Tales from the organ trade: trick or treat?

Human organs for transplantation are a desperately needed scarce resource worldwide. When any resource is scarce and desperately needed by human beings, like our thirst for oil, all sorts of things can happen. There is great potential for corruption, manipulation, irrationality, and violence, but also for some party to exact some gain, some advantage, some profit. The trade in human body parts -- bits of ourselves conventionally considered too precious to have a price -- is an bioethical conundrum custom-built for Halloween.

This time around, I did not have to reach far to find something about the global organ trade. I could look in my inbox, where lo and behold I found a message from one of HBO's publicists. HBO is screening a documentary on the global organ trade next week narrated by -- appropriately enough -- the Canadian film director David Cronenberg. As the press release goes:

This 83-minute documentary explores the legal, moral and ethical issues involved in the complex life-and-death drama or organ trafficking. More than a simple black-and-white story of exploitation, TALES FROM THE ORGAN TRADE is a nuanced and complex film that challenges moral and ethical beliefs. It delves into a world where “villains” often save lives and the medical establishment, helpless to its own rules and bureaucracy, too often watches people die. In the best scenario, victims walk away content and safe, and buyers of organs (the recipients) return home with a new lease on life. From Manila to Istanbul, Colorado to Kosovo, Toronto to Tel Aviv, this film spotlights a compelling cast whom fate has brought together, where the gift of life meets the shadow of death.

Tales of the Organ Trade airs Monday, November 4th on HBO as part of its HBO Documentary Fall Films Series at 9pm EST. And no, HBO is not giving me a red cent for plugging their business. It just looks like something that might be worth watching.

I pay thy poverty, and not thy will

In Romeo and Juliet, there is the scene where Romeo goes to an Apothecary to obtain a poison. Juliet is presumed dead; Romeo wishes to go to the Capulet's family tomb, take the poison and join her in a deadly embrace. The Apothecary hesitates: distribution of such poisons is against local law. The two have the following exchange:

ROMEO: Art thou so bare and full of wretchedness, and fear'st to die? Famine is in thy cheeks, need and oppression starveth in thine eyes, contempt and beggary hangs upon thy back. The world is not thy friend nor the world's law. The world affords no law to make thee rich; then be not poor, but break it, and take this.

APOTHECARY: My poverty, but not my will, consents.

ROMEO: I pay thy poverty, and not thy will.

I was reminded of this exchange while reading a blog post on the Washington Post website, entitled 'In Praise of Human Organ Sales.' The author, Gary S. Becker (a Nobel prize-winning economist) argues that allowing people to buy and sell their organs would help solve the problem of shortages in organs for transplant, while countering possible objections to this idea. Neither the proposition nor the objection are particularly new; people working in bioethics have made this proposal before and objected to it before. The novelty lies in how quickly and brutally Becker states his case. His response to issues of social justice is succinct:

Another set of critics fears that the organ supply would be likely to come mainly from the poor, who would be induced to sell their organs to the rich. It is hard to see any reasons to complain if organs of poor persons were sold with their permission after they died, and the proceeds went as bequests to their parents or children. The complaints would be louder if, for example, mainly poor persons sold one of their kidneys for live kidney transplants, but why would poor donors be better off if this option were taken away from them?

It is true, the poor who sell their organs, either when they are alive or posthumously, would get their cut -- like the Apothecary. The rich would get their organs, and the middlemen, well, they would get richer. The poor would be mined -- with their agreement, of course -- for organs, without this sacrifice of body parts being likely to improve their lot very much. They would not be in a position, for instance, to buy organs for themselves if they needed them. For their part, the rich would have no (economic) motivation to put up their own organs for sale. Hard to see any reasons to complain here? Depends where you are looking. Romeo was unbalanced, and desperate, but at least he was honest: I pay thy poverty, and not thy will.


Thanks to Steve Levingston at Washington Post, who sent me the link to Becker's piece, and thereby informed me about the Post's excellent Book World blog.

Singapore and compensation for organs and eggs

The National Bioethics Committee in Singapore has been pretty busy lately. At the start of November, the Singapore Ministry of Health announced a change to the Human Organs Transplant Act (HOTA), and the National Bioethics Committee publicly endorsed the revised law soon afterward. Just days later, the Committee released guidelines on the donation of female eggs for research. And one of the central ethical issues in both cases concerns compensation and inducement in the context of exchanging human biological materials.

