Nation of Beancounters

Why is the commodification of organs so bad?

Posted in Essays by Navin Kumar on October 28, 2012

Dr Simon Rippon, in a comment he left on this blog, directed me to his Journal of Medical Ethics paper which contains a novel argument against  organ markets. The paper is long, but lucid and jargon-free. For those of you too lazy to read it in full, the core of his argument is that

… if organs can be easily exchanged for cash they will then become commodified, and naturally subject to the kinds of social and legal demands and responsibilities that govern our other transactions in the marketplace. For example, faced with a rent demand and inadequate cash to pay for it under the status quo, a couple of the choices you could make currently would be to sell some of your possessions, or to find (additional) employment and sell some of your labour. One choice that most of us do not realistically have as things stand (and therefore do not have to consider) is to sell an organ to raise the funds. This means that even if you have no possessions to sell and cannot find a job, nobody can reasonably criticise you for, say, failing to sell a kidney to pay your rent. If a free market in organs was permitted and became widespread, then it is reasonable to assume that your organs would soon enough become economic resources like any other, in the context of the market. Selling your organs would become something that is simply expected of you as and when financial need arises. Our new ‘option’ can thus easily be transformed into a social or legal demand, and it can drastically change the attitudes that others adopt towards you.

… because people in poverty often find themselves either indebted or in need of cash to meet their own basic needs and those of their families, they would predictably find themselves faced with social or legal pressure to pay the bills by selling their organs, if selling organs were permitted. So we would harm people in poverty by introducing a legal market that would subject them to such pressures.

… we should not limit our consideration of the potential harms imposed by the market to … psychic costs [the anguish felt by those forced to sell their organs by the legal/social system] alone. Once we have come to conceptualise our ‘excess’ organs and organ parts as pieces of unnecessary property by commodifying them, there would naturally follow genuine social and legal costs to pay for failing to sell them when economically necessary, just as there are social and legal costs to pay for failing to take employment when you are able to do so. We should ask questions such as the following: Would those in poverty be eligible for bankruptcy protection, or for public assistance, if they have an organ that they choose not to sell? Could they be legally forced to sell an organ to pay taxes, paternity bills or rent? How would society view someone who asks for charitable assistance to meet her basic needs, if she could easily sell a healthy ‘excess’ organ to meet them?

In short, legalization would lead to commodification, which in turn would lead to legal/social sanctions against those who do not sell their organs in times of trouble. This has costs in the form of mental anguish (“psychic costs”) felt by those who are now “forced” to sell their kidneys, and by the legal sanctions themselves. The rest of the paper is context and preempting rebuttals (none of which will be fielded here.) I’m going to argue that psychic costs would be low, and (therefore) that the social and legal pressure is justified.

In order to focus on the core argument, I’m sending three points to the footnotes: that legalization doesn’t necessarily lead to commodification [1], that commodification doesn’t necessarily lead to legal/social pressure [2], and that since sellers are from poor countries with dysfuntional institutions, being blocked from the (non-extant) state welfare net is no big deal [3].

Let’s now assume the above points away. How high would the psychic costs be?

Not very. Social and legal systems suffer from inertia. In order for such norms/laws to be established, the attitude that organs are mere things (this is essentially what commodification means) must have permeated society thoroughly – individuals must believe that organs are commodities, nothing more special than a pot or pencil. Rippon, resident of, and brought up in, a world where organs are sacred, would feel great anguish if he were forced to sell his organs. He wouldn’t feel such horror if he were forced to sell his TV, ordinary good that it is. Commodification, if it happens, removes the psychic costs attached to selling your organs: people in the new world do not feel unfairly compelled to. If commodification doesn’t happen, social/legal systems will remain unchanged.

Broadly speaking, the error in the psychic cost argument is to imagine a world in which the legal/social system would place pressure on a person to sell his organs and then imagine how bad a person from this world would feel. The creation of a new legal/social welfare system would have to be preceded by (or accompanied by) the creation of a new kind of citizen – one who doesn’t think of buying or selling organs as terrible. [4]

Rippon’s argument about the non-psychic legal/social sanctions is somewhat unclear. Clearly, not all pressure is bad. There exists social and legal pressure to not rape people. Most philosophers would agree that this is a good thing.

Less facetiously, most social and legal pressure tactics have some plausible rationale backing them. We know people sometimes lose their jobs, frequently due to bad luck, and want to help them survive. Thus we have unemployment benefits. We also don’t want them to suffer excessively, so we try to provide generous unemployment benefits. But if the benefits get too generous, some people will be tempted to give up work and enjoy a life of leisure. They end up sucking resources away from other worthy causes like schools and hospitals. Thus we cut people out of the system after a fixed period – or if they turn down too many offers.

