Nation of Beancounters

Organ markets and fairness

Posted in Essays by Navin Kumar on September 21, 2012

A friend directed me to this interesting essay by Michael Sandel on what the scope of markets ought to be limited to. I highly recommend it because it is very nicely written. This may come as a surprise but I actually agree with the fundamental idea – there are things that should remain outside the scope of the ‘economic sphere’ and within the ‘social sphere’. I agree with him about best man toasts, gifts etc. I strongly disagree about kidneys.

A reading of his essay would turn up three reasons to oppose kidney markets: 1) They’re unfair 2) They’re corrupting and as a result of which 3) Legalising sales may paradoxically reduce the supply.

Let’s start with the first:

The fairness objection points to the injustice that can arise when people buy and sell things under conditions of inequality or dire economic necessity. According to this objection, market exchanges are not always as voluntary as market enthusiasts suggest. A peasant may agree to sell his kidney or cornea to feed his starving family, but his agreement may not really be voluntary. He may be unfairly coerced, in effect, by the necessities of his situation.

If the money he receives reduces the crushing burden of his situation, is he made better off? Yes. So what exactly is the objection?

The problem lies in the word ‘fairness’. While we don’t have to pull up the Scott Adams quote, the vagueness of the term makes any debate impossible. Sandel says it isn’t ‘fair’ that the impoverished Indian farmer has to sell his kidney due to circumstances. I say it’s not ‘fair’ that the peasant doesn’t have to option of selling his kidney to improve his situation when all else fails, just because a bunch of wealthy westerners who do have options don’t wanted be tainted by the association. The discussion goes nowhere.

Since we can’t examine Sandel’s ‘fairness’, let’s see if the implications of the concept make sense. Suppose I’m a wealthy economist (har har) who rents a nice flat and is now looking for a maid. I get two applicants, first time workers, identical except in one respect: one of them is a local looking to earn a bit of extra money and the other is a desperate woman who has run away from an abusive husband in her native village and will starve to death if she doesn’t get work soon. By Sandel’s logic I should hire the former, since the latter has been  ‘coerced’ and any agreement she and I come to will not be ‘voluntary’. This is not a forced example: poor people do desperate things all the time, including entering contracts with rich people; banning them from doing isn’t a good idea, morally. The ‘inequality’ line of thought has the same impact: perfectly equality occurs almost nowhere. By this argument, I shouldn’t pay a cycle-rickshawala* Rs.20 to take me to college; I doubt the warm glow of moral superiority I enjoy will make up for his lost income.

Phrased differently, Sandel’s fairness and equality principles** – as he conceives them – are not principles we want to adopt as a society, no matter how nice they sound. They will hurt the poor – and I don’t know what moral code considers that a worthwhile trade-off.

One may well argue that the poor should be uplifted until they’re at equal footing. I’d agree wholeheartedly. However, as a society, we’ve so far not been able to do so. Until we do, why sacrifice their well-being because we’re incompetent? People should be allowed to do desperate things when circumstances force them to, if we can’t lift their burdens. People should be allowed to deal with un-equals, if we can’t equalize them.

Next post: moral corruption.

*who ferry passengers in the Delhi heat, the cold, and rain, and sleep on their rickshaws.

** As I see it, the fairness principle is ‘a person should be forced to do X by circumstances’. The equality principle is ‘a person should not enter a contract with someone who isn’t his/her equal.’

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16 Responses

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  1. […] is the second post on Sandel’s essay on morality and markets. I dealt with fairness in my last post but that really wasn’t the thrust of his essay, merely something I keep hearing and so […]

  2. rohan said, on September 21, 2012 at 2:13 pm

    hi
    I have a question and i am not sure if i am able to frame it right or if it makes sense in the first place … but if we open organ markets, i.e. allow someone to sell kidneys for money then doesn’t it change the (relative?) value of both the kidney and of money, in the sense that now one will have to decide whether money is more important to him/her or a kidney?
    and i am wondering if the availability of this choice in itself is unfair or coercive for someone who is poor and has a dependent family. it seems to give a choice between fulfilling your responsibilities/taking care of the ones you love/etc and keeping both kidneys.
    what i am trying to say is that just by giving the choice you are forcing people to pick one of the options.