Should donors of organs or eggs receive some sort of compensation for their act of giving, or should it be a pure act of altruism? Should organ or egg exchange be a market-force driven transaction like any other -- like the buying and selling of cars -- or should these exchanges have a special, non-commercial status in keeping with the dignity of human beings? Positions in this domain often get polarized into the kinds of extremes that the media love: on the one hand, libertarians and utilitarians who think people ought to be able to do what they want with their body parts (including selling them), and that this sort of freedom is the ultimate solution to demands for organs and eggs. On the other hand, some believe that only the most restrictive laws are in keeping with the special status of our species, even if this comes with the cost of diminishing the supply of useable organs and eggs (for some members of that same species). For those unconvinced by the concept of 'dignity', there is also the consideration that wherever paid organ exchange takes place, the exchange from donor to recipient tends to channel along the lines of social injustice, i.e. from the poor to the rich, from women to men, and from non-Caucasian to Caucasian.

The Singapore approach involves a tricky distinction between compensation and (undue) inducement. The National Bioethics Committee is of the opinion that organ and egg donors should compensated for the costs to themselves involved in the act of donation, including loss of time and earnings, the burden of physical and psychological risks, transport and medical costs, including follow-up medical expenses and (in the case of organ donors) possible higher insurance premiums. Determining a fair level of compensation in general would seem to be very difficult, given that there will be diversity in (among other things) economic status between recipients and donors. The Committee wants to discourage people from seeing the donation of their organ and eggs as a for-profit activity -- even if third-parties do make money out of it -- while also avoiding placing an unfair burden on donors. The result will probably displease those on both ends of the bioethics extremes, but that is usually a sign of health when it comes to regulations.

Dirty Ugly Things

Okwe is a Nigerian cab driver who moonlights as a hotel desk clerk. Because he was a doctor in Africa -- but not able to practice in London -- he finds himself giving what medical treatment he can to fellow immigrants. Okwe shares an apartment with Senay, a Turkish Muslim woman, who works as a maid in the same hotel as Okwe. She has a rough time of it: a visit from the immigration service forces her to quit her job in the hotel and work in a clothing sweatshop, where the boss threatens to report her to the authorities unless she perform oral sex on him. Juan, the manager of the hotel, runs an illegal operation at the hotel where immigrants sell their kidneys for something precious: a new passport, a new identity. Senay, in desperate financial need, agrees to exchange a kidney for a passport, but not (of course) before Juan forces her to have sex with him first. When Okwe hears of Senay's plan, he tells Juan that he will perform the operation in order to ensure its safety. Here is the plot twist: Okwe and Senay drug Juan, harvest his kidney, sell it to Juan's contact, and lead new lives with new passports. The victims become victimizers and visa versa. This is the basic plot of Stephen Frear's Dirty Pretty Things.

Dirty Pretty Things is basically about how things go between haves and the have-nots within the global economy, and accompanying violence, coercion (sexual and otherwise), stigma, shame, fear. The film highlights how the disempowered are caught up in a system that strips them of what little control over their lives they still have. That's where the kidney comes in. To the extent that you belong to the so-called 'less fortunate', your body is not your own, because it (or bits of it) may be one of the few things of interest to the 'global market.' Globalization spawns new niches for prostitution.

I was reminded of Dirty Pretty Things when the scandal of kidney thefts in India broke out a couple of days ago. It is not news that there are unscruplous groups persuading mostly illiterate day laborers to sell their kidneys: this has been known to be going on for years. It is not new that some impoverished Indians seek to sell their kidneys: an expression of terrible human suffering, rather than the spirit of enterprise. What is somewhat new are emerging cases of forced trade -- persons lied to, held against their will, drugged, operated on and left to their own devices. A whole network of medical professionals and institutions seem to be entangled in the gruesome business, and it looks like police were paid to look the other way.

What is the significance of this scandal? There are some who might argue that these incidents will happen time and again until trade in organs is legalized. It is simple: there are significant demands for transplant organs, criminalizing organ trade drive it underground, and those who operate (literally) in a criminal underground are unsurprisingly weak in the ethics department. But given global and regional disparities, how could a regulated, legal, 'free' trade in organs be anything other than another way for the rich to cannibilize the poor? Would a legal organ trade in circumstances of poverty really be so morally superior to the outright stealing of body parts?