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April 29, 2010

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Peter Laird, MD

Anna, great to have you back here at DSEN. Thank you for the informed posts on organ donation and organ trafficking. I had begun to think that everyone was falling in love with the Iranian system when in actuality, it simply a sign of their desperation. We need intelligent solutions based on evidence. Thank you for your reports, I look forward to seeing more in the future.

Anna Bennett Meinuk@aol.com

Thanks Peter : )

somerville

Through underprovision of dialysis in order to make more money for private dialysis providers or to save money for taxpayers, through refusal to adopt presumed consent laws for cadaver donation, through the manifold inefficiencies and irrationalities in the administration of organizations like hospital transplant committees and UNOS, and through the ban on voluntary organ sales, there is presently a world-wide holocaust being conducted by a healthy majority which understands nothing of renal failure against a vulnerable minority of people with endstage renal disease. The hideous experience of patients left to languish on dialysis, the extremely short lifespan of dialyzed patients, and the massive voluntary withdrawal rate from a dialysis treatment which 25% of patients eventually find worse than death are all phenomena which the healthy majority leaves entirely out of consideration in smugly and irrationally forbidding organ sales.

Those impressed with Nancy Scheper-Hughes might want to consider how empathetic and understanding some of her published statements about the plight of renal patients in need of a replacement organ are. In her article, "Rotten Trade," Jounral of Human Rights, vol. 2, p. 197 (2003) she regards the desperation of renal patients to save their lives by buying a kidney as part of the misfortune that in "the late or postmodern consumer-oriented context, the ancient prescription for virtue in suffering and grace in dying can only appear patently absurd." (p. 200) She seems unable to understand the preference of renal patients to purchase a replacement organ from a paid volunteer rather than to suffer and die as a desperate bid for survival, but instead haughtily dismisses it as nothing more than "a new form of commodity fetishism." (p. 198) Her only solution to deal with the increasing numbers of patients languishing on the waiting lists is to question "the right of infants and those over 70 to be on the transplant list." (p. 221) Of course this would do nothing to address the shortfall of organs in any meaningful way, but even apart from that, the callousness of a healthy person looking at the vulnerable minority of dying renal patients and recommending that the infants and those over 70 among them be slaughtered so that she can indulge her own moral preferences about what should and should not be sold is astonishing -- and is nothing any renal patient should endorse.

Anna Bennett

Henry (Stauffenville) - I was so ready for this conversation two weeks ago! Where were you?

Look, I get it. You as an individual have a very strong opinion on dialysis, transplant and kidney markets. I love the passion in your words. Attributing to Dr. Scheper-Hughes the "slaughtering" of infants and old people, now THAT is classic spin. You are just like her. Radical, and willing to go to extremes to make your point. Henry, I admire you for your erudition and your passion. But I also admire Dr. Scheper-Hughes for her "in your face" advocacy for the black market donors who are being taken advantage of - have you seen the slides of the nephrectomy scars on the mental patients in Brazil?

I not only endorse her, but I admire her. She is not disenfranchising me. She is taking a stand and shining a spotlight on abuses that are happening right here and right now. People from Moldovia are being flown into NYC to be paid donors. They are not receiving follow up medical care - their organs are being harvested and then they are being shipped back to their country. I bet they don't even get to see the Statue of Liberty on their trip. At least one of the Hospitals has views of Central Park.

When I have the time, I will be writing more about Dr. Scheper-Hughes. BTW: That is not her only solution - Did you see the Nephronline quote of the day? I cited it in my post!!! Or was your blood pressure up and were you already on your soapbox, leaning down to rattle the keyboard? She concedes to a controlled study for compensating donors. That is a good start for a mediation. But this is just a small part of the sub economies that people living with CKD5 have spawned (as opposed to simply dying pre 1962).

I've only written a small amount about Transplant Tourism. I wish someone who purchased a kidney abroad would come forward and speak about their ensuing relationship with their donors. Some remain attached, and send a yearly "gift" to the person that they purchased the kidney from (Illegal, but very sweet - ok, the yearly honorarium not illegal. The initial purchase - Illegal). Others like "Bambi" the woman who blogged her whole journey - simply slipped the husband a bit of extra cash, left the young Pakistani mother at the hospital, flew to London to soak off the NHS for free follow up care and is now back in Beverly Hills.

