Paid organ donation: the case against

Paid organ donation is an emotive subject in the transplant community. Part of the reason for this is that in many countries, including the UK, the notion of organ donation as a ‘gift’ is highly valued. The difference between a gift and a commodity is clearly understood and applies equally to living as well as deceased organ donation. In the UK, legislation prohibits commercial dealings in human material for transplantation (Human Tissue act 2004 (England and Northern Ireland)¹ and 2006 (Scotland)²).

In other countries such legal protection does not exist and in 2004 the World Health organization (WHo) urged members ‘to take measures to protect the poorest and vulnerable groups from transplant tourism and the sale of tissues and organs'.³ Paid donation and transplant tourism are inseparably intertwined. Further debate at a summit in 2008 by the Transplantation Society and the International Society of Nephrology led to the Declaration of Istanbul on Organ Trafficking and Transplant Tourism stating: ‘Organ trafficking and transplant tourism violate the principles of equity, justice and respect for human dignity and should be prohibited. Transplant commercialism targets impoverished and otherwise vulnerable donors leading to inequity and injustice'.⁴

To understand the issue of paid donation it is necessary to understand the drivers for it. There is a global shortage of organs available for transplantation. This gap between demand and supply has prompted many people in the west with organ failure to seek transplants overseas, often in developing countries.^5,6 Frequently these individuals do not ask questions about how that organ was obtained.⁷ The process is further fuelled by unscrupulous health professionals and brokers seeing the potential for financial gain and taking advantage of both the desperate recipient and the vulnerable seller. It is a sad indictment of the human condition that wherever there is a market, people will strive to find a profit margin even when this results in human exploitation.

This problem is often compounded by the lack of a suitable healthcare infrastructure to provide a viable transplant programme in these countries. This may be due both to economic limitations and to the inability to establish a deceased donor programme because of cultural, social and religious barriers. In such healthcare systems the focus then turns to living donation provided by unregulated private clinics.^6,7 In the west the spirit of the Hippocratic oath, primum non nocere or ‘first do no harm’ is embraced and the emphasis of care rests on protecting the interests of the donor. Paid donation does not support this interest. This shift in balance of responsibility to the paying recipient is disturbing and unethical.

To understand this fully let us look at the demographic of the donor. Donors are poor, with most living below the poverty line. Most are illiterate and in low-paid manual jobs, their sole reason for donating not borne of altruism but to pay off debt.^7,8 In Pakistan many individuals donate kidneys to release themselves from bonded slavery but have insufficient capital to make a new life and often return to debt (Rizvi, personal communication). We find it difficult to relate to concepts such as the entrapment represented by bonded slavery but how would our society view individuals in our own country driven to donate a kidney to pay off credit card debt, college fees or to satisfy a drug problem?

Sadly for the majority of donors, selling a kidney does not result in the significant economic benefit of which they dreamed. often it is associated with a decline in general health. Many fall back into debt, often compounded by the inability to work following donation due to ill health.⁸ Supporters of paid donation argue that a person should have the basic right to choose the fate of his or her organs. In the setting of paid donation, informed consent is often of dubious quality, with the risks of surgery often not being properly explained or understood. Furthermore, many individuals are pressured to donate by family members, with the outcome of any ‘balanced discussions’ about wishing to proceed with organ donation predetermined.⁸

In the UK, our society believes that we have a responsibility to protect individuals from harm. This principal applies even when harm may be self-inflicted. That is why we have motorcycle helmet and seatbelt laws. Why should this state-brokered paternalism be overturned to allow paid donation?

Perhaps the problem lies not in the principle of paid donation but in its organisation and regulation? Some individuals believe that it is possible to create an ethical market in live organs that would possess regulations and safeguards against exploitation of the seller and provide justice and equity to the recipient. Harris et al suggest a ‘monopsony’ where only one buyer exists for the products of several sellers. This purchaser would be responsible for ensuring equitable distribution of all organs purchased. The purchaser would also be responsible for tissue typing and screening for infection. In the UK they suggest the NHS would be an appropriate buyer.⁹ In China attempts have been made to implement some form of government control over the selling of organs. Here permission is given to certain hospitals by the provincial health authorities, allowing them to offer organ transplants to foreign visitors, with punishment to those institutions that offer the service illegally.^10,11

Such systems are proposed to attempt to remove the need for an underground and illegal black market in organs. We would argue that however paid donation is dressed up, the buying and selling of human organs and tissues can never be made ethical because it will always penalise the weakest. Financial gradients are inherently exploitative, with the poorest in society being the ones who come forward as sellers every time.¹² We would further argue that the system can never be adequately regulated to prevent exploitation of the poor and where financial motivation drives the decisions of the health professionals this will also undermine the care of the recipient, with financial gain taking precedence over patient care.