  3. Navin Kumar said, on September 21, 2012 at 10:05 pm

    Yes, it would ‘force’ people to make a tough decision. Consider though:

    1. Do we want to start taking away tough decisions because those poor souls might get confused? I ask this as a normative question. Abortion for example, is not an easy choice, but it’s one we allow. Similarly, do we let a relative who has been comatose for 10 years die? This is a hard question but few suggest that the state make it for people.

    2. They’re already faced with the choice. Plenty of poor people currently sell their kidneys – and because there is no law, they do so under dangerous conditions, imperfect knowledge and end up getting defrauded. Legalizing the market and giving these poor people the protection of institutions and regulations would bring them relief.

    3. While they may suffer from the trauma of making a hard choice, it’s not clear that this is worse than the trauma of having no means of escaping poverty.

    4. To remove the decision from them is to make the decision for them; what you’re doing is declaring that there is no situation in which a person can be made better off, after deducting the costs of think about it. It’s not clear that this is THE right decision. The benefits that a sale can bring to people is immense: 2 lakh rupees is 5 years of income to the median Indian household.

    In other words, would they be made better off or worse off, after taking into account the cost of having to choose. It’s not clear that they would be made better off, given the sheer number of people who do it anyway for less money and at more risk.

  4. Coolshankin said, on September 23, 2012 at 3:45 am

    I came across your link from a comment on Sandel’s article. I would recommend his course he takes in Harvard called ‘Justice: What is the Right Thing to do?’ It’s all on http://www.justiceharvard.org . The class is about how various philosophers have defined fairness. He asks interesting questions about what people think is fair. He does describe liberalism (from which free market philosophy can be derived) and other ideas about what is fairness. You can decide which philosophy with which you agree all by yourself. You may make your own. Perhaps, the only constraint is that you stick to your philosophy even if it affects you negatively. Free market philosophy of justice is fairly popular one, and I see that your understanding is: if it is free market, it is fair. There have been philosopher who have exposed the flaws (or what they think are flaws) in that thinking. You will learn about them in the class.

    Sandel never insists that his idea of fairness is the right one. He asks you to describes yours. I highly recommend his course.

    Think about the following question:

    Suppose your boss knows that you and your colleague are both equally productive and equally valuable to the company. And he also *knows* that you are desperate to keep this job. Perhaps, you and your spouse just had a baby, and cannot afford to change health insurance plans, while your colleague can afford to quit the job and look for a new one because he has a richer ancestry. Or, perhaps, your colleague may be as desperate as you are. Or, perhaps, you just bought a house close to your office and kid’s school, and so, you are unlikely to quit your job. If your boss decides that only your colleague gets a bonus for no reason (your boss tells you so), would you still call that “fair?” Remember that reason why he decided to treat you unequally had nothing do your job, but other tangential reason, and everything here follows free market principles; you are free to walk away from your job if you don’t like the salary. Would you call what your boss did as “fair?”

    According to free market principles, it is fair. If you think otherwise, you idea of fairness is different from that of free market. Discover and explain what it is. Every person in this world has his ideas of fainess; it is upto them to discover it. The course will help you do that.

    • Navin Kumar said, on September 23, 2012 at 8:05 am

      Thank you, coolshankin, for your remarks and for the link to Sandel’s lectures. I shall watch them as soon as I get the time. I’m sure they’ll be illuminating.

      You believe that my notion of fairness is ‘if it is free market, it is fair.’ In the post I invoked no notion of fairness at all. I merely challenged the validity of the version of fairness Sandel uses in his article. Societies use fairness because it is believed to secure a superior outcome, especially for the poor. The version that Sandel uses secures an inferior outcome for the poor. Hence, this version should not be employed.

      I consider welfare paramount. If something secures a higher level of well-being for everyone in society without hurting anybody tangibly, than it shouldn’t be prevented by the what notions of fairness other people have. Organ sales benefit buyers and sellers without anyone else in any tangible way, thus they should be allowed regardless of what others think of them.

      As you can see, this argument applies only to this specific policy and not to more general debates about fairness etc. I do not argue that markets will always generate a ‘fair’ outcome, especially if there is more than one definition of fair. Thus, in order to avoid a ‘debate sprawl’ I shall avoid rebutting or agreeing with your example.

      I do argue that if a version of ‘fairness’ hurts innocents to noone’s benefit, it ought be discarded as a moral tool. I’m not sure you disagree.