Alternatively, imagine that a friend of yours is in trouble and needs money. You can afford to give it to him by sacrificing some luxuries. You notice that he has a 40-inch LCD television. Are you being a bad person by demanding that he sell his TV, rather than you give up your coffee?

When you sell your kidneys, you create value and wealth, some of which you enjoy. The rest of society doesn’t have to divert resources from other worthwhile pursuits to aid you. In a world where you don’t feel deep mental anguish about selling your kidneys, wanting to keep them puts you on the same moral footing as the lazy citizen [5].

(Incidentally, I doubt that this will happen. I’m merely arguing this from the perspective of a person who we’ve randomly plucked from this world. I do not share the view of this person, since I live in a world where people do in fact feel deep anguish about selling their body parts.)

Many feel that this attitude is somehow wrong; that organs are somehow different from televisions or labour and mustn’t be subject to legal or social pressure (Rippon explicitly denies he is one of them). But this is an unwarranted value judgement being passed by a resident of Earth S (where kidneys are sacred) upon the beliefs of the residents of Earth C (where kidneys are commodities). This is a general problem in ethical philosophy: people imagine a new world, and decide, based on their own values, that this world is undesirable. But the residents of Earth C don’t have the same desires and values as you and I. To them, their world is superior.

For example, people initially found life insurance repugnant: how can you benefit from a  person’s death?! However, we now regard it as wonderful device for protecting loved ones from excess suffering in the event of the breadwinners death. There is social and legal pressure on people to buy life insurance (some banks demand you take one out to be eligible for a home loan) – but few would argue that banning it would create a better world. Similarly, given the possibly abundant supply of organs there seems to be good reason to regard  Earth C as superior, just as the ability to provide for your children if you die makes this modern world superior.



1. Many countries permit prostitution but few would argue that the residents of the Netherlands regard sex as something to only be bought and sold. Furthermore, none of these places have laws demanding that women at least try to sell their bodies before they’re eligible for state aid, nor do friends and relatives refuse a woman help unless she’s given the brothel a shot. Thus, legalization didn’t cause commodification.

2. Donating a kidney renders you unable to work for month, making recovery from bad circumstance harder. If the price of kidneys are too low, it’s hard to see why any legal/social system would demand you sell them. Why would prices be ‘low’? See the first sentence of footnote 3.

3. Most of the sellers are (and will be from) countries where incomes are very low. Incomes are low due to dysfunctional institutions which are plagued by corruption and inefficiency. Dysfunctional institutions mean that (state) welfare nets are pretty bad anyway, so the poor do not lose much by being excluded from them due to the legal barriers. Social systems may be stronger, but even these are of no use in years where the entire community suffers an income shock simultaneously (due to drought, for example). Furthermore since all of the people in your community are as poor as you, the depth of this net is limited. Thus the debate uncomfortably narrows it’s scope to situations involving (a) poor communities, (b) social – rather than state – welfare nets and (c) individual-specific problems. Within this range, though, there is scope for debate.

4. Of course, there might exist some minority of citizens who still think of their organs as sacred. Since people who have similar moral beliefs cluster together (whether as religious communities or San Francisco, har har), I doubt that the interpersonal social support system that these individuals enjoy will be threatened by new norms which aren’t adopted. If he wishes to invoke the suffering of this minority, Rippon’s job is to show that it will (a) exist (b) be large enough such that psychic/legal costs will outweigh any gains – but (c) not so large that they can’t torpedo the new legal system. I do not envy this task.

5. One can mount a defence against these arguments for commodity-specific reasons. A longer benefits timeframe allows the worker to spend more time searching for a job better suited to him. If you force your friend to sell his TV, it would go at a steep loss. As I pointed out earlier, if you forced a person to sell his kidney, he’d be bedridden for a month, making it harder to recover from bad circumstances. However, these arguments can be – and are – made in a world where labour, televisions and kidneys are commodities as well.


4 Responses

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  1. Simon Rippon said, on November 4, 2012 at 9:53 pm

    Dear Navin,

    Many thanks for your detailed and most thoughtful and reply to the argument against permitting organ selling. I will do my best to respond here in a very brief way, but I think you should also send your reply in to JME in some form (on the instructions for authors page of the journal’s web site you will see the various types of submission that they accept).

    Regarding your mention of legalized sex in the Netherlands in your fn.1, I think that the link between legalization and commodification is hindered there by a widespread taboo against selling sex: the idea that it is just intrinsically wrong, or at least highly morally controversial, to exchange sex for money. It is not obvious to me that a similar taboo about organ selling would persist in the face of legalization (cf. life insurance, with which you made your own very interesting analogy).

