In this paper, I present two types of arguments against the prohibition as they apply to a regulated market in kidneys from living suppliers: the utilitarian argument and the argument from non-uniqueness. The utilitarian argument shows a regulated market is likely to result in a significant increase in overall well-being. The international guidelines and treaties supporting the prohibition invariably quote the harm associated with the illegal organ trade; yet, a regulated market does not share the characteristics (...) of the illegal trade that gives rise to such harm. I argue that objections to such a market claiming that it would result in poor health outcomes, lead to crowding-out, and harm the global poor are unfounded. The argument from non-uniqueness, on the other hand, focuses on three objections to the market following the pattern of widely quoted principles of bioethics: objections from autonomy, “do no harm”, and justice. I argue that these objections, if taken seriously, apply equally to the sale and donation of kidneys, the latter of which is unanimously endorsed in all international guidelines and treaties. Unable to identify any relevant unique aspect of a market, these objections fail to justify an exclusive prohibition of a market in kidneys. (shrink)

We do not always benefit from the expansion of our choice sets. This is because some options change the context in which we must make decisions in ways that render us worse off than we would have been otherwise. One promising argument against paid living kidney donation holds that having the option of selling a ‘spare’ kidney would impact people facing financial pressures in precisely this way. I defend this argument from two related criticisms: first, that having the option to (...) sell one’s kidney would only be harmful if one is pressured or coerced to take this specific course of action; and second, that such forms of pressure are unlikely to feature in a legal market. (shrink)

This article concerns the morality of establishing regulated kidney markets in an effort to reduce the chronic shortage of kidneys for transplant. The article tries to rebut the view, recently defended by James Taylor, that if we hold autonomy to be intrinsically valuable, then we should be in favor of such markets. The article then argues that, under current conditions, the buying and selling of organs in regulated markets would sometimes violate two Kantian principles that are seen as moral (...) constraints. One principle forbids expressing disrespect for the dignity of humanity; the other forbids treating others merely as means. In light of the moral danger posed by regulated markets, the article advocates an alternative way of diminishing the current organ shortage, namely opt-out systems of cadaveric organ donation. (shrink)

The current system of organ procurement which relies on donation is inadequate to the current and future need for transplantable kidneys. The growing disparity between demand and supply is accompanied by a steep human cost. I argue that a regulated market in organs from living vendors is the only plausible solution, and that objections common to opponents of organ markets are defeasible. I argue that a morally defensible market in kidneys from living vendors includes four characteristics: (...) (1) the priority of safety for both vendors and recipients, (2) transparency regarding the risks to vendors and recipients, (3) institutional integrity regarding guidelines for cooperating with kidney vendors, and (4) operation under a rule of law. I conclude with some remarks on remaining problems with this account, and offer some suggestions as to how these problems might be addressed. (shrink)

Here, I briefly respond to a recent paper by Julian Koplin, in which he criticises my earlier work in this journal. I show that Koplin has misunderstood the distinction I have made between pressure to vend and pressure with the option to vend. I also show that his pessimism about the market regulations I favour is unwarranted.

In 'Stakes and Kidneys' the author discusses various ethical issues surrounding the international trade in human organs.

Sigrid Fry-Revere’s The Kidney Sellers: A Journey of Discovery in Iran, an allegedly first-hand examination of the Iranian paid kidney donation model, has been criticized by Koplin in an essay formerly published in the Monash Bioethics Review. Koplin especially challenges Fry-Revere’s claim that financially compensating kidney vendors might facilitate altruistic kidney donation. The current situation in Iran, according to Koplin, suggests that the market model has undermined altruistic donation. On this point, this commentary tries to show that healthcare policymakers (...) in Iran no longer see the Iranian paid kidney donation model as a sustainable and ethically justifiable status quo. Briefly touching on the criticisms that have been made even by some positive commentators of the Iranian model, this commentary aims to call attention to the fact that the current dynamic within healthcare policymaking in Iran seeks primarily to decrease its reliance on the organ market instead of revising and modifying it. This complicates the plausibility of any kind of extrapolation, replication or extracting empirical support from the Iranian model to create organ markets in other countries, for example, as Fry-Revere suggests to conduct a trial of a financially incentivized kidney donation scheme in the US. The conclusion is that the Iranian healthcare system should tackle the organ shortage through increasing altruistic living and postmortem kidney donations. This might also provide, finally, a space for conducting extensive and long-term follow-up studies on well-being, satisfaction and social integration of Iranian kidney vendors. (shrink)

