Organ trade

Organ trade (also known as the blood market) is the trading of human organs, tissues, or other body products, usually for transplantation.^[1][2] According to the World Health Organization (WHO), organ trade is a commercial transplantation where there is a profit, or transplantations that occur outside of national medical systems. There is a global need or demand for healthy body parts for transplantation, which exceeds the numbers available.

As of January 2020^[update], there are more than 100,000 candidates waiting for organ transplant in the United States.^[3] The median wait time for heart and liver transplants in the U.S. between 2003 and 2014, was approximately 148 days.^[4]

Commercial trade in human organs is currently illegal in all countries except Iran. Recent bans on the commercial organ trade (e.g. India in 1994 and the Phillipines in 2008) have increased the availability of transplants and the safety of the procedures. Despite these prohibitions, organ trafficking and transplant tourism remain widespread (however, the data on the extent of the black market trade in organs is difficult to obtain). The question of whether to legalize and regulate the organ trade to combat illegal trafficking and the significant global organ shortage is greatly debated. This discussion typically centers on the sale of kidneys by living donors, since human beings are born with two kidneys but need only one to survive.

History

The first scientific report of the phenomenon dates back to a publication in The Lancet in 1990. The study tracked 131 patients from the United Arab Emirates and Oman who underwent kidney transplants in Bombay and who reportedly experienced numerous post-operative problems^[5]

In its report on organ trafficking in Europe, the Social, Health and Family Affairs Committee of the Council of Europe wrote: "On a global scale, organ trafficking is not a new problem. In the 1980s, experts began to notice a practice that was later dubbed 'transplant tourism': wealthy Asians traveled to India and other parts of Southeast Asia to obtain organs from poor donors. Since then, other destinations have emerged, such as Brazil and the Philippines. According to some allegations, China is involved in the trade of organs taken from executed prisoners. Organ sales continue in India despite new laws in the country that make this practice illegal in most regions. While current estimates suggest that the illicit organ trade remains relatively modest in Europe, this problem does not lose any of its seriousness, as it is very likely that with new medical advances, the gap between supply and demand for organs will continue to widen."^[6]

Legal organ trade

Iran

See also: Kidney trade in Iran

Iran is the only nation that allows organs to be bought and sold for money. Due to lack of infrastructure to maintain an efficient organ transplant system in the early 1980s, Iran legalized living non-related donation (LNRD) of kidneys in 1988.^[7] The Charity Association for the Support of Kidney Patients (CASKP) and the Charity Foundation for Special Diseases (CFSD) control the trade of organs, with the support of the government. These nonprofit organizations match donors to recipients, setting up tests to ensure compatibility. Donors receive tax credit compensation from the government, free health care insurance, and often direct payment from the recipient with the average donor being paid $1,200.^[7][8] Some donors are also offered employment opportunities. Charity organizations support recipients that cannot afford the cost of the organ.^[9]

Iran does place restrictions on the commercial organ trade in an attempt to limit transplant tourism. The market is contained within the country; that is, foreigners are not allowed to buy the organs of Iranian citizens. Additionally, organs can only be transplanted between people of the same nationality – so, for example, an Iranian cannot purchase a kidney from a refugee from another country.^[8]

Proponents of legalized organ trade have hailed the Iranian system as an example of an effective and safe organ trading model. In addition, the LNRD model is compatible with the social climate in the country. Religious practices in Iran stymies donation culture in the country as organ donations is often viewed as taboo. In 2017, from a possible 8,000 cases of brain death, 4,000 organs were viable, but only 808 were transplanted due to lack of consent.^[10]

Some critics argue that the Iranian system is in some ways coercive, as over 70% of donors are poor.^[11] There is no short-term or long-term follow-up on the health of organ donors.^[12] In fact, there is evidence that Iranian donors experience highly negative outcomes, both in terms of health and emotional well-being.^[13]

Organ prices

In Iran's legal markets, the price of a kidney ranges from $28000 to $45000.^{[14][failed verification][15][failed verification]} On the black market, the same kidney can be worth over $100000, with most of proceeds taken up by middlemen.^{[16][failed verification]} The typical price paid to donors on the black market is thought to be about US$5,000, but some donors receive as little as $1,000.^[17] In addition, these black market transplants are often dangerous to both the donor and recipient, with some contracting hepatitis or HIV.^[14]

Government compensation for donors

Australia and Singapore recently legalized monetary compensation for living organ donors. Proponents of such initiatives say that these measures do not pay people for their organs; rather, these measures merely compensate donors for the costs associated with donating an organ.^[18] For example, Australian donors receive 9 weeks' paid leave at a rate corresponding to the national minimum wage.^[19] Kidney disease advocacy organizations in both countries have expressed their support for this new initiative.^[20][21]