    Let me skip now to your main argument. Briefly, you claim that people would not feel significant discomfort about pressure to sell their organs in a world where they were commodified. And crucially, you claim that they would be making no mistake in feeling this way. So the costs of social and legal pressure to sell organs in such a world would be low. My argument is mistaken, you claim, in imagining the badness of this social and legal pressure from the point of view of residents of *this* world, in which organs are not commodified, and the costs of such pressure would be much higher.

    I will grant for the sake of argument that your psychological predictions are correct. I think the nub of the argument then comes down to an objection to your view that you yourself anticipated: “Many feel that this attitude is somehow wrong; that organs are somehow different from televisions or labour and mustn’t be subject to legal or social pressure (Rippon explicitly denies he is one of them). But this is an unwarranted value judgement being passed by a resident of Earth S (where kidneys are sacred) upon the beliefs of the residents of Earth C (where kidneys are commodities). This is a general problem in ethical philosophy…the residents of Earth C don’t have the same desires and values as you and I. To them, their world is superior.”

    Now in fact I did not explicitly deny in my article that organs are different from TVs or labour. What I explicitly denied was that there is anything intrinsically wrong with exchanging organs for money – but that’s a different point. In fact, I do think that organs are different from TVs or labour in that being put under pressure to sell organs is particularly harmful: I think we have a right not to be exposed to such pressure, and it so happens that it matters a lot to most of us in this world to have this right protected. I also think we have a right not to have significant risks unfairly allocated onto us, as they would be on organ sellers. (Incidentally, I would not describe this as the view that “kidneys are sacred”, and more than I would describe moral disapproval of rape as based on the view that “sex is sacred”. I think that’s a bit of a caricature.) So I do want to endorse the objection you anticipated.

    So what about your point that residents of Earth C don’t share my desires and values, that “to them, their world is superior”. Well, that might be relevant, and it might reduce the harm of an organ market in their world, relative to our world. One harm that they wouldn’t suffer, presumably, is the frustration of strong desires to be free from pressure to sell their organs. But I cannot agree with your view that they suffer no harm just because they do not think that they suffer a harm. On the contrary, they are clearly subjected to a kind of domination and exploitation that is harmful to them. And it’s still morally impermissible, I think, for others to impose these harms on them.

    To see my point, imagine instead a slaveholder society in which the slaves have come to see themselves as naturally belonging in “their place”. So long as they are reasonably well treated by their masters, they feel no great shame or discomfort about being slaves, because they have come to accept that it is irght for them to be treated in this way. The values and desires of people in this society line up with the way it is structured, and they would see their own society as superior to ours, in which people who they would see as “slave types” have come to mistakenly desire and even to judge that they have a right to freedom. Shall we judge that the slaveholder society is just as good as our own, or even better? If not, then we’ve no reason to accept your Earth C is just as good as ours either.


  2. Navin Kumar said, on November 5, 2012 at 12:11 am

    Dear Simon,

    Thank you for your kind reply, which was a good deal timelier than mine. Incidentally, I’ve edited it to add spaces between paragraphs. I hope you don’t mind. It’s easier to read this way.

    Whether the taboo would persist or not is hard to prove one way or another, which is why I used the phrase “not necessarily”. It seemed more fruitful to discuss the question of whether is matters that it does or not, so I relegated it to a footnote.

    I agree that “kidneys are sacred” is a caricature; I was merely using it as a shorthand for a view that imparts some special significance to kidneys beyond the simply utilitarian. I apologize for any confusion or offence.

    You assert that “being put under pressure to sell organs is particularly harmful” and present being “subjected to a kind of domination and exploitation” as examples. (I believe you invoked it in the paper as well.) I’ve been meaning to write on exploitation but that warrants a post, not a comment. So I’m afraid my reply will have to remain incomplete for a while. In the meantime I’d like to know: what, besides exploitation, are the other harms that are unique to kidney sales (but absent in selling labour/TVs)?

    With regards to risks, I’d like to direct you to this paper, which asserts that “living kidney donors have survival similar to that of nondonors and that their risk of end-stage renal disease (ESRD) is not increased.”


    • Simon Rippon said, on November 5, 2012 at 12:22 am

      No offence taken! I’ve outlined what I think the special harms of being put under pressure to sell organs are in the JME paper, and I think it would be pointless for me to try to add to that here. On the paper you link on risks, it’s a rather small study that in the words of its authors is “subject to survival bias”! So not very reliable evidence for lack of risk in organ selling!


  3. Navin Kumar said, on December 9, 2012 at 1:26 pm

    Dear Simon,

    Once again, I apologize for my untimely response.

    After re-reading your JME paper, I’ve found two arguments claiming that the pressure to sell kidneys is uniquely pernicious: the psychological importance of prevent incursions into our body, and risk. To this, I’ll add the exploitation point you made above. There are also two, less exclusive, harms cited by Dworkin. If I’ve missed something please let me know.


