might invoke the estimate that even if all eligible cadaveric kidneys are donated, there will still be a shortage in organs.11 An additional response might be that should live donors/sellers be given a truly basic good they cannot otherwise receive and which is at the level of the good lost (the kidney), procurement from live people might be a reasonable course of action, especially when the alternative is forceful harvest from the dead.
NON-PECUNIARY LIFE-LONG AND INALIENABLE BENEFITS AS INCENTIVES TO LIVE DONATIONS
A society that is genuinely motivated by care for basic human values must not promote transplantation by encouraging people to waive their right to bodily integrity. In order for transplantation from the living to be morally valid, organs should be taken from people who desire to do so, and with good reasons. Hence, the incentive to be offered must be substantial, inalienable, and inevitably good for the personal well-being of the donors/sellers.
I believe that non-fungible and lasting basic human goods (hence PGB), such as health insurance and nursing insurance for life, may constitute moral and effective incentives for live donors. As a matter of fact, I will argue that society has the moral duty to confer such goods on altruistic donors as well; that it is immoral to accept organs from well intentioned donors without giving them health care when they need it themselves, whenever society can afford such care.
Kant divided everything that exists into objects that are tradable and consequently have market value, and persons who are unique and irreplaceable and consequently have dignity that is beyond value. One needs not be a Kantian in order to realize that whereas every person may accumulate and may lose money and property, it is only possible to lose body parts, not acquire them. Once given away, they are irreplaceable. It is impossible to undo the violation of the body and the invasion of a person. Hence, nobody wants to give a kidney. People either consent due to dire circumstances or want to help a needy person. In the absence of pressing exigency of either the self or a needy other, nobody will consent to the removal of a healthy kidney.
The typical poor seller cannot retain any future benefit from the money collected, since the money disappears in the form of payment for an old debt or is directed to cover an unexpected life-cycle need. Even sellers who manage to retain the revenue are always at risk of losing it in the future. In terms of security and reversibility, fungible benefits cannot match the loss of a vital organ. However, when a person receives health insurance and similar personal and non-transferable benefits, their values last for the rest of his or her life. Moreover, the transaction redeems the person (and his or her immediate family) from worry about falling into crises of the kind that stimulates sells of organs.
Since every society that supports organ transplantation can also afford PGB to the donors/sellers, abstention from doing so seems immoral. This is especially relevant with regard to the United States and other OECD countries, which can easily afford high-quality health and nursing insurances for donors, whose donations will reduce the financial burden of dialysis care.
Moreover, as much as altruistic giving is commendable, taking without reciprocal giving is not. A helpless needy recipient is not bound to pay back his altruistic donor; but society, which benefits from the donation as well, has a moral duty to care for the donors. People who risk their health by handing over a vital organ certainly deserve health care and nursing care when they need it.
When people seek to give kidneys in exchange for PGB, all other people involved in the process know that the harm incurred is reciprocated by a substantial human good which is lasting and promotive of the human dignity of the persons. The persons giving the organs are less likely to regret it in the future, since the benefit incurred will last for the rest of their lives and is directly related to the very risks involved in losing a kidney. It also contributes directly to saving human life and to amelioration of suffering. Many people will not consider PGB as either incentives or rewards, but as moral duties owed by society to altruistic and non-altruistic givers of organs for transplantation. Perhaps some altruistic donors hesitate because of fears of future medical complications so as to render PGB a removal of disincentives rather than as incentives or rewards. Moreover, once we conceptualize and institute PGBs as moral duties to live organ donors, PGB may not be considered incentives or rewards anymore.
Critics might point out that PGBs might fail because people respond to immediate cash and not to long-term benefits, their ultimate value notwithstanding. Consequently, PGB will not work as efficient incentives, and the supply of kidneys will lag behind that which is expected in so-called free markets for organs. But, in a second thought, this very possibility is one more argument against social participation in markets for organs. If, indeed, people would sell kidneys for ready cash and not for health insurance whose value is much higher, this is a reason not to buy from them, as such business will be clearly harmful, even exploitative.