One of the most common arguments against legalising markets in human kidneys is that this would result in the widespread misuse that is present in the black market becoming more prevalent. In particular, it is argued that if such markets were to be legalised, this would lead to an increase in the number of people being coerced into selling their kidneys. Moreover, such coercion would occur even if markets in kidneys were regulated, for those subject to (...) such coercion would not be able to avail themselves of the legal protections that regulation would afford them. Despite the initial plausibility of this argument, there are three reasons to reject it. Firstly, the advantages of legalising markets in human kidneys would probably outweigh its possible disadvantages. Secondly, if it is believed that no such coercion can ever be tolerated, markets in only those human kidneys that fail to do away with coercion should be condemned. Finally, if coercion is genuinely opposed, then legalising kidney markets should be supported rather than opposed, for more people would be coerced were such markets to be prohibited. (shrink)

In this paper I shall be arguing against the claim made by Erin and Harris and others, that creating a “regulated market” in organs for transplantation taken from living vendors is both viable practically and a moral imperative. No-one can doubt that there is currently a crisis in the provision of organs for transplantation, with a massive gap between supply and demand. There are a number of reasons for this crisis. Since its development as a life-saving measure in the (...) second half of the last century, organ transplantation has expanded exponentially, both in terms of survival rates, the number of people on the waiting list for the procedure, and the range of transplantable organs. Advances in immuno-suppression and in prevention of infection have led to improvement in both the survival of the recipients and of the transplanted organs. At the same time, there has been an increase in repeat transplantations and in multiple organ transplants. The range of conditions for which transplantation is offered has widened, and transplantable organs now include: kidney, liver, pancreas, heart and lung. Brain-dead donors can provide all of these organs, while the kidney and sections of the liver and pancreas can also be obtained from living donors. Survival outcomes are better from living donors than from cadaveric donors, and, in the case of kidney failure, better from transplantation than from dialysis. [End Page 164] The relevant question, however, is whether permitting a market in human organs is morally justifiable, and, even if it were, whether it would provide a solution to the current crisis. I argue in this paper that organ trading is wrong in principle, since it commodifies the human body and inevitably exploits the poor and the socially vulnerable, and that, far from alleviating the crisis, it is likely to make it worse. First we should note that there is an uncompromising opposition to all forms of organ trading from two major international healthcare organisations. (shrink)

Advocates of paid living kidney donation frequently argue that kidney sellers would benefit from paid donation under a properly regulated kidney market. The poor outcomes experienced by participants in existing markets are often entirely attributed to harmful black-market practices. This article reviews the medical and anthropological literature on the physical, psychological, social, and financial harms experienced by vendors under Iran's regulated system of donor compensation and black markets throughout the world and argues that this body of research not (...) only documents significant harms to vendors, but also provides reasons to believe that such harms would persist under a regulated system. This does not settle the question of whether or not a regulated market should be introduced, but it does strengthen the case against markets in kidneys while suggesting that those advocating such a system cannot appeal to the purported benefits to vendors to support their case. (shrink)

The article considers the objection to a commercial market in living donor organs for transplantation on the ground that such a market would be exploitative of the vendors. It examines a key challenge to that objection, to the effect that denying poor people the option to sell an organ is to withhold from them the best that a bad situation has to offer. The article casts serious doubt on this attempt at justifying an organ market, and its (...) philosophical underpinning. Drawing, in part, from the catalogued consequences of a thriving kidney market in some parts of India, it is argued that the justification relies on conditions which are extremely unlikely to obtain, even in a regulated donor market: that organ selling meaningfully improves the material situation of the organ vendor. Far from being axiomatic, both logic and the extant empirical evidence point towards the unlikelihood of such an upshot. Finally, the article considers a few conventional counter-arguments in favour of a permissive stance on organ sales. (shrink)