Although American federal law prohibits the sale of organs, it does permit state governments to compensate donors for travel, medical, and other incidental expenses associated with their donation. In 2004, the state of Wisconsin took advantage of this law to provide tax deductions to living donors to defray the costs of donation.^[22]

Kidney paired donations

See also: Kidney paired donation

Although all nations apart from Iran prohibit financial transactions for organs, most permit "paired donations" or kidney swaps across multiple parties. Paired donations address the problem of tissue compatibility in organ transplants.^[23] For example, you may wish to donate a kidney to your spouse but cannot to due to antibody incompatibilities. However, your kidney is a good match for a stranger who happens to be married to someone whose kidney would be compatible with your spouse. In a paired donation, you would agree to donate your kidney to the stranger, in exchange for the stranger's spouse promising to donate a kidney to your spouse.

Such paired donations are arguably a form of organ sale – instead of purchasing a kidney for a loved one with cash, a person pays for it with her own kidney.^[24] In fact, in the United States, the spread of kidney paired donations was initially stymied due to language in the National Organ Transplantation Act barring the transfer of human organs for "valuable consideration".^[24] It was only after the law was amended to specifically allow for kidney paired donations that the practice became popular.

Illegal organ trade

According to the World Health Organization (WHO), illegal organ trade occurs when organs are removed from the body for the purpose of commercial transactions.^[25] Despite ordinances against organ sales, this practice persists, with studies estimating that anywhere from 5% to 42% of transplanted organs are illicitly purchased.^[26][27][28] Research indicates that illegal organ trade is on the rise^{[citation needed]}, with a recent report by Global Financial Integrity estimating that the illegal organ trade generates profits between $600 million and $1.2 billion per year, with a span over many countries. These countries include, but are not limited to:

• Angola
• Brazil^[29][30][31]
• Canada^[32]
• China^[33][34][35]
• Colombia^[36][37]
• Costa Rica^[38]
• Egypt^[39]
• Georgia
• Haiti^[40]
• Israel^[41][42][43]
• Libya^[44]
• Mexico^[45]
• Peru^[29]
• Philippines^[46][47]
• Russia
• South Africa^[29][31]
• United Kingdom
• United States^[31]

Though claims of organ trafficking are difficult to substantiate due to lack of evidence and reliable data, cases of illegal organ trade have been tried and prosecuted. The persons and entities prosecuted have included criminal gangs,^[45][48] hospitals,^[49] third-party organ brokers,^[50] nephrologists,^[13] and individuals attempting to sell their own organs.^[51]Poverty, corruption, and insufficiencies in legislation and enforcement drive the prevalence of the illegal organ trade. These factors also pose difficulties in tracking accurate statistics of the trade and market forces across countries.^[52]

Transplant tourism

The United Network for Organ Sharing defines transplant tourism as "the purchase of a transplant organ abroad that includes access to an organ while bypassing laws, rules, or processes of any or all countries involved".^[53] The term "transplant tourism" describes the commercialism that drives illegal organ trade, but not all medical tourism for organs is illegal. For example, in some cases, both the donor and the recipient of the organ travel to a country with adequate facilities to perform a legal surgery. In other cases, a recipient travels to receive the organ of a relative living abroad.^[53] Transplant tourism raises concerns because it involves the transfer of healthy organs in one direction, depleting the regions where organs are bought. This transfer typically occurs in trends: from South to North, from developing to developed nations, from females to males, and from people of color to whites.^[13] In 2007, for example, 2,500 kidneys were purchased in Pakistan, with foreign recipients making up two-thirds of the buyers.^[25] In the same year, in Canada and the United Kingdom, experts estimated that about 30 to 50 of their transplant patients illegally purchased organs abroad.^[26]

The kidney is the most commonly sought-after organ in transplant tourism, with prices for the organ ranging from as little as $1,300^[13] to as much as $150,000.^[53] Reports estimate that 75% of all illegal organ trading involves kidneys.^[54] The liver trade is also prominent in transplant tourism, with prices ranging from $4,000^[55] to $157,000.^[2] Though livers are regenerative, making liver donations non-fatal, they are much less common due to an excruciating post-operative recovery period that deters donors. Other high-priced body parts commonly sold include corneas ($24,400) and unfertilized eggs ($12,400), while lower-priced bodily commodities include blood ($25–337), skin ($10 per square inch), and bones/ligaments ($5,465).^[2] While there is a high demand, and correspondingly a very high price, for vital organs such as hearts and lungs, transplant tourism and organ trafficking of these parts is very rare due to the sophisticated nature of the transplant surgery and the state-of-the-art facilities required for such transplants.^[2]