Henry, you and I are just different. I can't appreciate the desperation that would cause someone to enter into the black market world of organ trafficking. This is a sad, sobering topic for me and frankly knowing that Dr. Scheper-Hughes is out there, I'll leave it to her. I'll write the occasional post about it and will look forward to your dissenting view.

But there is so much to advocate for - a very small percentage of rich people (super rich compared to their donors) can afford to take part in the black market. The majority are tied to a chair, probably receiving suboptimal dialysis. I wish I could be their Dr. Nancy Sheper-Hughes. As for me, in my tiny little sphere of influence, I'll try. I want better dialysis available for anyone who needs it. This is "Dialysis from the Sharp end of the Needle" after all.

Zach

"I wish someone who purchased a kidney abroad would come forward and speak about their ensuing relationship with their donors."

Well Somerville-Stauffenberg, we're waiting.
Salamat Po.
:)

somerville

Obviously, the situation resulting from a sucessful renal purchase and transplant from a willing donor represents an infinitely superior result for human happiness to what would have happened had the transaction been forbidden. The donor gets to exercise an enhanced autonomy to combat his poverty, and he receives money with which he can rescue himself and his family from a poverty which, in the Third World, is often itself ultimately lethal. The recipient avoids death by enjoying a triple life expectancy from what he would have had by continuing with the living death of dialysis. If the transaction had been forbidden, the result would have been one unnecessary death and one unnecessary continuation of human poverty. Scientifically-educated people should adopt a positivistic perspective and decide whether paid organ donation should be permitted based on the objective, measurably superior outcome in actual human happiness which arises from allowing sales to occur. In contrast, it is humanists without scientific training, like the anthropologist Scheper-Hughes, who irrationally promote unncessary deaths among renal patients and unnecessary poverty among Third World volunteers on the basis of breathless emoting and subjective intuition about some 'sacredness' of the body (I guess all surgery should be forbidden then), about 'post-millenial consumer fetishism' (as though nothing could motivate someone with collapsed veins and lack of access for dialysis to buy a kidney other than rank consumerism), and false comparisons of economic exploitation of the Third Third world by wealthy entrepreneurs acting out of pure monetary greed with a desperate bid for life among utterly helpless renal patienst on the verge of death, negotiating from a position of extreme disadvantage against kidney sellers who can always live without the money. Scheper-Hughes has built her career with regard to organ sales on images and intuition rather than on solid medical information (she falsely claims that the majority of Third World donors are women, since this fits so well into the current chic images of discrimination, when in fact the whole underground kidney trade knows that male kidneys make better grafts and act upon that), and argues with no firm grounding in law or philosophy, but only with very, very much softer 'sciences,' like anthropology, in her intellectual armory.

Many contracts used to be forbidden on the grounds that they were immoral for violating some vague 'sacredness,' such as contracts for saving lives at sea or for life insurance, but by the mid-19th century the world had grown out of this irrational logic of intution and instead accepted, correctly, that everything which serves human good should be allowed in contract. The only basis on which an attack on the organ trade can be based would be if it were demonstrably unacceptably dangerous, so that the risk of death or serious injury to the donor were much greater than the risk of death or serious injury to the dying renal patient, so the trade would not serve the net human good. This same danger, of course, would logically require all renal donation to be forbidden, since being paid with money or paid with affection does nothing to change the danger.

But this, as the scientifically illiterate articles of organ sales opponents universally ignore, is simply not true. The essential harmlessness of donating a kidney is scientific fact: just look at the two large-scale, long-term studies by I. Fehrman-Ekholm, et al, "Kidney Donors Live Longer," (1997) 64 Transplantation 976, and "No Evidence of Accelerated Loss of Kidney Function in Living Donors," (2003) 72 Transplantation 444. If you think somehow this harmlessness is magically transformed in the Third World, then look at the article by E. Santiago, et al, "Life Insurance Perspectives for the Living Kidney Donor," (1972) 14 Transplantation 131. Santiago's First World study showed that renal donation was essentially harmless to donors 38 years ago, which represented a context of medical science even less advanced than you would find in the Third World today. Fehrman-Eckholm above has shown that only minimal follow-up, mainly by GPs, is necessary for successful outcome for renal donors. In the Philippines, the average price a donor receives for selling a kidney is $4700, and the average cost of a half-hour appointment with a nephrologist there is $10, so if a donor does not receive adequate follow-up, that is his own choice, not some necessity imposed on him by an exploitative sale. So the entire notion of some dire medical injury to renal donors is pure nonsense emerging from the pens of scientifically illiterate authors whose only serious training is in the enthusiasms of political correctness.