Marion Lee Sanders,1 Anthony James Langone2 1Department of Medicine, Division of Nephrology and Hypertension, University of Iowa, Iowa City, IA, 2Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA: Transplantation is the preferred treatment option for individuals with end-stage renal disease. Individuals who undergo transplantation must chronically be maintained on an immunosuppression regimen for rejection prophylaxis to help ensure graft survival. Current rejection prophylaxis consists of using a combination of calcineurin inhibitors, mTOR inhibitors, antimetabolite (...) agents, and/or corticosteroids. These agents have collectively improved the short-term outcomes of renal transplantation, but improvements in late/chronic graft loss and recipient survival have lagged significantly behind challenging the field of transplantation to develop novel prophylactic agents. There have been several clinical trials conducted within the last 5 years in an attempt to bring such novel agents to the commercial market. These trials have resulted in the US Food and Drug Administration approval of extended-release tacrolimus, as well as belatacept, which has the potential to replace calcineurin inhibitors for rejection prophylaxis. Other trials have focused on the development of novel calcineurin inhibitors, costimulation blockade, kinase inhibitors, and inhibitors of leukocyte migration. While these later agents have not been FDA-approved for use in transplantation, they remain noteworthy, as these agents explore pathways not previously targeted for allograft-rejection prophylaxis. The purpose of this review was to consolidate available clinical trial data with regard to the recent developments in rejection prophylaxis in kidney transplantation. Keywords: rejection, prophylaxis, immunosuppression, transplantation. (shrink)

People tend to be repulsed by the idea of cash markets in kidneys, but support the trading of kidneys through paired exchanges or chains. We reject anti-commodification accounts of this reaction and offer an egalitarian one. We argue that the morally significant difference between cash markets and kidney chains is that the former allow the wealthy greater access to kidneys, while the latter do not. The only problem with kidney chains is that they do not go far (...) enough in addressing equality concerns, and we show how the introduction of cash payments by the state could remedy this. (shrink)

There has been considerable debate over regulated organ markets. Especially current markets, where people sell one of their kidneys while still alive, have received increased attention. Futures markets remain an interesting and under-discussed alternative specification of a market-based solution to the organ shortage. Futures markets pertain to the sale of the right to procure people’s organs after they die. There is a wide range of possible specifications of the futures market. There are, however, some major unaddressed efficiency (...) concerns. This article presents this class of concerns and discusses the implication for organ futures markets. It identifies a number of inefficiency sources pertaining to crowding out, bad organs, costs and missed opportunities, family refusals, moral hazard and strength of the provided incentive. However, a complete assessment of futures market requires better knowledge regarding the potential reaction from donors, families and health professionals. (shrink)

The market for kidneys offers a case study of Baptists and Bootleggers. In almost every country, sales are currently illegal and donated organs are allocated by a central planner. Thousands of people die every year, because of the shortage caused by the absence of markets. This paper starts by examining the free-market alternative, and shows that a market would solve the shortage. It then uses gains-from-trade analysis to explain why current vested interests oppose a move to (...) a market, despite the immense potential for saved lives. In a shift to a market, gains from trade would be distributed away from lucky patients and various industries that benefit from the shortage ; these “Bootleggers” form an alliance with “Baptists”. (shrink)

Background: It is often claimed that a regulated kidney market would significantly reduce the kidney shortage, thus saving or improving many lives. Data are lacking, however, on how many people would consider selling a kidney in such a market. Methods: A survey instrument, developed to assess behavioural dispositions to and attitudes about a hypothetical regulated kidney market, was given to Swiss third-year medical students. Results: Respondents’ median age was 23 years. Their socioeconomic status was high or middle. (...) 48 considered selling a kidney in a regulated kidney market, of whom 31 would sell only to overcome a particularly difficult financial situation. High social status and male gender was the strongest predictor of a disposition to sell. 32 of all respondents supported legalising a regulated kidney market. This attitude was not associated with a disposition to sell a kidney. 5 respondents endorsed a market and considered providing a kidney to a stranger if and only if paid. 4 of those 5 would sell only under financial duress. Conclusions: Current understanding of a regulated kidney market is insufficient. It is unclear whether a regulated market would result in a net gain of kidneys. Most possible kidney vendors would only sell in a particularly difficult financial situation, raising concerns about the validity of consent and inequities in the provision of organs. Further empirical and normative analysis of these issues is required. Any calls to implement and evaluate a regulated kidney market in pilot studies are therefore premature. (shrink)