    As I’ve already argued in the post, commodification, a prerequisite for pressure to exist, also means people do not feel mental anguish about selling kidneys. Based on your comment, I do not think you disagree. Example: sales of sperm and eggs.


    There are two types of risk here: the risk of dying on the operating table (1 in 3000 according to your paper) and the risk of dying afterwards. I don’t think the latter risks are substantial, but we must agree to disagree since the empirical work is somewhat inconclusive, no doubt because it’s expensive to track people over a long time.

    I do argue, though, that over a medium range, risk is not an adequate grounds for distinguishing kidney selling from labour selling. For example, in the US, the riskiest jobs have a fatality rate in the range 1 in 1000 per year. ( Over a thirty year career, that’s a one in 30 chance of dying. Do we ban these jobs (with their attendant risk premium) on the grounds that people might be driven by desperation to take them? No: we try to minimize the risk (with safety standards etc), and the fallout of accidents, with disability payments, life insurance etc.

    Second, over a high range of risk, there will be no pressure. You might push your friend to accept a job as a policeman – but not as a drug dealer (even if you had no qualms about drugs themselves).

    Third, for a subset of sellers, a legal market in organs is risk reducing. These are the individuals who are currently selling their organs on the black market. They’re certainly not being operated upon by highly qualified surgeons, nor in a modern, sanitary hospital with access to drugs post-operation. A legal market would be of immense aid to them.

    (At the risk of going off on a tangent, they’re certainly not informed about the costs and risks, and since you’ve read Goyal et al, you know that they’re fraudulently paid between a tenth to a half of what they were promised.)


    We need some sort of definition of exploitation before we continue. I propose the following: a transaction is said to be exploitative if (1) two individual, one of “high” status and one of “low” status interact (2) and the high status person benefits from the interaction (3) as a consequence of the difference between their status. Notice I’ve carefully left out the question of whether the “low” status person benefits or not.

    By this definition, trade between the US and China is clearly exploitative. It is because of the poverty of the Chinese people that US consumers enjoy such low prices (or US companies enjoy such high profits, depending on how you see it). Should the US government then ban Chinese imports? Even the most vocal of activists would be horrified by the idea! It would sharply reduce the already low income of Chinese workers. What most activists want (although I’m not sure how they’ll achieve it) is to enforce safety and health standards, impose a minimum wage, to get factories to allow the formation of unions etc. In other words, they want to make trade less exploitative, not to ban it altogether. As you yourself note, the kidney selling system can be made less exploitative by creating an international price floor.

    When it comes to Chinese/Filipino/South African labour there is the problem that some might sell their labour “out of economic desperation, rather than out of a choice made free from external pressure”. The solution is not to ban the sale of labour. By analogy, the same argument applies to kidneys.


    Dworkin has identified two problems: ‘‘individuals may choose not to sell [organs] in the knowledge that they have made a choice which leaves their family worse off economically than they might have been’ and ‘introducing markets is likely to strain family relations’ because ‘[f]amily members are likely to be resentful of being asked to contribute without compensation when a stranger would receive substantial payment.’ In passing, I note that neither of these are commodification dependent.

    Regarding the first problem, I’d say: that’s true of many of life’s choices. If I refuse to sell dearly beloved baseball card when I become unemployed, I’m going to feel like a horrible person because my family might suffer. But this hardly means that people under pressure should be banned from selling their physical assets. The costs of people ‘feeling like an asshole’ must be weighed against the benefit of them having cash when they desperately need it and can’t get it from elsewhere. So kidney sales are hardly unique.

    I’m dubious of the second: labour can be bought and sold, yet people routinely help their friends and families move, organize parties, cleanup etc. Furthermore, most of the points you make in the section “What is the alternative” can, I think, apply here.


    I’ve already argued that exploitation isn’t adequate grounds to ban organ markets (although it’s excellent grounds to regulate it, like the labour activists want.) So the fact the people of Earth C are subject to exploitation and domination isn’t a reason to prevent the residents of Earth C from organizing their affairs as they wish.

    To invert the slavery example, imagine a slave owner arguing that slaves wouldn’t be better off as freedmen because then they’d be subject to the pressures and responsibilities that freedmen face, and more since they’ve no assets to speak of, are unaccustomed to freedom etc. This was a fairly common argument in the 1800s. It didn’t work then. I don’t think it ought work now: the poor should be free to sell their kidneys and deal with whatever pressure arises.

    My argument can be condensed as follows: the pressure to sell labour/physical assets is justified; on Earth C, kidneys are no different from labour/physical assets; thus on Earth C, pressure to sell kidneys is justified. Earth C is not inferior to Earth S.


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