The July 2009 arrest in New York of Izhak Rosenbaum, a gray-haired Brooklyn businessman whom police allege tried to act as a broker in a deal to buy a kidney for $160,000, coincided with the passage of a law in Singapore that some say will open the way for organ trading there. In 2008, Singapore retail magnate Tang Wee Sung was sentenced to one day in jail for agreeing to buy a kidney illegally. He subsequently received a kidney from the body of a murderer who had been executed. Though that is legal in Singapore, I find it more dubious ethically than buying a kidney since it creates an incentive for convicting and executing those accused of capital crimes. Now, Singapore has legalized payments to organ donors. Officially, these payments may only reimburse a donor’s costs. Payment of an amount that would constitute an “undue inducement” remains prohibited, but the law is vague as to what an “undue inducement” might be.
Both of these developments raise, once again, the question of whether selling organs should be a crime at all. In the United States alone, 100,000 people seek an organ transplant each year, but only 23,000 are successful. Some 6,000 people die before receiving an organ. In New York, patients wait an average of nine years to receive a kidney. At the same time, many poor people would be willing to sell a kidney for far less than Izhak Rosenbaum’s $160,000. Although buying and selling human organs is illegal almost everywhere, the World Health Organization estimates that worldwide about 10 percent of all kidneys transplanted are bought on the black market.
The most common objection to organ trading is that it exploits the poor. That view received support from a 2002 study of 350 Indians who illegally sold one of their kidneys. Most told the researchers that they were motivated by a desire to pay off their debts, but six years later, three-quarters of them were still in debt and said they regretted having sold their kidneys.
Some free-market advocates reject the view that the government should decide for individuals what body parts they can sell—hair, for instance, and in the United States, sperm and eggs—and what they cannot sell. When the television program Taboo covered the sale of body parts, it showed a slum dweller in Manila who sold his kidney so that he could buy a motorized tricycle taxi to provide income for his family. After the operation, the donor was shown driving around in his shiny new taxi, beaming happily. Should he have been prevented from making that choice? The program also showed unhappy sellers, but there are unhappy sellers in, say, the housing market as well.
To those who argue that legalizing organ sales would help the poor, Nancy Sheper-Hughes, founder of Organ Watch, pointedly replies: “Perhaps we should look for better ways of helping the destitute than dismantling them.” No doubt we should, but we don’t: our assistance to the poor is woefully inadequate and leaves more than a billion people living in extreme poverty.
In an ideal world, there would be no destitute people and there would be enough altruistic donors so that no one would die while waiting to receive a kidney. Zell Kravinsky, an American who gave a kidney to a stranger, points out that donating a kidney can save a life, while the risk of dying as a result of the donation is only 1 in 4,000. Hence, not donating a kidney, he says, means valuing your own life at 4,000 times that of a stranger, a ratio he describes as “obscene.” But most of us still have two kidneys, and the need for more kidneys persists, along with the poverty of those we do not help.
We must make policies for the real world, not an ideal one. Could a legal market in kidneys be regulated to ensure that sellers were fully informed about what they were doing, including the risks to their health? Would the demand for kidneys then be met? Would this produce an acceptable outcome for the sellers? To seek an answer, we can turn to a country that we do not usually think of as a leader in either market deregulation or social experimentation: Iran. Since 1988, Iran has had a government-funded, regulated system for purchasing kidneys. A charitable association of patients arranges transactions for a set price, and no one except sellers profit from it. According to a study published in 2006 by Iranian kidney specialists, the scheme has eliminated the waiting list for kidneys in that country without giving rise to ethical problems. A 2006 BBC television program showed many potential donors turned away because they did not meet strict age criteria and others who were required to visit a psychologist. A more systematic study of the Iranian system is still needed. Meanwhile, developments in Singapore will be interesting to watch.
Peter Singer is professor of bioethics at Princeton University and Laureate Professor at the University of Melbourne. His most recent book is The Life You Can Save: Acting Now to End World Poverty (Random House, 2009).
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