Considering efficiency, equality, and morality, this book argues for qualified market expansion, particularly in legalizing kidney sales and prostitution. Legalizing prostitution will benefit both men and women, as argued in a chapter jointly written with Yan Wang. Blood donation without monetary compensation can still result in adequate blood supply if schools educate children that blood donation can actually benefit a donor's health. As a society becomes more advanced, with higher incomes and a better educated populace, more activities can be (...) subject to market exchange, with gradual popular acceptance. Without serious misinformation and irrationality, inequality/fairness as such cannot be a valid reason for limiting the scope of the market. The book supports the use of markets to increase efficiency while also increasing the effort to promote equality, making all income groups better off. (shrink)

Background Advocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales. Methods This study (...) reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation. Results and discussion According to Islamic law, organ donation is an act of _sadaqatul jariyah,_ and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim _eethaar_, undermining donors of ‘selfless’ or ‘altruistic’ motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran’s unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran’s unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of ‘buyer and seller’, ensuring the philosophy of ‘donor and recipient’ is maintained. Conclusions Offering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors’ health and reducing human suffering without legalizing the human organ trade. (shrink)

Markets have long had a whiff of sulphur about them. Plato condemned innkeepers, whose pursuit of profit he believed led them to take advantage of their customers, Aristotle believed that the pursuit of profit was indicative of moral debasement, and Cicero held that retailers are typically dishonest as this was the only path to gain. And even those who are more favorably disposed towards markets in general are frequently inclined to be suspicious of markets in medical goods and services. For (...) example, Margaret Thatcher supported the legal prohibition of markets in kidneys despite being arguably the most pro-market Prime Minister the United Kingdom saw in the 20th century. (shrink)

In this article, I argue we have collective duties to people who suffer from kidney failure and these duties are best fulfilled through a government-monopsony market in kidneys. A government-monopsony market is a model where the government is the sole buyer, and kidneys are distributed according to need, not ability to pay. The framework of collective duties enables us to respond to several of the most pressing ethical and practical objections to kidney markets, including Cécile Fabre's (...) objection that it is unjust to be paid to do one's duty, Simon Rippon's objections that it is harmful to be pressured to sell a kidney and that a market is unfair, Richard Titmuss's crowding out objection, and Ronald Dworkin's objection that body parts should not be among the goods we owe each other. (shrink)

Luke Semrau argues that the documented harms of existing organ markets do not undermine the case for establishing regulated systems of paid kidney donation. He offers two arguments in support of this conclusion. First, Semrau argues that the harms of kidney selling are straightforwardly amenable to regulatory solution. Second, Semrau argues that even in existing black markets, sellers would likely have experienced greater harm if the option of selling a kidney were not available. This commentary challenges both of Semrau’s claims. (...) I argue that there is no reason to believe that kidney sellers benefit from the current black market trade in organs, and highlight a number of potential issues regarding the effectiveness and feasibility of Semrau’s proposed market regulations. (shrink)

Julian Koplin, drawing extensively on empirical data, has argued that vendors, even in well-regulated kidney markets, are likely to be significantly harmed. I contend that his reasoning to this conclusion is dangerously mistaken. I highlight two failures. First, Koplin is insufficiently attentive to the differences between existing markets and the regulated markets proposed by advocates. On the basis of this error, he wrongly concludes that many harms will persist even in a well-regulated system. Second, Koplin misunderstands the utilitarian assessment of (...) the market. He focuses on the costs and benefits of the transaction for the vendor. But, the relevant comparison is between an individual’s welfare across different courses of action, namely, vending and the nonvending alternative. Although Koplin’s empirically informed contribution is a welcome addition to this literature, the mistakes that pervade his interpretation of the data demand correction. (shrink)

