'Strip-mining' the Dead: When human organs are for sale.

Mr. Meilaender is professor of theology at Valparaiso University.

Eliminate suffering and expand the range of human choice. That sentence expresses the moral wisdom toward which our society is moving, and it is very minimal wisdom indeed. We can observe this minimalism at work especially well in the realm of bioethics, where we seem unable to find any guidance other than (1) relieve suffering and (2) promote self-determination. In accordance with such wisdom, we have forged ahead in the use of new technologies at the beginning of life and-with constantly increasing pressure for assisted suicide-at the end of it.

Less noticed-and perhaps not quite as significant-is the continuing pressure to increase the supply of organs for transplant. For the past quarter-century, transplantation technology has made rapid progress, though the "success rates" given for transplants may often conceal an enormous amount of suffering and frustration endured by those who accept a transplant as the price of possible survival. During this time, there has been continuing debate about what policies ought to govern the procurement of organs from the dead for transplant. Should we simply wait to see whether the dying person, or, after death, his family, decides to offer usable organs? Should we require, as some states now do, that medical caregivers request donation? Should we presume that organs for transplant may be salvaged from a corpse unless the deceased had explicitly rejected the possibility or the family rejects it later? Should we "buy" organs, using financial incentives to encourage people to sell what they had not thought or wanted to give? And, if we did use financial inducements, could one also sell organs such as kidneys even before death?

What we think about such questions depends on why we think some people might hesitate to give organs for transplant. If their refusal is a thoughtless act, perhaps we simply need greater public education and awareness to encourage more people to give. If their refusal is not just thoughtless but wrong, perhaps we should authorize medical professionals routinely to salvage cadaver organs for transplant. If their refusal is selfish or, at least, self-regarding, perhaps we should appeal to their self-regarding impulses with an offer of financial compensation.

Moreover, if it is, as we are so often told, a "tragedy" or a "catastrophe" that many die while waiting for an organ transplant, perhaps we need to be more daring in our public policy. That is the view of many who are in the transplant business and many who ponder transplantation as a public-policy issue. While these issues have been debated over the last several decades, our society has steadfastly refused to consider any form of payment for organs. "Giving" rather than "selling" has been the moral category governing organ procurement. Indeed, the National Organ Transplant Act of 1984 forbids "any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation, if the transfer affects interstate commerce."

It's not hard to understand our national reluctance to permit the buying and selling of human organs for transplant, for it expresses a repugnance that is deeply rooted in important moral sentiments. In part, the very idea of organ transplantation-which is, after all, in Leon Kass's striking phrase, "a noble form of cannibalism"-is unsettling. If we cannot always articulate clearly the reasons that it troubles us, the sentiment is nonetheless powerful. To view the body-even the newly or nearly dead body-as simply a useful collection of organs requires that we stifle within ourselves a fundamental human response. "We do not," C. S. Lewis once wrote, "look at trees either as Dryads or as beautiful objects while we cut them into beams; the first man who did so may have felt the price keenly, and the bleeding trees in Virgil and Spenser may be far-off echoes of that primeval sense of impiety." Far more powerful impulses must be overcome if we are to view the human form simply as a natural object available for our use. Perhaps we are right to view it as such when transplantation is truly lifesaving, but doing so exacts a cost. By insisting that organs must be given freely rather than bought and sold, we have tried to find a way to live with this cost. The "donated" organ-even separated from the body, objectified, and used-remains, in a sense, connected with the one who freely gave it, whose person we continue to respect. By contrast, buying and selling-even if it would provide more organs needed for transplant-would make of the body simply a natural object, at our disposal if the price is right.

Our repugnance is rooted also in the sense that some things are simply not for sale. As a medium of exchange, money makes possible advanced civilization, which depends on countless exchanges in which our interdependence is expressed. But if we allow ourselves to suppose that it is a universal medium of exchange, we are bound to lose our moral bearings. Although there is nothing degrading about buying and selling, since exchange binds us together and allows us to delight in the diversity of goods, commerce enhances human life only when that life itself is not also turned into a commodity. Hence, our society has over time had to make clear that certain things-ecclesiastical and public offices, criminal justice, human beings themselves-may not be bought and sold.

Discussing the limits to money as a medium of exchange, Michael Walzer recounts an instructive story from our own history. In 1863, during the Civil War, the Union enacted an Enrollment and Conscription Act, which was the first military draft at the national level in our history. But the act contained a provision that allowed any man whose name was drawn in the lottery to purchase an exemption by paying $300 for a substitute (which, in effect, also offered an incentive for others who wanted or needed $300, even at the risk of death). Anti-draft riots broke out in July 1863 after the first drawing of lots, and we have never since-at least in such overt, crass form-allowed citizens to buy their way out of military service. It is one of those things that should not be for sale, one instance in which money should not be allowed to serve as a medium of exchange, and so we block that exchange.

