Kidnap a kidney
- The Ethics of Transplants: Why Careless Thought Costs Lives by Janet Radcliffe Richards
Oxford, 278 pp, £16.99, March 2012, ISBN 978 0 19 957555 8
Organ transplants save lives: 1107 of them in the UK between March 2011 and April 2012. But the demand for transplantable organs greatly exceeds supply. Currently, about ten thousand people in the UK are in need of a transplant and about a thousand die every year while on the waiting list. Some ways of increasing the number of available organs, such as urging people to sign up with the Organ Donor Register, are ethically unproblematic. But others raise ethical issues, or have been rejected on ethical grounds. These ethical objections are the subject of Janet Radcliffe Richards’s admirably lucid book. She believes that some widely accepted objections to organ procurement are based on mistakes in moral reasoning: the ‘careless thought’ that ‘costs lives’. Identifying and analysing these mistakes is one of her aims, but she has a broader purpose as well: to show that, as experts in moral reasoning, philosophers have a unique role in debates about public policy.
As medical technology advances it becomes possible to collect and transfer more and more parts of the body: organs, tissues, blood, gametes and so on. But Radcliffe Richards restricts her attention to the major organs – kidneys, liver, heart, lungs – whose transplantation is most likely to save lives. Her starting point is the proposition that saving someone’s life, or preserving someone’s health, by means of a transplant is an intrinsically good thing. This establishes a rebuttable presumption in favour of any method of procuring organs for transplant. The rebuttal may take the form of an argument against a particular method: against, for example, the suggestion that we should randomly kidnap people off the street to harvest their organs. But the burden of proof lies on the opponents to find some such argument; if those they advance do not survive critical scrutiny, then the initial presumption will stand.
This analytic procedure, Radcliffe Richards contends, enables us to identify the ethically salient factors concerning any proposed means of organ procurement. (She doesn’t deal, except in passing, with the allocation of organs.) She applies the procedure to two practices which have been widely condemned as unethical – allowing the purchase of kidneys from live donors and permitting those who sign up for posthumous donation to direct their organs to specific recipients – and argues that there is no good ethical reason to reject either.
Payment for kidney donation is currently prohibited in the UK, as it is in most of the world, and has been condemned by the World Health Organisation and in the 2008 Declaration of Istanbul on Organ Trafficking and Transplant Tourism. The main objections are well known: those who might be tempted to sell a kidney need to be protected against harming themselves; only the poor would be so tempted, but their consent would be invalid since it would be coerced by their poverty; any purchase of a kidney by the rich from the poor would inevitably be exploitative; payment for organs would foreclose opportunities for altruism; a market in organs would be an offence against human dignity. Radcliffe Richards works through each of these arguments with care and concludes that none of them is sufficient to rebut the initial presumption in favour of procurement.
The full text of this book review is only available to subscribers of the London Review of Books.
Vol. 35 No. 14 · 18 July 2013
Wayne Sumner gives a misleading account of the way brain death for organ donation is diagnosed, suggesting that both spontaneous respiration and circulation may be present at the time of diagnosis (LRB, 4 July). In fact in the UK since 1976 brain death has been based on the diagnosis of brain stem death. This is an irreversible condition characterised by, among other clinical tests, the absence of spontaneous respiration. Potential donors for organ transplantation usually have a severe head injury and end up in an intensive care unit, where they may be placed on a ventilator. If in due course a diagnosis of brain stem death is made, disconnection from the ventilator will result in cessation of heartbeat and hence circulation within a very few minutes. However, if the individual had previously indicated consent for their organs to be used for transplantation, artificial ventilation is continued for a few more hours so that when the organs are removed they are in good condition. This in no way constitutes what Sumner describes as a sleight of hand designed to determine death in such a way as to acquire desperately needed organs for transplantation.
Vol. 35 No. 15 · 8 August 2013
When Janet Radcliffe Richards claims, in talking about paying living organ donors for their kidneys, that ‘careless thought costs lives’, the careless thoughts she is referring to are mine and those of my many colleagues who believe that such payments would undermine the life-saving and life-enhancing capacities of organ donation. As Wayne Sumner points out, Radcliffe Richards avoids ‘messy practical issues’ and is thus freed from having to deal with empirical data (LRB, 4 July). Yet organ transplantation is primarily a medical endeavour not a philosophical one, and the data show that in addition to the exploitation of the vulnerable and the displacement of altruism by commercialism, the outcome of vended transplants is poor, for both recipients and donors.
A high incidence of infection and rejection has been reported in recipients from the UK, the US, Australia, Canada and the Indian subcontinent. Commercial donors from India, Pakistan and the Philippines, purportedly healthy at the time of donation, reportedly display an increased incidence of infection, surgical complications and death. Depression and deterioration in quality of life have been a feature of the post-operative experience of paid donors even in the ‘regulated’ and often touted commercial donation system in Iran.
The decision to go ahead with a living donation requires refined and dispassionate clinical judgment by the medical team and critical thinking on the part of the donor. In commercial donation none of this can be presumed. The high rate of complications for commercial donation suggests that somebody is lying: the donor to the doctor, the doctor to the donor, the doctor to the recipient, or all three. Studies on the influence of money on the behaviour of subjects in clinical trials have shown, unsurprisingly, that the greater the potential monetary reward the greater the tendency for subjects to conceal the ways in which they might not meet the trial criteria. It has been suggested that in a regulated commercial donation system, the worst manifestations of commercial donation could be prevented. Perhaps some of them would, but global regulation is a fantasy, and there is no shortage of vulnerable and desperate donors.
University of California, Los Angeles
Terence English misrepresents the point I was making about the determination of death (Letters, 18 July). I did not suggest that ‘both spontaneous respiration and circulation may be present at the time of diagnosis.’ Rather, I said that respiration and circulation, along with such other traditional signs of life as digestion, excretion and homeostasis, may all be present when death is declared. My point was that, in determining whether a person is alive or dead, it is irrelevant whether these functions are spontaneous or artificially supported. The shift to ‘brain stem death’ sidelines these obvious indicators of life, as well as contradicting the common observation that the discontinuation of artificial ventilation is the ‘removal of life support’. I would not wish to claim that the shift in the 1970s from traditional cardiopulmonary criteria for determining death to the focus on brain stem death was motivated, primarily or in part, by the desire to ensure a supply of recoverable organs in good condition. But it certainly meshed nicely with that aim.