An important argument against prohibiting organ sales is that it removes the best option available to individuals in dire circumstances. However, this line of reasoning fails to recognise that selling a kidney on a regulated market is only the best option in a very narrow comparison, where a regulated organ market is compared with banning organ sales. Once we acknowledge this narrowness, selling a kidney is not the best option. This paves the way for a distributive justice-based critique (...) of the ‘best option’ argument for organ markets, which illuminates that organ markets should be compared with a broader set of alternatives. If providing the option of selling a kidney is not the best option, but rather the best option we are willing to provide, and one which means that many people will remain in poverty and unjust circumstances, then this reflects poorly on those societies willing to offer only this option and not a better one. (shrink)

Public surveys conducted in many countries report widespread willingness of individuals to donate a kidney while alive to a family member or close friend, yet thousands suffer and many die each year while waiting for a kidney transplant. Advocates of financial incentive programs or “regulated markets” in kidneys present the problem of the kidney shortage as one of insufficient public motivation to donate, arguing that incentives will increase the number of donors. Others believe the solutions lie—at least in part—in (...) facilitating so-called “altruistic donation;” harnessing the willingness of relatives and friends to donate by addressing the many barriers which serve as disincentives to living donation. Strategies designed to minimize financial barriers to donation and the use of paired kidney exchange programs are increasingly enabling donation, and now, an innovative program designed to address what has been termed “chronologically incompatible donation” is being piloted at the University of California, Los Angeles, and elsewhere in the United States. In this program, a person whose kidney is not currently required for transplantation in a specific recipient may instead donate to the paired exchange program; in return, a commitment is made to the specified recipient that priority access for a living-donor transplant in a paired exchange program will be offered when or if the need arises in the future. We address here potential ethical concerns related to this form of organ “banking” from living donors, and argue that it offers significant benefits without undermining the well-established ethical principles and values currently underpinning living donation programs. (shrink)

This paper argues that the rules that constitute a market protect autonomy and increase welfare in healthcare. Markets do the former through protecting rights to self-ownership and a cluster of rights that protect its exercise. Markets protect welfare by organizing and protecting trades. In contrast, prohibition destroys legitimate markets, giving rise to so-called black markets that harm both the autonomy and well-being of agents. For example, a fee-for-service medical system is a highly developed and specialized market. It is (...) individuals working together, through the division of labor, to provide mutual insurance. This coordination, and the benefits it makes possible, is not possible without injunctions against harm. Prohibitions on harm are not mere ethical niceties, they are practice rules for both healthcare and markets. Placing the doctor within a healthcare market actually reinforces the doctor’s moral obligation, and the legal enforcement of that obligation, not to harm. Similarly, markets reinforce patient rights to self-determination through legal and institutional enforcement of the harm principle in the form of the protection of certain basic welfare rights to life, bodily integrity, property, trade, and contract. Since the establishment of markets protects agent autonomy and welfare, and prohibition directly harms the same, there are strong reasons for establishing markets to protect trade in precisely those areas where autonomy and well-being are most vulnerable to exploitation, for example, the trade in human kidneys. (shrink)

In theory, a commercial market for kidneys could increase the scarce supply of transplantable organs and give impoverished people a new way to lift themselves out of poverty. In‐depth sociological work on those who opt to sell their kidneys reveals a different set of realities. Around the town of Sarghoda, Pakistan, the negative social and psychological ramifications of selling a kidney affect not only the vendors themselves, but also their families, communities, and even the country as a (...) whole. (shrink)

The essays in this issue of The Journal of Medicine and Philosophy explore an innovative voucher program for encouraging kidney donation. Discussions cluster around a number of central moral and political/theoretical themes: What are the direct and indirect health care costs and benefits of such a voucher system in human organs? Do vouchers lead to more effective and efficient organ procurement and allocation or contribute to greater inequalities and inefficiencies in the transplantation system? Do vouchers contribute to the inappropriate commodification (...) of human body parts? Is there a significant moral difference between such a voucher system and a market in human organs for transplantation? This paper argues that while kidney vouchers constitute a step in the right direction, fuller utilization of market-based incentives, including, but not limited to, barter exchanges, would save more lives and further reduce human suffering. (shrink)

