Why is the commodification of organs so bad?
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 , that commodification doesn’t necessarily lead to legal/social pressure , and that since sellers are from poor countries with dysfuntional institutions, being blocked from the (non-extant) state welfare net is no big deal .
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. 
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 .
(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.