Global reaction

The international community has issued many ordinances and declarations against the organ trade. Examples include the World Medical Authority's 1985 denouncement of organs for commercial use; the Council of Europe's Convention on Human Rights and Biomedicine of 1997 and its 2002 Optional Protocol Concerning Transplantation of Organs and Tissues of Human Origin; and the Declaration of Istanbul on organ trafficking and transplant tourism.^[56] The Declaration of Istanbul defines transplant commercialism, organ trafficking, and transplant tourism.^[32] It condemns these practices based on violations to equity, justice, and human dignity.^[27] The declaration aims to promote ethical practices in organ transplantation and donation on an international level.^[32] It is nonbinding, but over 100 transplant organizations support its principles, including countries such as China, Israel, the Philippines, and Pakistan, which strengthened their laws against illegal organ trading after the declaration's release.^[32]

The World Health Organization (WHO) has also played a prominent role in condemning the illegal organ trade. The WHO first declared organ trade illegal in 1987, stating that such a trade violates the Universal Declaration of Human Rights.^[32] It also condemns the practice on the grounds that it "is likely to take unfair advantage of the poorest and most vulnerable groups, undermines altruistic donation and leads to profiteering and human trafficking."^[32] In 1991, at the 44th World Health Assembly, it approved nine guiding principles for human organ transplant. The principles clearly stated that organs cannot be the subject of financial transactions. On May 22, 2004, these guidelines were slightly amended at the 57th World Health Assembly. They are intended for the use of governments worldwide.^[25] These global initiatives have served as a helpful resource for establishing medical professional codes and a legal framework for the issue, but have not provided the sanctions required for enforcement.^[53]

Illicit organ trade in specific countries

China

See also: Organ transplantation in China and Organ harvesting from Falun Gong practitioners in China

Since the late 1980s, China relied on executed prisoners to provide the bulk of its transplanted organs.^[57] This ready source of organs made it second only to the United States for numbers of transplantations performed.^[58] There is evidence that the government attempted to downplay the scope of organ harvesting through confidentiality agreements^[59] and laws, such as the Temporary Rules Concerning the Utilization of Corpses or Organs from the Corpses of Executed Prisoners.^[60] Critics further allege that organs were not distributed on the basis of need, but rather allocated through a corrupt system or simply sold to wealthy Chinese and foreign individuals.^[58] One source estimates that China executed at least 4,000 prisoners in 2006 to supply approximately 8,000 kidneys and 3,000 livers for foreign buyers.^[27] China was also accused of fueling its transplant industry with organs harvested from living Falun Gong practitioners. The Kilgour–Matas report^[61] concluded that China was guilty of this practice; however, the report has come under criticism for its methodology, by both Chinese and Western sources.^[58][62]

In the 2000s, the country came under increasing international and domestic pressure to end the practice of using organs from prisoners. Since then, it has implemented a number of reforms addressing these allegations. It has developed a registry of voluntary, non-incarcerated donors; it is believed that these living and deceased donors supply most of the organs transplanted in the country today.^[58] China also standardized its organ collection process, specifying which hospitals can perform operations and establishing the legal definition of brain death. In 2007, China banned foreign transplant patients and formally outlawed the sale of organs and collecting a person's organs without their consent.^[63][53][64] In China, minorities including Uighurs, Tibetans, Muslims and Christians are targeted for 'organ harvesting', with Falun Gong practitioners being the primary victims of this brutal practice.^[65]

Many non-profit organizations and international jurists are skeptical that China has truly reformed its organ transplant industry.^[66] In particular, although the number of organs taken from prisoners has dropped dramatically, there is no prohibition on collecting organs from deceased inmates who sign agreements purporting to donate their organs. There continue to be reports of prison officials offering death row inmates the opportunity to "voluntarily" donate their organs upon death, with the implication that those who decline may get worse treatment from their jailers.^[58]

India

Before 1994, India had no legislation banning the sale of organs.^[67] Low costs and high availability brought in business from around the globe, and transformed India into one of the largest kidney transplant centers in the world.^[68] However, several problems began to surface. Patients were often promised payments that were much higher than what they actually received.^[69] Other patients reported that their kidneys were removed without their consent after they underwent procedures for other reasons.^[70]

