Satel's review of Fox and Swazey's Observing Bioethics is telling

By Bill Peckham

Sally Satel has a review of Observing Bioethics by Renee C. Fox and Judith P. Swazey, posted on The New Republic's new website the Book. Beginning over 30 years ago Fox and Swazey have study bioethics, through an in depth study of organ transplantation and chronic dialysis first in in their seminal book the Courage to Fail and then in Spare Parts.

Satel's review, The Right (and Wrong) Answers, is striking in its dismissiveness of bioethics:

American bioethics was born out of a desire to be relevant.

Ah, no. Bioethics was born out of a desperate need. 

While bioethics has been around for as long as humans have been sentient, in the sense of how to treat the dead and dying, bioethics really came to the fore with the advent of chronic dialysis and the decisions faced and made by Belding Scribner, in the early '60s. This is thoroughly documented in Fox and Swazey's earlier books and informs their concerns about modern efforts to use bioethics for political advantage and co-opt the hardest cases to create culture war cause célèbres (see Schiavo, Terri). And one should remember that it is Fox and Swazwey's early work that  overlaps Satel's well developed interest in creating an organ market.

The underlying problem Satel has with Fox and Swazey's work is the "Gift Exchange" that Fox and Swazey first document in '70s. The Gift Exchange is as relevant today as it was then and then as now, it undercuts the supposed moral imperative of establishing remuneration for kidney's, something which Satel is wholly in favor (optimal dialysis also undercuts the supposed imperative, but Satel has never addressed that point). In her review Satel offers:

Though clearly fond of the bioethicist-physicians, bioethicist-philosophers, and bioethicist-legal scholars they interviewed, Fox and Swazey describe themselves as “critical of what we regard as the field's deficiencies and blind spots.” They identify these as the use of dumbed-down teaching formulae, an insensitivity to cultural differences, and the tendency of American bioethicists to emphasize “individual rights, and rationality” instead of “community, and common good,” which are the values that Fox and Swazey  favor.

Here is Satel's core libertarian beef with bioethics, the idea that when society's collective needs are weighed against an individual's right to act as they wish, the individual is not given more weight. 

As recently as the Monday before Christmas Satel wrote:

Sadly, the transplant establishment insists that sick people languish on dialysis for years or die waiting for a kidney. They fear, on one hand, that the patient might remunerate someone for saving his life and, on the other, that any donor in financial need can’t possibly make a rational decision about his own best interest.

The problem isn't with the transplant establishment or bioethics, which holds the myopic in check, the problem Satal has is with libertarianism's inability to make her case.

Comments

[Peter Laird, MD]

Bill, she is simply following suit with population based ethics as we have discussed in prior threads. Unfortunately, this is simply a sign of the changing ethics that in the long run shall place all chronic renal replacement patients at great risk when we compare our expenditures compared to the average patient.

http://www.billpeckham.com/from_the_sharp_end_of_the/2009/08/the-new-medical-ethics-population-based-outcomes.html

Over time, with pressure placed on the physicians to stay with in the average utilization when compared to their peers, with the outliers constantly counseled, the average drops dramatically. However, without a concomitant decrease in fixed expenditures of the various renal replacement therapies, this gap is likely to increase making the inevitable difficult decisions that are likely to come.

When these hard decisions are made, in my opinion, fellow CKD patient, Dr. Sally Satel is likely to be their champion on why it is needed. The doors of fiscal responsibility and social duty shall march forth as the solution by reducing and ending renal replacement therapies for those too expensive to continue. This is the inevitable end of their philosophy and ethics when the population over rides the ethical concerns of the individual.

[Lifepactx2]

Bill Peckham's point: Fox and Swasey's work precedes Sally Satel's insights into organ transplantation is gladly taken. Nowhere does she seem to be holding her scholarly qualifications higher or better grounded than theirs-, her angle to the theme is that of a patient who came through the system and is now empowered to call for change.
Also unfounded is his view of her pointing to a "moral imperative" when it comes to financial incentives in organ transplantation. All she is advocating for is to include as equal the option of incentives of a monetary value in the arsenal of upping the number of living donations.
Being successfully on dialysis as Bill has been for many more years than most patients allows him to view that treatment and future betterment's of it as an answer to transplants.
Sally Satel also contends that gains in transplants to a level that eliminates the backlog of wait-listed patients could be used to revert to an altruistic-only system.
In the end her critique of Fox & Swasey's latest book is not so much an expose of philosophical differences but a persistent effort on her side to move the discussion out of the theoretical realm and into an actionable mode.
The activist-patient, employed by a republican-leaning think tank saying: we can-we must-and now!