  5. Simon Rippon said, on October 3, 2012 at 5:03 pm

    I don’t think you’re right – although, in all fairness, your criticisms of Sandel’s arguments are on target. Read this:
    http://jme.bmj.com/content/early/2012/06/27/medethics-2011-100318.full

  6. Rodrigo said, on October 5, 2012 at 7:13 am

    Interesting post, but I think you miss an important point. Sandel is talking about transactions that involve certain goods that should not be subject to market forces. The poor person would be better off in terms of income, but she would be worse off in terms of her physical well being. Should our bodies be up for sale? That is the fundamental question. You might say that they should, but in the beginning of your response you say that certain goods should be kept out of the economic sphere. If our bodies shouldn’t be kept out of the marketplace, than what should?

    • Navin Kumar said, on October 8, 2012 at 9:14 am

      Why shouldn’t they be? “I really don’t like the idea” is not a reason. The sale of sperm, eggs etc is legal in many countries.

      Sandel provides a list of reasons, I attempt to rebut them.

  7. […] Simon Rippon, in a comment he left on this blog, directed me to his Journal of Medical Ethics paper which contains a novel argument […]

  8. Stumbler said, on October 29, 2012 at 7:43 pm

    “I say it’s not ‘fair’ that the peasant doesn’t have to option of selling his kidney to improve his situation when all else fails, just because a bunch of wealthy westerners who do have options don’t wanted be tainted by the association” – Nail meets head. Incidentally, why are organ markets unfair when India is the west’s favourite centre for surrogacy? 🙂

    On the fairness discussion, surely the individualistic nature of a definition of fairness means it really can’t be used as a steady argument against something? Or of course, my personal favourite – “Life is never fair, and perhaps it is a good thing for most of us that it is not.”- Oscar Wilde

    Excellent blog, really enjoyed reading it so far

    • Navin Kumar said, on October 30, 2012 at 12:12 am

      Thank you! I hope you enjoy future posts.

      Incidentally, there are plenty of people who want to end commercial surrogacy as well, although not in India itself. Many Western countries have banned it (France etc).

  9. Michael said, on March 13, 2013 at 1:46 pm

    I think you are setting the scope to much too narrow bounds. In the final transaction, the organ seller and buyers find themselves in an unbalanced situation, where the economic powers of both are, or might be very unequal. The consequences of such an imbalance might be unfair to the various reasons described elsewhere in the setting of an organ market. That means that there might as well be transactions which are fair.

    The question raised by Randel, to my understanding, is: Are economic principles the right or the best systematic to govern the exchange of organs? To answer this, we need to explore what the “right” or the “best” means in this case. Without going into details, even a superficial consideration reveals that an economic system tends to promote efficiency in the sense that the volume of transactions is favored over the balance of values which are exchanged. Moral considerations are simply not represented in a market, unless it is regulated.

    Economic systems reduce the components of a decision making process to the aspect of monetary potential. How much money can a needy patient possibly spend to get an organ, how much money do you need to offer to coerce somebody into spending an organ who would otherwise much prefer to keep it.

    What if, a year after spending a redundant organ, the donor needs to replace the remaining one, can he buy one from the money that he received from his deal? Well only if he either did not use the money he received or if he invested it so that he can re-evaluate it. That basically means that our seller is only then as worthy to receive an organ as the buyer was, if he managed to preserve the money he got. His neighbor who might have had only one organ could never afford to replace it.

    Any other system might not come to different conclusions than an economic system, when applied to a concrete buyer and seller, but it should take into consideration that there is more than just economic value which should govern a transaction which directly affects health or maybe even the lives of the participants. Market fails to deliver this consideration.

    • Michael said, on March 13, 2013 at 1:51 pm

      Just to clarify my point about the seller being able to buy: If, to preserve his personal integrity (health) he is bound not to spend the money of to risk dying, then the value of the money he receives is limited. In the absense of an assurance, he is bound to not use the money or to take the risk to die if he uses it and gets into a similarly needy position, which is now more likely than before, because he lost his redundant organ.

      Selling organs out of a weak economic situation is as sustainable as gambling.

    • Navin Kumar said, on March 13, 2013 at 7:35 pm

      Hi Michael,

      I’m very open to the idea that there may exist moral principles under which a market might be impermissible. I just haven’t found a plausible one yet.