In 1994, the country passed the Transplantation of Human Organs Act (THOA), banning commerce in organs and promoting posthumous donation of organs.^[71] The law's primary mechanism for preventing the sale of organs was to restrict who could donate a kidney to another person. In particular, the THOA bars strangers from donating to one another; a person can only donate to a relative, spouse, or someone bound by "affection". In practice, though, people evade the law's restrictions to continue the trade in organs. Often, claims of "affection" are unfounded and the organ donor has no connection to the recipient.^[56] In many cases, the donor may not be Indian or even speak the same language as the recipient.^[72] There have also been reports of the donor marrying the recipient to circumvent THOA's prohibition.^[73]

Philippines

Although the sale of organs was not legal in the Philippines, prior to 2008 the practice was tolerated and even endorsed by the government.^[74] The Philippine Information Agency, a branch of the government, even promoted "all-inclusive" kidney transplant packages that retailed for roughly $25,000. The donors themselves often received as little as $2,000 for their kidneys.^[74] The country was a popular destination for transplant tourism. One high-ranking government official estimated that 800 kidneys were sold annually in the country prior to 2008,^[75] and the WHO listed it as one of the top five sites for transplant tourists in 2005.^[46]

In March 2008, the government passed new legislation enforcing the ban on organ sales. After the crackdown on the practice, the number of transplants has decreased from 1,046 in 2007 to 511 in 2010.^[76] Since then, the government has taken a much more active stance against transplant tourism.

United States

On September 21, 2021, 92 Republican members of the U.S. Senate and House asked the heads of multiple federal agencies to investigate organ harvesting for research purposes. The letter stated, "We are alarmed by public records obtained from the National Institutes of Heath (NIH) which show that the University of Pittsburgh (Pitt) may have violated federal law by altering abortion procedures to harvest organs from babies who were old enough to live outside the womb."^[77] However, PolitiFact reported several months earlier that "There is no indication that the fetal tissues used in the [University of Pittsburgh] experiments were 'purchased'," suggesting that the congress members' later description of this research as involving organ harvesting was inaccurate.^[78]

Impact on the poor

See also: Human trafficking § Trafficking for organ trade

Data from the World Health Organization indicates that donors in the illegal organ trade are predominantly impoverished people in developing nations. In one study of organ donors in India, for example, 71% of all donors fell below the poverty line.^[26] Poor people (including poor migrants) are more likely to fall victim of organ theft. Accounts of this practice usually characterize the victims as unemployed individuals (often but not always men) between the ages of 20 and 40 who were seeking work and were taken out of the country for operations.^[25]

Poor people are also more likely to volunteer to sell their organs. One of the primary reasons donors articulate for why they sell their organs is to pay off debt.^[25] Migrants for instance may use the money to pay off human traffickers. The most impoverished are frequently viewed as more reliable targets for transplant tourists because they are the most in need of money. While some supporters of the organ trade argue that it helps lift some people out of poverty by providing compensation to donors, evidence of this claim is hotly debated.^[11] In many cases, people who sell their organs in order to pay off debt do not manage to escape this debt and remain trapped in debt cycles.^[79][80] Often, people feel like they have no choice but to donate their kidneys due to extreme poverty.^[80][81] In some cases, organs are sold to family members, either from parents to offspring, or from adult children to parents. This is more frequent in nations where waitlists are less formal, and among families which cannot afford to leave the country for transplants.

Reports by the World Health Organization show decreased health and economic well-being for those who donate organs through transplant tourism. In Iran (where organ sales are legal), 58% of donors reported negative health consequences. In Egypt, as many as 78% of donors experienced negative health outcomes, and 96% of donors stated that they regretted donating.^[26] These findings are relatively consistent across all countries: those who sell their organs on the market tend to have poorer overall health. Substandard conditions during transplant surgeries can also lead to transmission of diseases like hepatitis B, hepatitis C, and HIV. Donors' poor health is further exacerbated by depression and other mental illnesses brought on by the stress of donating and insufficient care after surgery.^[25][53]

Impoverished donors' economic outcomes are no better than their health outcomes. A study of Indian donors found that while 96% of donors sold a kidney to pay off debts, 75% still required operative care that is not provided by the buyer.^[74] Donors in all countries often report weakness after surgery that leads to decreased employment opportunities, especially for those who make a living through physical labor.^[74]

Issues with enforcement

Though many statutes regarding organ trade exist, law officials have failed to enforce these mandates successfully. One barrier to enforcement is a lack of communication between medical authorities and law enforcement agencies. Often, enforcement officials' access to information regarding individuals involved in illegal organ transplants is hindered by medical confidentiality regulations. Without the ability to review medical records and histories to build an effective case against perpetrators, officials cannot fully enforce organ trade laws.^[28] Many critics state that in order to prohibit illegal organ trading effectively, criminal justice agencies must collaborate with medical authorities to strengthen knowledge and enforcement of organ trade laws. Critics also support other criminal justice actions to meet this goal, such as prioritizing organ trafficking issues among local legislative bodies; multidisciplinary collaboration in cross-border offenses; and further police training in dealing with organ trafficking crimes.^[32]

