Paid Organ Donation - the Grey Basket Concept a S Daar Sultan Qaboos University, Oman, and University of Toronto, Ontario, Canada

J Med Ethics: first published as 10.1136/jme.24.6.365 on 1 December 1998. Downloaded from Journal ofMedical Ethics 1998;24:365-368 Guest editorial Paid organ donation - the Grey Basket concept A S Daar Sultan Qaboos University, Oman, and University of Toronto, Ontario, Canada Few questions in biomedical ethics are as for payment ... it is not necessarily a fault to accept challenging at present as the question of paid it".' The 1997 Bellagio Task Force Report on organ donation for transplantation, raising as it Transplantation, Bodily Integrity and the Inter- does difficult issues related to the body, the soul, national Traffic in Organs,3 found no unarguable property rights, autonomy, limitations to freedom, ethical principle that would justify a ban on the cultural/ethical pluralism and professional versus sale of organs under all circumstances; this is a societal perceptions. The arguments against paid position held by many other secular scholars, for donation are familiar. Here I look at the less example Englehardt,' Sells,5 Dossetor,6 and familiar countervailing arguments. Radcliffe-Richards et al.7 (See reference 8 for a The shortage of organs is getting worse and sig- review).The publication recently in the Lancet of by copyright. nificant numbers of are on a patients dying waiting controversial paper by the International lists. There is fear that as the situation worsens, Forum on unethical behaviour will likely become criminal Tranplant Ethics,7 was greeted by enormous behaviour. Xenotransplantation and tissue engi- international media attention, with a number of neering offer some hope for the future, but at editorials agreeing with the position taken by the present it appears that there are no methods of authors that the debate on organ sales needs to be increasing donation that are not themselves reopened, since pragmatically, at least, more harm seriously controversial. than good seems to result from the worldwide For these and other reasons, the question of ban. http://jme.bmj.com/ payments for organs is currently very topical. The Radcliffe-Richards et af have demonstrated that 1998 Aristotle Onassis Award for Best Theatrical almost all the familiar arguments against the sale Play went to an Indian playwright, Manjula of organs, for example, exploitation, lack of Padmanaban, for her play, Harvest, a grim informed consent, level of risk assumed by the portrayal of the organ trade in an Indian village in vendors/donors, difficulty of control/regulation of the year 2010 AD. The Ashkenazi Chief Rabbi of the sale of organs, lack of fairness for the rich to Israel, basing his opinion on the rabbinical schol- have privileges that the poor do not have, absence on September 23, 2021 by guest. Protected ars Shlomo Zalman Auerbach and Shaul Yisraeli, and erosion of altruism as the basis for donation of declared earlier this year that Jewish law permits organs, undermining of confidence in the medical the sale of organs if their removal does not harm profession, etc, are all deficient and the donor's health.' (Unilateral nephrectomy in cannot stand healthy donors is accepted by the profession as up to robust scrutiny. safe enough now to constitute over 30% of kidney Furthermore, since it appears at the outset that transplants in the USA, nearly 50% in Norway allowing the regulated sale of organs would and nearly 100% in much ofthe rest ofthe world.) increase their supply to those who desperately Father Healy, a Catholic priest and bioethicist, needed them, the onus of proof must be with presenting a paper a few months ago at the Con- those who oppose this position to demonstrate gress of the Asian Society of Transplantation in why a worldwide ban should be maintained. The Manila, declared that in the context of Filipino Kantian argument that selling a body part is society, an indiscriminate ban on payment for degrading does not always apply, as degradation organs is inappropriate. He went on to quote Pope very much depends on one's own perception of Pius XII who said, in reference to cadaveric what is degrading. And the very familiar slippery corneal donation, that "it would be going too far slope arguments, were they to form the basis of to declare immoral every acceptance or demand public policy, would exclude almost every public J Med Ethics: first published as 10.1136/jme.24.6.365 on 1 December 1998. Downloaded from 366 Guest editorial: Paid organ donation - the Grey Basket concept activity that had the slightest risk (driving, scuba the issues, accept and reject the obvious early in diving, nuclear reactors). We cope because we regu- the discourse, and focus on the contentious. For late. living kidney donors, the categories were 1) living Medical professionals accept autonomy as a (genetically) related donors; 2) living (emotion- major bioethical principle, but are repulsed