"Gratuities" for donated organs: ethically indefensible.

With the encouragement of more than 90 medical bodies (the Declaration of Istanbul) and WHO—which in May, 2010, endorsed revised Guiding Principles that confi rm the ban on payment for organs from living or deceased donors—several of the countries that have been the most notorious organ bazaars, including Egypt, Pakistan, China, and the Philippines, have recently outlawed organ sales and taken steps to prevent traffi cking of organs to transplant tourists. Yet the risk to people who are poor remains, as proponents of markets for organs seek to circumvent or reverse the prohibitions. For example, at the end of June, the Minister of Health in the new Philippine Government expressed his opposition to the ban imposed there 2 years ago on foreigners receiving transplants from Filipinos, and his intention to allow organ donors to be compensated by a “gratuity package” as large as US$3200. The Minister has joined several US advocates of regulated organ markets to sponsor an international forum on rewarded organ donation, in November in Manila. Yet the ethical arguments raised by those who favour fi nancial incentives for organ donation have been repeatedly—and rightly—rejected by WHO because they are unpersuasive and would worsen the plight of patients awaiting transplants. Drawing on the principle of benefi cience, proponents of organ markets claim that sales will increase the availability of desperately needed organs and serve the good of all involved. Yet studies consistently show that vendors are not likely to benefi t sustainably, and that any increase in purchased organs will be matched by a crowding-out of altruistic donations, resulting in a net reduction in transplants and in greater risks for recipients because sellers are more likely to withhold adverse information about their health history. Next, market proponents contend that allowing organ vending would respect the autonomy of individuals who are poor, augmenting (or at least not curtailing) the already limited options available to them. Invoking free choice might merely seem like armchair philosophy were it not for the documented poverty of organ vendors, which renders this embrace of autonomy more a cruel hoax. When people are choosing between selling their children and their kidneys to meet essential family needs or to temporarily escape crushing debt, coercion and exploitation—not autonomy—are the more apposite terms. Moreover, it seems that few among those who can exercise genuine choice would opt to sell, rather than to donate, an organ. Finally, market proponents invoke the principle of justice, arguing that if everyone else involved in transplant ation is paid, it is only fair that organ donors get their share. Yet what would be a fair share for providing the “gift of life”? Would this be fi xed by the value of life to the recipient? That is not how other participants, such as physicians and nurses, are paid; rather, they are compensated for their services. Or would the amount result from diff erential pricing in a global market, 9 Holm JD, Malete L. Nine problems that hinder partnerships in Africa. Chronicle Higher Education June 13, 2010. http://chronicle.com/article/ Nine-Problems-That-Hinder/65892 (accessed Aug 10, 2010). 10 WHO Regional Offi ce for Africa, Division of Health Systems and Services Development. Report of the internal workshop on primary health care and health systems: Brazzaville, 11–13 September 2007. Sept 11–13, 2007. http://www.afro.who.int/en/tanzania/tanzania-publications/cat_ view/1501-english/901-events/902-2008/925-international-conferenceon-primary-health-care-and-health-systems-in-africa/926-backgrounddocuments-.html (accessed Aug 10, 2010). 11 Volmink J, Dare L. Addressing inequalities in research capacity in Africa. BMJ 2005; 33: 705–56. 12 Sub-Saharan African Medical Schools Study. http://www.samss.org (accessed Nov 9, 2010). 13 QuigQuigley F. Walking together, walking far. Bloomington: Indiana University Press, 2009.