Media portrayal

There have been various portrayals of illegal organ trade and organ trafficking in the mass media over the past few decades. Many, such as the 1993 book The Baby Train by Jan Brunvand, are variations of the urban legend of an individual who wakes up in a hotel bathtub to discover that one of his or her kidneys has been removed.^[28] The 1977 novel Coma by Robin Cook, made into a movie by Michael Crichton, tells of unsuspecting medical patients who are put into a coma in order for their organs to be removed. In addition to books and films, stories of organ trafficking are often depicted through television, tabloid magazines, emails, and the Internet.^[82][83] Many of the organ trafficking tales depicted in the media contain unsubstantiated claims. For example, the 1993 British/Canadian TV program The Body Parts Business made a number of claims about organ trafficking that later proved to be false. The program investigated alleged organ and tissue trafficking in Guatemala, Honduras, Argentina, and Russia. One episode discussed a man named Pedro Reggi, reporting that his corneas had been removed without his consent while he was hospitalized in a mental facility. Reggi later disputed this claim, saying that his corneas were still intact, and he had just been suffering from an acute eye infection.^[82]

Critics, such as Silke Meyer, argue that this sensationalized view of organ trafficking, often based in urban myth, distracts attention from the illegal organ trade. They call for increased scientific research on illegal organ trade, so that organ trafficking legends can be replaced by scientific fact. Meyer argues: "Only then will [organ trafficking] be taken seriously by all governments affected and will the results constitute a solid ground for the field of policy-making."^[28]

Proposed solutions

Various solutions have been proposed to staunch the flow of illegal organs around the globe. The primary strategy is to increase the supply of legally donated organs, thereby decreasing the demand that drives the illicit organ trade. One way to accomplish this goal is for states to implement policies of presumed consent.^[60] With presumed consent laws (also known as "opt out" laws), consent for organ donation is assumed upon death unless the individual previously "opted out" by submitting documentation. This is in contrast to "opt-in" organ donation policies, which assume that a deceased person would not have wished to donate unless they had previously notified the government of their intention to donate. Presumed consent policies have already been adopted in various countries, including Brazil, certain jurisdictions of the United States, and several European nations. Research shows a 25–30% increase in the amount of available organs in "opt-out" countries.^[25]

Another proposed method is to enact laws that would hold doctors accountable for not reporting suspected organ trafficking. Scheper-Hughes has written extensively on the issue of doctors knowingly performing illegal operations with illicit organs.^[13] She argues that though doctors might be violating doctor-patient privilege by reporting suspected organ trafficking, their legal obligation to the patient is superseded by public interest in ending medical violations of human rights. If accountability measures were imposed, doctors would be liable as accomplices if they knowingly performed operations with black market organs.^[60]

Personal health records for migrants can help to document information on detected missing organs, and even previously done surgeries. Some projects have been started to keep personal health records of immigrants.^[84] Detection of missing organs and associated surgeries is an important first step to detect illicit organ harvesting.

Many people in the United States believe that adopting a system for regulating organ trading similar to Iran's will help to decrease the national shortage of kidneys. They argue that the U.S. could adopt similar policies to promote accountability, ensure safety in surgical practices, employ vendor registries, and provide donors with lifetime care. They further argue that private insurance companies and the federal government would be invested in providing such care for donors, and that laws could be enacted to make long-term care an inviolable condition of any donation agreement.^[11]

Ethical debate for organ trade

The ethical debate of organ trade rests on whether or not people have an inherent right to sell their own organs and, if so, whether or not the potential harms of organ sales override that right.^[85][86] While in most democratic countries, there is an implied ethical right to what happens to one’s body, in the US this right was dictated by the Scheloendorff decision through the court's opinion by Justice Benjamin Cardozo,

"Every human being of adult years and sound mind has a right to determine what shall be done with her own body"^[87]

However, this autonomy is limited in organ trade as governments and some ethicist argue the potential harm of organ trade outweighs the rights of an individual. The closest legalized comparison of a right to bodily autonomy for financial gain would be prostitution.^[87] Currently 32 countries allow prostitution; none of them allow for the sale of an organ.^[88] Views on legalization of prostitution have often viewed it as a "necessary evil" and of prostitution can be legalized as long as the sex worker's human rights such as freedom of speech, travel, work, immigration, health insurance, and housing, are not deprived.^[89] Similarly, many argue that as long as the donors rights are respected and the trade is regulated, it would be ethically responsible for organ trade to exist.^[90]