by the ally) related donors; 3) donation by altruistic autonomous wish of the donor of a kidney to strangers (is there a good reason why not?); 4) the obtain money, resulting in what we have called the Grey Basket; 5) rampant commercialism (no "autonomy paradox",9 even when the money is checks, balances, and including exploitation by needed for purely altruistic reasons, for example middlemen) 6) criminally coerced procurement. to buy medication to save the life of a beloved It seems to me that categories 1-3 are easily daughter. John Dossetor6 has argued very effec- acceptable, while 5 and 6 are not. This allows us, tively that the burden-benefit equation in these then, to concentrate on the Grey Basket concept, "indirect atruism" circumstances would justify which would admit any principle-based idea to allowing such payments, at least in those cultures critical scrutiny. It might contain ideas such as the where this would be acceptable and under Donors' Trust,5 whereby there are societal/ circumstances where the alternatives for potential professional mechanisms to separate payments recipients would be death because dialysis was not from treatment, and available funds to ensure available. A woman in the US recently offered to equal access. Francis Moore hinted at something sell a kidney to pay for a laparoscopic cholecystec- like this when he said that "selling of kidneys from tomy; she found this to be against the law. The living donors, evidently a common practice in bigger question here is the morality of legislation India, finds a negative response in our society that bars a life-saving option for an individual unless the recipients are chosen without respect to while failing to provide societal relief. If it is moral ability to pay, ie some form of government to allow 20% of your population to have no medi- or, there are Dossetor's ideas, which subsidy""5; by copyright. cal insurance because your society is based on free take into account cultural and economic realities markets and rugged individualism, and damn and which refer to "indirect altruism" and "man- those who are incapable, surely such a society dated philanthropy".' would value a presumption for autonomy in deci- What is perhaps surprising is that paid organ sions on how best to find remedy? donation is not more common than it actually is. Ask any economist and you will learn that the Whiff ofhypocrisy combination of demand, scarcity and need There is also a whiff of hypocrisy about the automatically equals a black market. As I write profession's attitude to the subject. In a recent there is a debate taking place on the worldwidehttp://jme.bmj.com/ article'0 I proposed a ten-point charter meant to web magazine, Slate, between a physician and increase living renal donation generally. Half in Richard A Epstein, a well-known economist who jest I included a point which suggested that trans- convincingly argues, as have other Chicago (where plant teams should be the first to encourage altru- else) economists, for the introduction of market ism by forgoing part of their usual fees. I was only mechanisms.'6 Readers are asked to vote online as partly surprised at the number of letters I received the debate unfolds and currently, in answer to the objecting to that particular point while agreeing question "Is organ peddling ethical?" the majority on September 23, 2021 by guest. Protected with the other nine. Dickens" has wondered why response is in favour - which is in keeping with when hospitals, laboratories, pharmaceutical other polls in the past."' The Stanford/Hoover companies, physicians, surgeons etc, financially Institution Nobel Prize winner Gary S Becker also benefit from transplantation, it is only from the believes that introducing market mechanisms will donor that we demand unmitigated altruism, substantially ease the shortage of organs, and that which manifestly fails to distinguish donor from one possible market structure would be to grant vendor anyway.7 Childress, in relation to this very authority to buy and sell (cadaveric) organs exclu- question, has pointed out that altruism is sively to the federal government." over-estimated as the basis of human behaviour.'2 We should try to base organ donation on altruism, Confusion and complexity but how often do we hold that if an action is not Four months ago a highly respected Israeli trans- based on altruism we should ban it altogether? plant surgeon was alleged to have been involved in The subject is obviously much more complex six kidney transplants on Israelis in Estonia using than would appear at the outset. How, then, does organs that had been sold by Romanians."' He one approach it? We have introduced a denied knowing that the kidneys were sold, but classification'3-'" based on the (much misunder- said he encourages expanding the supply oforgans stood) concept of gifting. The aim was to clarify for people who would die without them.

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