Erik Malmqvist defends the prohibition on kidney sales as a justifiable measure to protect individuals from harms they have not autonomously chosen. This appeal to ‘group soft paternalism’ requires that three conditions be met. It must be shown that some vendors will be harmed, that some will be subject to undue pressure to vend, and that we cannot feasibly distinguish between the autonomous and the non-autonomous. I argue that Malmqvist fails to demonstrate that any of these conditions are likely to (...) obtain. His argument involves two common errors. First, he, like many, proceeds on a mistaken understanding of how to assess harm. What matters is not the balance of costs and benefits of vending, but a comparison of potential vendors’ welfare across two possible courses of action. Second, Malmqvist's concerns about third-party pressure are predicated on an empirically unrealistic understanding of the operation of a regulated market. A widely underappreciated fact is that kidney sales will be relatively rare, and most who try to vend will be unable to. Because pressure on another to vend will not result in the desired outcome, few will exert it. (shrink)

Living donor kidney transplantation has increased significantly in the past 10 years. Currently it accounts for 41% of all kidney transplants in the USA.1 While the percentage is lower in the United Kingdom and other European countries, the number of living compared with cadaveric kidney donors will probably continue to increase globally. Mortality associated with surgery on live donors is low, thanks largely to the success of laparoscopic nephrectomy. Kidney transplantation from a living donor is preferable to that from a (...) cadaveric, or deceased, donor because of its superior graft and patient survival outcomes. It also preempts the need for or reduces the duration of dialysis for individuals with end-stage renal disease and therefore greatly improves their quality of life.Some who donate kidneys to anonymous recipients are motivated by altruism, with no direct benefit and only an indirect psychological benefit as a consequence of donating. Those who donate may be motivated by prudential reasons involving shared interests, or by a sense of obligation grounded in emotional relations. This includes donations between spouses, siblings, parents and children and may also include donations between intimate friends. Others may be motivated to donate by the prospect of financial gain. In a recent article on kidney markets, The Economist claimed that those who donate one of their healthy kidneys do so at “very little risk to their health”.2 Presumably, this provides support for these markets. In 2004, Zell Kravinsky, an American in his early 40s, gave away one of his healthy kidneys to a stranger as part of a utilitarian obligation to help other people and maximise the good by saving or improving the quality of their lives.3 He estimated that this entailed a statistically insignificant risk to his health. In a lecture to an ethics class at …. (shrink)

This paper canvasses recent arguments in favor of commercial markets in human transplant kidneys, raising objections to those arguments on grounds of the role of injustice, exploitation, and coercion in compromising the autonomy of those most likely to sell a kidney, namely, the least well off members of society.

An innovative program recently initiated at the University of California, Los Angeles Medical Center allows people to donate a kidney in exchange for a voucher that a loved one can redeem for a kidney if and when needed. As a relatively new practice, the ethical implications of advanced kidney donation have not yet been widely discussed. This paper reflects on some of the bioethical issues at stake in this new donation program, as well as some broader philosophical issues related to (...) the meaning and moral salience of commodification. I first consider whether the literature on commercial markets in organs––a longstanding topic of bioethical debate––can meaningfully inform ethical analysis of kidney voucher programs. Specifically, I consider whether and to what extent common objections to the exchange of kidneys for cash also apply to the exchange of kidneys for “kidney vouchers.” Second, I argue that the contrast between the ethical issues raised by these two practices highlights the need to understand commodification as existing on a continuum, with different degrees of commodification giving rise to different ethical issues. Doing so can help sharpen our understanding of commodification as a moral concept, as well as its relevance to broader debates about the moral limits of markets. (shrink)

Kidney for Sale by Owner discusses a range of different arguments that can be offered in defence of live donor kidney markets. Although Cherry’s case for establishing such markets does not rest on consequentialist considerations, Cherry nonetheless suggests that allowing the sale of organs would have net positive consequences. He argues that both renal failure patients and people living in poverty could benefit from participating in the market, and further claims that a legal trade in organs would not shape (...) society in harmful ways. This paper argues that the likely consequences of establishing an open market in kidneys are less benign than Cherry suggests. Specifically, I argue that a live donor kidney market could plausibly harm sellers, give rise to harmful pressures to participate in the market, and reinforce unjust political and social structures. I conclude by considering the implications of these arguments for the organ market debate. (shrink)