      You’re primary concern seems to be that the impoverished donor, once he has sold his kidney, might not be able to afford one when he needs his. Thus your primary concern seems to be the welfare of the donor, a most noble cause and one in which I’m right there with you. You and I are both concerned about the well-being of the poor and, I assume, the well-being of mankind. Where we differ, then, is our conclusions of what an organ market will lead to.

      1. There is a negligible increase in mortality caused by kidney donations: http://www.nejm.org/doi/full/10.1056/NEJMoa0804883

      2. Thus, if a person “needs” a kidney, it’s because something has caused his remaining kidney to fail – a disease, most likely. In such a case not having sold his kidney is redundant – the “surplus” kidney would’ve failed as well.

      3. Thus there is a vanishingly small chance that he will “need” his kidney. In other words, a person does NOT have to save money to offset a chance that he will need it in the future.

      4. Meanwhile there is a 100% chance that this patient here suffering from renal failure will die if he doesn’t get a kidney. If lives are the yardstick by which you judge a policy, legalizing organ markets is a slam dunk.

      5. But suppose that there IS some small chance that he will die as a consequence of having donated his kidney – who should decide whether he should or should not sell it? Driving to work is a risk. Less trivially, 1 in 30 fishers (that’s in the US) will die while working. If such people are allowed take risks in exchange for money, why shouldn’t this chap?

      (At the risk of going off on a tangent, I submit the reason we “feel” that such a risk is unacceptable is because we feel that he shouldn’t be selling it in the first place – we find the transaction itself repugnant.)

      The poor are as rational as you and I. If a person it selling his kidney, it must be because it is his best option. It would reduce his welfare to take away his best option. Unless you or I deign to provide him with a superior option, it is wrong for us to take his best option away.

      6. We regulate risky jobs; we ought to regulate risky transactions as well (not that this is a particularly risky transaction). No-one is thinking of laissez-faire market.

      Now coming to the health of the poor, I want you to remember two things:

      7. Firstly, that the poor suffer from kidney failure as well! This includes the poor in wealthy nations, who have access to some form of public healthcare, as well as well as developing countries who are trying to provide such care to their citizens. To heal these individuals – some of whom won’t have a matching, willing relative – we need a supply of kidneys. The current system has failed to provide it.

      8. Secondly, poor households have very limited access to credit, and if a member falls ill, that person might die if they don’t get access to money fast. This is the single-most important financial issue for the poor (See Portfolios of the Poor for a clearer idea). By legalizing organ markets you’re providing a much needed source of funds to deal with a life-or-death situation – the person or his family members can sell a kidney, or offer it as collateral against a loan.

      To put the question sharply – is it okay to sell a kidney to finance a much-needed heart surgery? Because that’s primarily what the poor are going to do.

      9. You could say the same thing about the thousands of voluntary, altruistic donations that happen every year in which children provide kidneys for their parents etc. If a person altruistically donates his kidney, and a year later needs one but doesn’t have friends who are willing and able, what will happen to him? And if we’re willing to let people take a risk with their lives out of filial love, why not for money?

      • Eric said, on March 23, 2014 at 4:04 pm

        I really think you missed the point of Sandel’s discussion. He didn’t say that we shouldn’t sell organs but that we as a society should discuss and decide the right course as opposed to assuming the ‘rightness’ of a particular man-made economic model. There is absolutely nothing inherently ‘right’ about your chosen method of exchange.

  10. Amara said, on August 27, 2013 at 10:29 pm

    Navin, I think your arguments are good and well put, but you seem to be missing the point.

    Selling limited body parts for money is coercive. In a humane society, no one would need to undertake such a risk or go through the agony of reaching such a decision just to earn a few dollars. And I think that is what Prof. Sandel is making us aware us.

    I wouldn’t want to live in a society, knowing that my fellow man must use this option and sell his body parts. I find this highly immoral. The disgust I feel is directed more toward the buyer than the seller.

    We are no longer in the dark ages and have been enlightened. Why should we move backward? We should all be striving for a just society, where equality prevails. I realize these are goals, that may seem unattainable. Should we stop trying?

    Don’t you think there are things money shouldn’t be able to buy?

    Even in India, there must be other options than selling organs?


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