Organ trade also raises ethical and legal concerns for healthcare providers towards the treatment of patient. Specifically, currently there is little to no guidance on how does the doctor–patient relationship change if the patient received an organ through illegal means.^[91] Further more, if organ trade is legalized, an obligation for a physician to respect the patients wish to sell an organ. In the US, there is controversy on whether organ donation wishes are legally enforceable.^[92] The primary law governing organ donation is the Uniform Anatomical Gift Act (UAGA). However, it is widely considered inadequate as it is up to each state to regulate and uphold this law, with enforcement varying between states for cadaver body donation. Further more, donor shortages still persists in the United States.^[93] To avoid lawsuits, providers would violate UAGA and side with the next of kin and ignore any preexisting organ donation requests.^[85][92] As such, if organ trade is legalized, there will need to be ethical consideration on if a physician has a duty to perform financially motivated organ transplants.

Arguments for legalization

Increased organ supply

The main argument made in favor of legalized organ sales is that it would increase the number of organs available for transplantation.^[94] Although governments have implemented other initiatives to increase organ donation – such as public awareness campaigns, presumed consent laws, and the legal definition of brain death – the waitlist for vital organs continues to grow. Further more, cadaver organ transplantations have poorer clinical outcomes as compared with live organ donations.^[95] Legalizing payments for organs would encourage more people to donate their organs. Each organ sold on a market could potentially save the life (and improve the quality of life) of its recipient.^[96] For example, patients with kidney disease who receive a kidney transplant from a living donor typically live 7 to 15 years longer than those who depend on dialysis.^[95]

Economists generally lean in favor of legalizing organ markets. The consensus of American Economic Association members is that organ trade should be allowed, with 70% in favor and 16% opposed.^[97] Another literature review, looking at the publications of 72 economic researchers who have studied organ trade, reached a similar conclusion: 68% supported legalization of the organ trade, while only 21% opposed it.^[98]

Minimal negative consequences for donors

Proponents also assert that organ sales ought to be legal because the procedure is relatively safe for donors.^[99] The short-term risk of donation is low – patients have a mortality rate of 0.03%,^[100] similar to that of certain elective cosmetic procedures such as liposuction.^[101] Moreover, they argue, the long-term risks are also relatively minimal. A 2018 systematic review found that kidney donors did not die earlier than non-donors.^[102] Donors did have a slightly increased risk of chronic kidney disease and pre-eclampsia (a condition sometimes seen in pregnancy). The review found no difference in the rates of diabetes, heart disease, high blood pressure, or mental illness. Multiple studies of American and Japanese donors found that they reported a higher quality of life than the average non-donor.^[100] Proponents of organ markets argue that, given the comparative safety of donating a kidney, individuals should be permitted to undergo this operation in exchange for payment.

Critics challenge this view of transplantation as being overly optimistic. Specifically, they cite research suggesting that individuals who sell their organs fare worse after the procedure than those who freely donate their organs. Kidney sellers are more likely to have renal problems after the operation (such as hypertension and chronic kidney disease), to report reduced overall health, and to suffer from psychological side effects such as depression.^[103] Opponents of markets usually ascribe these worse outcomes to the fact that kidney sellers are drawn from the ranks of the poor; if organ sales are permitted, most sellers will be poor and can expect the same dangerous consequences. Proponents of organ markets respond by blaming these bad outcomes on the fact that kidney sellers have been forced into the black market, with minimal oversight, follow-up care, or legal protections from abuse; thus in a regulated market in the developed world, kidney sellers could expect to see outcomes more akin to those of kidney donors

Respect for autonomy

Many proponents argue for legalized organ sales on the grounds of autonomy. Individuals are generally free to buy or sell their possessions and their labor. Advocates of organ markets say that, likewise, people ought to be free to buy or sell organs as well.^[104] According to this perspective, prohibitions against selling organs are a paternalistic or moralistic intrusion upon individuals' freedom. Proponents acknowledge that, unlike selling a material possession such as a car, selling a kidney does carry some risk of harm. However, they note that people are able to undertake dangerous occupations (such as logging, soldiering, or surrogacy) which carry significant chance of bodily harm.^[105] If individuals are allowed to take on that risk in exchange for money, then they ought to be able to take on the risks of selling a kidney as well.