James Stacy Taylor advances a thorough argument for the legalization of markets in current (live) human kidneys. The market is seemly the most abhorrent type of market, a market where the least well-off sell part of their body to the most well off. Though rigorously defended overall, his arguments concerning exploitation are thin. I examine a number of prominent bioethicists’ account of exploitation: most importantly, Ruth Sample’s exploitation as degradation. I do so in the context of (...) Taylor’s argument, with the aim of buttressing Taylor’s position that a regulated kidney market is morally allowable. I argue that Sample fails to provide normative grounds consistent with her claim that exploitation is wrong. I then reformulate her account for consistency and plausibility. Still, this seemingly more plausible view does not show that Taylor’s regulated kidney market is prohibitively exploitative of impoverished persons. I tack into place one more piece of support for Taylor’s conclusion. (shrink)

The target article challenges the increasingly popular portrayal of living kidney sale as potentially a mutually beneficial arrangement, capable not only of saving or improving the lives of patients in need of transplants but also of significantly benefiting poor vendors. Carefully reviewing the literature on harms to vendors in illegal kidney markets and in Iran’s legal market, Koplin argues that many of these harms would persist in the sort of legal regulated system that kidney sale advocates envision. This is (...) an important argument. The kidney sales debate has been skewed in favor of permitting sales by a simplified view of the potential harms involved and excessive optimism about the capacity of regulation to prevent these harms. The article counterbalances these tendencies and thus considerably weakens the case for allowing sales. Nonetheless, some market proponents might remain unconvinced. I shall suggest that in addition to the lessons that Koplin draws from existing kidney markets, there is yet another one, which casts further doubt on the advisability of allowing kidney sales. (shrink)

Effective altruists aim to do the most good that they can do with the resources available to them, without causing themselves or their dependents significant harm thereby. The argument presented in this paper demonstrates that there are no morally relevant dissimilarities between living kidney donation and living kidney selling for effective altruistic reasons. Thus, since the former is allowed, the latter ought to be allowed as well. And, there are important moral differences between living kidney selling for effective altruistic reasons (...) and other reasons for kidney vending, such that standard objections against markets in human kidneys do not attach to those markets designed around principles of effective altruism. The reasonable conclusion to draw from this is that eligible effective altruist kidney donors ought to be allowed to sell their kidneys to others in need, if they so desire. Because of this, law and policy ought to be changed to allow for this exceptional case: current laws that ban kidney selling for everyone, irrespective of their reason for selling, are unjustified. (shrink)

Janet Radcliffe Richards’ The Ethics of Transplants outlines a novel framework for moral inquiry in practical contexts and applies it to the topic of paid living kidney donation. In doing so, Radcliffe Richards makes two key claims: that opponents of organ markets bear the burden of proof, and that this burden has not yet been satisfied. This paper raises four related objections to Radcliffe Richards’ methodological framework, focusing largely on how Radcliffe Richards uses this framework in her discussion of kidney (...) sales. We conclude that Radcliffe Richards’ method of inquiry hinders our ability to answer the very question that it ought to help us resolve: What is there best reason to do, all things considered? (shrink)

The trade in human body parts can be understood as a solution to key challenges for both buyers and suppliers, as well as being a manifestation of individual property rights over one’s own body. However, it can be argued that there are serious ethical issues involved in commercializing the body in this way, despite which there has recently been a large increase in the international trade in human body parts. The most extensive transactions have concerned the trade in kidneys (...) and the services of the fertility industry. An important driver of this is the fact that the medical profession is increasingly able to facilitate exchanges of human body parts relatively smoothly. The chapter focuses on commercial surrogacy as an example of the ethical aspects of the trade in human body parts and addresses the potential interplay between markets and ethical issues. (shrink)

