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The point of control: can a regulated organ market be moral?

To the Editor: We read with interest the article by Farhat Moazam, Riffat Moazam Zaman, and Aamir M. Jafarey ("Conversations with Kidney Vendors in Pakistan: An Ethnographic Study," May-Jun 2009). Given that the authors have generically characterized our views as "parochial and cavalier" and "cynical and out of touch with reality," we feel compelled to respond.

Moazam and colleagues decline to mention that nearly every contemporary defender of a regulated market in organs scrupulously distinguishes the features of illegal, underground organ trafficking (which they describe) from the function of a regulated market, governed by moral principle. They characterize our arguments as either ignorant of or indifferent to the vast literature cataloging exploitation that has occurred in unregulated markets.

We are neither ignorant nor indifferent. Indeed, we have made substantive efforts to outline the causal connection between the organ shortage in wealthy countries and the flourishing of the underground organ trade in developing countries. By merely deploring the employment of the language of supply and demand, rather than the brute fact of this causal connection, Moazam et al. miss the point: exploitation of the vulnerable occurs in large part because of organ demand. A regulated system in the developed world may reduce (or eliminate) this demand from recipients of means, which in turn will reduce their economic support of organ trafficking in developing countries. While this will not eliminate organ trafficking, reducing the demand from the developed world will substantially raise the opportunity costs for indigenous middlemen, who as a group have not been moved by moral exhortation nor by the empty threat of inconsistently enforced (or deliberately unenforced) laws. Merely outlawing organ trafficking has not substantively attenuated its practice--a point reinforced both by this article and by a front-page story in Pakistan's Dawn from June 17, 2009. In the latter article, S. Adibul Hasan Rizvi, director of the Singh Institute of Urology and Transplantation in Karachi, is quoted as blaming "the government and law-enforcers who, [Rizvi] says, are conniving in making Pakistan a 'bazaar for cheap organs.'" Invoking the manifest failures of an unregulated system in Pakistan as an argument against a regulated system in Western Europe, the United States, and Canada is simply a non sequitur.

Moazam and colleagues reiterate the objection that a market in organs would come at the expense of altruistic donation, citing evidence of this in Iran, Israel, and Hong Kong. However, the regulated system of exchange in Iran came about because altruistic donation there failed to meet the demand for kidneys. Since the inception of this system of exchange twenty years ago, rates of uncompensated altruistic kidney donation from living related donors in Iran has remained at 11 to 13 percent of all organs donated. No attrition was observed. Furthermore, far from attenuating the growth of deceased donation-which was hampered in Iran by a lack of legislative recognition of brain death until 2000--the market in organs appears to have done the opposite: uncompensated deceased donation in Iran has increased tenfold since 2000 and now represents 15 percent of all procured organs. For reasons beyond the scope of this letter, the cases of Hong Kong and Israel are not nearly as straightforward as Moazam et al. represent. Regardless, an incomplete understanding of the social forces at work in these countries and cultures is not improved upon when methodologically sound ethnography is enveloped by the cant of ideologically predetermined conclusions.

The disparity between the supply of and demand for organs for transplantation will continue to buttress illegal organ trafficking in developing countries. We suggest, as a falsifiable hypothesis, that a regulated market in organs, undertaken in countries where safeguards and oversight are possible, is a plausible and morally defensible solution to the growing shortage of available organs.

Benjamin Hippen

Metrolina Nephrology Associates

Arthur Matas

University of Minnesota

Medical School

Moazam et al. reply:

We are pleased that Benjamin Hippen and Arthur Matas find our study methodologically sound, but we take exception to having the ethical arguments we make described as ideological "cant." There is substantial literature that casts empirical doubt on their confidence that allowing a system of organ sales in affluent countries would "reduce (or eliminate) the demand" for organs in the developing world, and their contention that regulated organ markets are "morally defensible." It is also a fallacy to believe that support for regulated markets for organs, based on the application of "the law of supply and demand" to the human body, is morally neutral. Proposals for "regulated markets" have been rejected on ethical and human rights grounds by international groups including the World Health Organization, the Council of Europe, The Asian Taskforce, and the Declaration of Istanbul. The last, developed in 2008 following meetings of medical professionals from leading organ transplantation organizations, bioethicists, and social scientists from around the world, has since been endorsed by eighty professional and governmental groups.

Our study shows that organ commerce, if tolerated, is destructive not only to patient-physician relationships but also to communities and societal ethos. Much has been learned through experience with the Iranian "regulated" system. It reveals not only that most organ vendors end up regretting their action, but also that the universal practice of patients making side-payments to obtain organs makes data about the rate of uncompensated donations inherently unreliable. Based on cumulative experience of the last two decades, there is a growing international consensus supporting prohibitions on organ sales; this has helped to make substantial inroads in reducing exploitation and abuse of the disadvantaged over the past decade in India, Pakistan, the Philippines, China, and elsewhere.

Quoting an article (an op-ed, not a "front-page story") from the newspaper Dawn, Matas and Hippen imply that "outlawing organ trafficking has not substantively attenuated its practice" in Pakistan. This is erroneous and misleading. Following passage of the Transplantation of Organs and Tissues Ordinance in 2007, which criminalized organ commerce in the country, data from the last eighteen months reveal a precipitous drop in the number of paid, unrelated kidney transplants. The article they quote is in fact a report about two specific hospitals in Pakistan found to have transplanted some "foreigners," and the insistence of Dr. Rizvi that the government must take action. Subsequent to the Dawn report, involved physicians from the named hospitals were summoned by the Supreme Court of Pakistan for an inquiry, and their practices were curtailed.

Poverty and socioeconomic disparities together with the desperation of patients to obtain kidneys are universal facts from which no country can now claim to be totally free. A scandal was recently unearthed in Brooklyn concerning Levy Izhak Rosenbaum, who called himself a "matchmaker" and brokered kidney sales between disadvantaged Israelis and affluent U.S. patients. The contention that some "developed" countries can provide safeguards and oversight against abuses related to organ sales is an insular point of view in which certain societies are perceived as disconnected islands existing isolated from, and untouched by, the realities of the rest of the world.

As health care professionals we, too, like Matas and Hippen, would like to see an increase in the number of patients receiving lifesaving transplants in both developed and developing countries. There are many initiatives being undertaken by Western countries to successfully increase the rates of voluntary, unpaid donation. These--and not regulated organ markets, with their inherent potential for exploitation of the vulnerable--are the "solutions" we should be moving toward, together.
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Author:Hippen, Benjamin; Matas, Arthur
Publication:The Hastings Center Report
Article Type:Letter to the editor
Geographic Code:1USA
Date:Nov 1, 2009
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