Harm reduction

Other physicians and philosophers argue that legalization will remedy the abuses of the illicit trade in organs.^[106][107] The current ban on the sale of organs has driven both sellers and buyers into the black market, out of sight of the law.^[108] Criminal middlemen often take a large cut of the payment for the organ, leaving comparatively little money left for the donor.^[109] Because the mainstream medical establishment is barred from participating in the transplantation, the procedure typically occurs in substandard facilities and not according to best practices.^[110] Afterwards, the donors often do not receive important medical follow-up because they are afraid that their role in the crime will be discovered. There have also been reports of criminal gangs kidnapping people and illegally harvesting their organs for sale on the black market.^[109] Proponents of legalization argue that it will result in better medical care for donors and recipients alike, as well as larger payments to the donors.

Some critics challenge the proponents' assumptions that legalization will eliminate the black market for organs or its problems. For example, one scholar argues that once the organ trade became legalized in Iran, it did not end the under-the-table sales in organs.^[111] Instead, people made deals outside the government-sanctioned system to acquire organs from more desirable (i.e., healthier) donors.

Arguments against legalization

Susceptibility to coercion

Critics often argue that organ sales should remain prohibited because any market solution will take advantage of the poor. Specifically, they fear that a large financial incentive for donating organs will prove irresistible to individuals in extreme poverty: such individuals may feel like they have no choice but to agree to sell a kidney. Under these circumstances, the decision to sell cannot be regarded as truly voluntary.^[112] Consequently, it is appropriate for the government to protect poor people by prohibiting the sale of organs.

Critics of legalization argue that proponents exaggerate the impact that a market would have on the supply of organs. In particular, they note that legalized organ sales may “crowd out” altruistic donations.^[113] In other words, people who would otherwise give their organs to relatives may decline to do so, opting instead to purchase the organ (or rely on the government to buy one) for their relatives. Proponents of markets counter that while altruistic donations might decrease slightly if organ sales were legalized, this decrease would be more than offset by the influx of organs.

Legalization of human organ trading has been opposed by a variety of human rights groups. One such group is Organs Watch, which was established by Nancy Scheper-Hughes – a medical anthropologist who was instrumental in exposing illegal international organ-selling rings. Scheper-Hughes is famous for her investigations, which have led to several arrests due to people from developing countries being forced or fooled into organ donations.^[114] Like the World Health Organization, Organs Watch seeks to protect and benefit the poverty-stricken individuals who participate in the illegal organ trade out of necessity.^[115]

Direct harms of organ selling

Some opponents of markets adopt a paternalistic stance that prohibits organ sales on the grounds that the government has a duty to prevent harm to its citizens. Unlike the "coercion by poverty" line of argumentation discussed above, these critics do not necessarily question the validity of the donors' consent. Rather, they say that the dangers posed by donating an organ are too great to allow a person to voluntarily undertake them in exchange for money. As noted previously, critics of organ sales cite research suggesting that kidney sellers suffer serious consequences of the operation, faring far worse than altruistic kidney donors. Even if one assumes that kidney sellers will have similar outcomes to donors in a regulated market, one cannot ignore the fact that a nephrectomy is an invasive procedure that – by definition – inflicts some injury upon the patient.^[116] These critics argue that the government has a duty to prevent these harms, even if the would-be seller is willing to undertake them.

A similar argument focuses on the fact that selling a kidney involves the loss of something unique and essentially irreplaceable on the part of the donor.^[117] Given the special value placed on bodily integrity in society, it is appropriate to outlaw the sale of body parts to protect that value.

Objectification

Another criticism of legalized organ sales is that it objectifies human beings. This argument typically starts with the Kantian assumption that every human being is a creature of innate dignity, who must always be regarded as an end to itself and never just a means to an end. A market for organs would reduce body parts to commodities to be bought and sold. Critics argue that, by permitting such transactions, society would reduce the seller of the organ to an object of commerce – a mere means to an ends.^[118] Assigning a monetary value to a key organ is essentially assigning a value to its bearer, and putting a price on a human being violates his or her intrinsic dignity.

Proponents of organ sales claim that this line of argument confuses the kidney with the whole person;^[119] so long as the transaction is conducted in a way that minimizes risks to the donor and fairly compensates him or her, that person is not reduced to a means to an end.

Unwanted pressure to sell an organ

Another argument against organ markets is that they will give rise to a pressure to sell organs which would harm all people (even those who did not participate directly in the market).^[120] Under the current ban on the organ trade, debtors and heads of families in the developed world face little pressure to sell their organs. If a person's creditors or dependents suggest that said person sell their kidney to raise money, they could refuse on the grounds that it is illegal. In contrast, if organ sales were legalized, a destitute individual could face pressure from family and creditors to sell a kidney – and possibly endure social consequences such as scorn or guilt if they declined. Legalizing organ sales would create this unwanted pressure (and attendant disapproval) for all poor individuals, regardless of whether or not they wished to sell their kidneys. Thus a legal prohibition on selling organs is warranted to protect poor people from this undesirable pressure.