Similarly, we have decided to block exchanges for human organs, even though they do take place in some other countries. That decision has been under attack for some time. It has even been criticized by Thomas Peters, for example, as-behold here the degradation of our public moral discourse-"imposing" the value of altruistic donation on those who do not appreciate such a value or "coercing" families "to accept concepts foreign to them at a time of great personal loss." But the first real crack in the public-policy dike appeared in May of this year, when the state of Pennsylvania announced its intention to begin paying relatives of organ donors $300 toward funeral expenses of their deceased relative. (Clearly, $300 doesn't buy as much as it did in 1863.)

Pennsylvania's decision has been characterized by Charles Krauthammer as "strip-mining" the dead-and this in an essay defending the decision. It would, Krauthammer asserts, violate human dignity to permit the living to sell organs, but the newly dead body may be treated as a commodity if doing so promises "to alleviate the catastrophic shortage of donated organs." (Note, again, the language of catastrophe. Just as many workers might not have known their labor was "alienated" until Marxists told them, so we might not have thought it "catastrophic" that we die rather than strip-mine the human body in order to stay alive until transplant technology began to tell us it was.) Indeed, Krauthammer quite reasonably claims that the Pennsylvania program is, if anything, far too timid. If the idea is to get more organs for transplant, he suggests that not $300 but $3,000-paid directly to relatives rather than to funeral homes-might be more the ticket.

To the degree that he persuades us, however, we might well judge that Krauthammer himself has been too timid. Pennsylvania's plan for compensation continues to operate within the organ-donation system currently in place. It aims simply to provide a somewhat greater incentive for people to donate organs. What it will not affect is the reluctance-based in sound moral sentiment-of medical caregivers to ask dying people or their families to consider organ donation. If we really face a tragedy of catastrophic proportions, we might do better to allow organ-procurement firms seeking a profit to be the middleman. (After all, a human kidney was recently offered for sale on the Internet auction site eBay-and bidding reached $5.7 million before the company stopped it.) With profit to be made, firms would find ways to overcome our natural reluctance to ask others to strip-mine the dead body. We could deal not only with our reluctance to give organs but also with our reluctance to ask for them by letting the market do what it does best. That Krauthammer does not suggest this-even for organs from the dead-suggests to me that he finds more "dignity" than he thinks not only in still-living human beings but also in the newly dead body.

Or, again, if it is a catastrophe that we face, we might simply abandon the claim that it is always necessary to wait for death before procuring organs for transplant. For example, as Robert Arnold and Stuart Youngner have noted, a ventilator-dependent patient could request that life support be removed and that, eight or so hours before, he be taken to the operating room and anesthetized, to have his kidneys, liver, and pancreas taken out. Bleeding vessels could be tied off, and the patient's heart would stop only after the ventilator was removed later that day, well before the patient could die of renal, hepatic, or pancreatic failure. And, of course, if our moral wisdom is confined to relieving suffering and respecting autonomy, we may find ourselves very hard pressed to explain why this should not be done-especially in the face of a "catastrophic shortage" of organs.

One might ask, If my death is an evil, why not at least try to get some good for others out of it? If my corpse is no longer my person, as it surely is not, why not treat it as a commodity if doing so helps the living? Ah, but that corpse is my mortal remains. There is no way to think of my person apart from it and no way to gaze upon it without thinking of my person-which person is a whole web of human relations, not a thing or a commodity. A corpse is uncanny precisely because we cannot, without doing violence to our humanity, divorce it fully from the person. To treat those mortal remains with respect, to refuse to see them as merely in service of other goods, is our last chance to honor the "extraterritoriality" of each human life and to affirm that the human person is not simply a "part" of a human community. Perhaps, if we do so honor even the corpse, I or some others will not live as long as we might, but we will have taken at least a small step toward preserving the kind of society in which anyone might wish to live.

More than a quarter century ago, writing about "Attitudes toward the newly dead," William F. May called attention to one of the Grimm Brothers tales about a young man who is incapable of horror. He does not shrink back from a hanged man, and he attempts to play with a corpse. His behavior might seem childish, but it is in fact inhuman. And his father sends him away "to learn how to shudder"-that is, to become human. In our society-where we devote enormous energy and money to keeping human beings alive-perhaps we too, in the face of proposals to strip-mine the dead, should consider learning once again how to shudder.