[Somerville]

Sally Satel is a dialysis patient and understands the reality. Fox and Swazey are just bioethicists, and have recently announced that they are leaving the field of dialysis bioethics to go home and sulk about the fact that dialysis patients are for some incomprehensible reason not willing to accept their professional wisdom and die as they should rather than buy their way of out a slow death on dialysis.

What bioethicists ignore is the fact that allowing patients to buy their way out of dialysis by purchasing a transplant from a volunteer benefits BOTH the individual and the community, according to John Rawls' famous 'difference' principle of justice. This is the case because the rich who can afford to buy an organ benefit the poor who can't afford to, because the poor move up one on the tansplant list for every rich person who inducts an extra kidney into the pool of organs available for transplant by a monetary inducement. It is a win-win outcome, with the poor organ donor gaining the money he demands for the sale; the organ recipient saving his life; and the whole population of the community becoming healthier. It is only irrational notions of the 'sacredness' of the body which prevent a rational, supervised, kidney market from being introduced.

[Bill Peckham]

Sommerville, long time no read - can't say I missed you though. Satel never was on dialysis she had a preemptive transplant.

As readers of DSEN know "'sacredness' of the body" has nothing to do with Peter's or my concern about creating an organ market for kidneys.

Concern about the donor is a factor and if the proponents of a kidney market advocated as hard for lifetime followup - study - of donor outcomes, their arguments would not seem so self centered.

[Somerville]

I still think the ultimate reason for objections to the voluntary sale of kidneys is some covert assumption that the sacredness of the body must not be violated, as though what was sacred about humans was not their moral autonomy but the fleshy substrate of that autonomy. I say this because the data simply don't support the theory that living donation is harmful, or that lack of medical follow-up for living donors is a serious problem. Look at the extensive studies by Ingela Fehrman-Ekholm, et al, "Kidney Donors Live Longer" (1997) 64 Transplantation 976 and Fehrman-Ekholm, et al, "No Evidence of Accelerated Loss of Kidney Function in Living Kidney Donors" (2001) 72 Transplantation 444. The donors followed more than 30 years in Fehrman-Ekholm's study had one medical follow-up two months after donation, and after that there were "no regular check-ups." Even if you assume that check-ups are required, in a Third-World country like the Philippines an appointment with a nephrologist costs about $10, so for the $4000 payment the donors there receive, follow-ups should be affordable.

But the logic of the objection collapses when we consider that in Kantian morality, which characterizes the basis of much Western thinking about morals, what we respect about other humans is their autonomous will, not their bodies. Thus if a person decides that for him, selling his kidney is worthwhile, we disrespect him and treat him immorally if we deny him that freedom. Motorcycle racing and other sports which our culture permits are more dangerous than donating a kidney, and these exercises of autonomy are much less important than the third-world donor rescuing himself from dire and perhaps lethal poverty by selling a kidney. So forbidding organ sales simply makes no sense, and thus it must rely on some covert, irrational, emotional aversion to the imagery of organ sales.

I suspect that a lot of the objection to kidney sales also represents the manifestation of an unexamined hatred and loathing for sick persons among the healthy majority, and this comes out strongly in the articles by the main opponent of organ sales, Nancy Scheper-Hughes, who has characterized the sale of kidneys are due solely to a "commodity fetishism" among wealthy dialysis patients who simply want the best organs rather than the cadaver organs they could otherwise easily access. (N. Scheper-Hughes, "Rotten Trade" (2003) 2 Journal of Human Rights 197, 198) She regrets that to dialysis patients on the verge of dying without a transplant, "the ancient prescription for virtue in suffering and grace in dying can only appear patently absurd." (Ibid., 200) There is no need for CKD5 patients to join forces with people like this.