Models for legalization

Erin Harris model

Ethicists Charles A. Erin and John Harris have proposed a much more heavily regulated model for organ transactions.^[121] Under this scheme, would-be sellers of organs do not contract with would-be recipients. Instead, a government agency would be the sole buyer of organs, paying a standard price set by law and then distributing the organs to its citizens. This safeguard is designed to prevent unscrupulous buyers from taking advantage of potential donors and to ensure that the benefits of the increased organ supply are not limited to the rich. Moreover, participation in the market would be confined to citizens of the state where the market is located, to prevent the unilateral movement of organs from developing nations to the developed world. Erin and Harris's model has been endorsed by a number of prominent advocates of organ markets.^[122][123]

Free market model

Many scholars advocate the implementation of a free market system to combat the organ shortage that helps drive illegal organ trade.^[124] The organ trade's illegal status creates a price ceiling for organs at zero dollars. This price ceiling affects supply and demand, creating a shortage of organs in the face of a growing demand.^[125][126] According to a report published by the Cato Institute, a US-based libertarian think tank, eliminating the price ceiling would eliminate the organ shortage.^[11] In the Journal of Economic Perspectives, Nobel laureate Gary Becker and Julio Elias estimated that a $31,700 compensation would provide enough kidneys for everyone on the wait list.^[127] The government could pay the compensation to guarantee equality. This would save public money, as dialysis for kidney failure patients is far more expensive.^[9]

However, other critics argue that such a free market system for organ trade would encourage organ theft through murder and neglect of sick individuals for financial gain. Advocates for the free market of organs counter these claims by saying that murder for financial gain already happens; sanctions against such acts exist to minimize their occurrence; and with proper regulation and law enforcement, such incidents in a legal organ trade could be minimized as well.^[124]

Other models

The incentivized Kidney Donation Model (IKDM) exists as an intermediate between complete Free Market Model and Erin Harris Model, with strong government regulation and rewards with free market approach to donations.^[128] Currently in place in Turkey, Iran, in which a free organ market exists which "donations" between donor and recipients are allowed. However, the government also supplements this donation with incentives such as free/discounted medical health insurance, exemptions from co payments/contribution shares, priority when receiving an organ in the future, priority when finding a job, income tax exemptions for salaried employees, and free or discounted public utilities.

In popular culture

• The American death metal band Cannibal Corpse released a song in 2021 titled "Inhumane Harvest", which has lyrical content about organ harvesting. The song was also released with a music video.
• The 1994 video game Policenauts revolves around an illegal drug and organ trafficking ring in outer space, which is run cooperatively by a multinational pharmaceutical corporation and corrupt police officers.
• The 2006 horror film Turistas focuses on a group of American tourists in Brazil who find themselves in the clutches of an underground organ harvesting ring.

Proposed solutions

There are several proposed solutions to increase the number of legally available human organs and reduce the growing illicit trade in these organs around the world. Policies of presumed consent have been successful in different countries, including Brazil, the United States, and many European countries. These policies can be either presumed consent (during life) or withdrawal (after death). In the category of withdrawal policies, organ donation is presumed after death, although it is possible to choose not to donate by submitting documents. Research has shown an increase of around 25 to 30% in the amount of organs available in countries with presumed consent policies.^[129] In the category of presumed consent policies, like the United States or France, a person may choose to donate their organs during their lifetime. In a presumed consent policy, families sometimes succeed in making the decision to donate the heart.

A program to reduce organ trafficking is supposed to have several ways to work. These laws help to increase the amount of organs available, which reduces the number of patients who turn to the black market. At the same time, the increase in the supply of organs reduces the financial cost of a transplant and, therefore, the need for medical tourism.

Another proposed method is to adopt laws that would impose on doctors the responsibility to report suspected organ traffickers. Chiper Hughes has written extensively on the issue of doctors who perform illegal operations while knowing that they are illegal.

Many people in the United States believe that adopting a regulated organ trading system similar to Iran's would help to reduce the shortage of kidneys for transplantation. They believe that the United States should adopt similar policies to ensure the safety of surgery, provide lifelong care for donors. They also consider that private insurance companies will invest in providing this care to donors, which would make long-term care laws more favorable by protecting the terms of any donation agreement.

See also

• Black market
• China:
  • Organ transplantation in China
  • Organ harvesting from Falun Gong practitioners in China
• Fetus Farming Prohibition Act
• Gurgaon kidney scandal
• Organ donation
• Organ donation in Israel
• Organ harvesting

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External links

• Doctors Against Forced Organ Harvesting