Semiotic objections to market exchange of a good or service maintain that such exchanges signal an inappropriate attitude to the good or to associated individuals, and that this provides a weighty reason against having or participating in such markets. This style of argument has recently come under withering attack from Jason Brennan and Peter Jaworski (2015a, 2015b). They point out that the significance of any market exchange is explained by a contingent semiotic norm. Given the tremendous value that (...) could be realised by markets in, for instance, bone marrow, or kidneys, deferring to such norms across the board would have very significant opportunity costs. In the absence of any rationale for these norms, they should be ignored completely. We provide one important rationale. Unlike many semiotic objections to markets, we provide a broadly consequentialist semiotic argument. We argue that a range of behaviours play important signalling roles in interpersonal social practices; in particular, in practices involving caring, esteem, and testimony. Markets in these behaviours would distort these signals. Moreover, many of the productive advantages yielded by markets rely in turn on positive market norms that also inhibit the signalling behaviours associated with these nonmarket behaviours. We conclude that there will inevitably be trade-offs between the distributive advantages of new markets and these interpersonal social practices. (shrink)

Kidney markets are prohibited in principle because they are assumed to undermine the seller’s dignity. Considering the trade-off between saving more lives by introducing regulated kidney markets and preserving the seller’s dignity, we argue that it is advisable to demand that citizens restrain their own moral judgements and not interfere with the judgements of those who are willing to sell a kidney. We also argue that it is advisable not only to limit the political implications of the moral argument of (...) dignity concerns toward a market-based solution but also to re-evaluate the dignity argument itself. First, if the dignity argument is to be given normative force, it must also consider the dignity violation of the potential transplant recipient. Second, there seems to be no compelling notion of dignity that demonstrates why it is morally permissible to donate but not to sell a kidney. (shrink)

The ‘limits of markets’ debate broadly concerns the question of when it is (im)permissible to have a market in some good. Markets can be of tremendous benefit to society, but many have felt that certain goods should not be for sale (e.g., sex, kidneys, bombs). Their sale is argued to be corrupting, exploitative, or to express a form of disrespect. InMarkets without Limits, Jason Brennan and Peter Jaworski have recently argued to the contrary: For any good, as long (...) as it is permissible to give it for free, then it is permissible to give it for money. Their thesis has led to a number of engaging objections, and I leverage recent work on the nature of feasibility within political philosophy to offer a new challenge.I argue that feasibility offers a constraint on which markets can be permissibly implemented. Though it may be possible to create a morally acceptable version of an otherwise repugnant market, some of these markets may be infeasible, and so we are not permitted to implement them. After laying out this challenge, I consider several replies. They concern the relevance of feasibility, and whether any markets really are infeasible. This provides an opportunity to explore the dangers of pursuing the infeasible and with markets generally. I conclude by considering what might lead us to pursue these markets despite their infeasibility, or how knowledge of infeasibility may prove useful regardless. (shrink)

Every year, hundreds of patients in England die whilst waiting for a kidney transplant, and this is evidence that the current system of altruistic-based donation is not sufficient to address the shortage of kidneys available for transplant. To address this problem, we propose a monopsony system whereby kidney donors can opt-in to receive financial compensation, whilst still preserving the right of individuals to donate without receiving any compensation. A monopsony system describes a market structure where there is only (...) one ‘buyer’—in this case the National Health Service. By doing so, several hundred lives could be saved each year in England, wait times for a kidney transplant could be significantly reduced, and it would lessen the burden on dialysis services. Furthermore, compensation would help alleviate the common disincentives to living kidney donation, such as its potential associated health and psychological costs, and it would also help to increase awareness of living kidney donation. The proposed system would also result in significant cost savings that could then be redirected towards preventing kidney disease and reducing health disparities. While concerns about exploitation, coercion, and the ‘crowding out’ of altruistic donors exist, we believe that careful implementation can mitigate these issues. Therefore, we recommend piloting financial compensation for living kidney donors at a transplant centre in England. (shrink)

Many people believe that some things, like kidneys or sex, should not be for sale. Let us call these things “contested commodities.” Against this, Brennan and Jaworksi defend “markets without limits” (hereafter: MwL). According to this thesis: “If you may do it for free, you may do it for money” (2016, p. 10). Since we can give away our kidneys for free and have sex for free, we should be able to do these things for money. Brennan and (...) Jaworksi deftly blend rigorous philosophical argument with the latest research in social science to counter some of the most prominent against commodification. But, I will argue, their arguments stop short of establishing MwL. Brennan and Jaworksi do not say enough in favor of markets in contested commodities. (shrink)