Even though there is of course some danger, though small, in selling a kidney, this is much smaller than the danger of participation in countless activities, mainly by poor people, which is considered perfectly legal and moral throughout the world, such as skydiving, police service, fire service, military service, coal mining, deep sea diving, forestry, boxing, motorcycle racing, daredevil exhibitions, etc. So the argument against organ sales must depend on some hysterical, immature, irrational response to vague intuitions about the horrendousness of instrumentalizing the sacredness of the body (such as everyone needing a leg amputation routinely does -- sacrificing a part of his flesh for the benefit of his wider life purposes), and there is no reason for anyone above the level of that sort of 'thinking' to endorse the unnecessary murder of renal patients by denying them what is in many cases their last hope of survival.

Peter Laird, MD

Dear Somerville, you are quoting data from health, and highly selected developed nations. The data on third world vendors is pitiful. They do NOT escape from poverty and their earning potential for future incomes falls. They have a very high rate of depression and the situation is not anywhere near as rosy for the oppressed people economically forced to sell kidneys. Unfortunately, there situation does not improve. That is why it is unethical to coerce these people with our colonial mentality.

Anna Bennett

Ok Henry, you buried me in academia. Which is very easy nowadays - even though I only have three classes for the summer, my eyes are usually glazed over before I even get to my own personal reading.

I was originally thinking that you are writing from an idealistic world. Maybe more of a theoretic point of view. Great to debate over a glass of wine. But in the reality of today's health care system - how could it ever be administered ethically? We can't even dose EPO properly.

When you wrote: "scientifically-educated people should adopt a positivistic perspective and decide whether paid organ donation should be permitted based on the objective, measurably superior outcome in actual human happiness which arises from allowing sales to occur."

In a Utopian world, with no abuses - I'd ask why not? But we live in a far from perfect world.

Why can't we start where there is no conflict by making sure that altruistic donors TODAY are taken care of. Life long medical insurance. No medical bills from the donation. Paid time off from work for recovery. These are not a given here in the United States. Donors need the basics. Will they get those benefits in your utopian organ market?

Why not transplant hepatitis C infected UNOS donors to Hep C infected recipients?

Why not encouraged paired donations?

All of these are solutions that would free up many many kidneys, and there is NO moral or ethical question about it. We already have the infrastructure to administer the programs, we just need to do it.

My observation of Dr. Scheper-Hughes was that she did NOT say that women were a disproportionate number of trafficked or coerced donors (former Soviet States and Brazil being the examples from the night of her presentation at KUFA) - far from it, I saw pictures of men, interviews with men, as a matter of fact, I kinda got the vibe from Dr. S-H that it was all about men. She even struck up a bizarre friendship with a charismatic organ trafficker now in prison - she even commented about his charisma - I did not view her as having a feminist tilt at all.

somerville

Of course I agree with all your suggestions, Anna, as to the minor and non-controversial improvements which can be made to increase the supply of organs for transplant, but the focus has to be on drastic innovations necessary to save large numbers of lives.

You should also read the article by Scheper-Hughes, "Rotten Trade," which I fully referenced above in an earlier post, since on p. 200 of that article she does indeed say that organs come predominantly from women to men, just the way political correctness requires. I find her assertion here ironic, since every single example of a person selling a kidney she mentions in her article involves male vendors.

Peter, you seem to have ignored in your reply my reasoning surrounding my reference to the Santiago article from 1972, when the technology of even that primitive period could extract a kidney from a renal donor with no loss of life expectancy. Surely medical technology in the Third World today is no worse than that of the First World so many years ago. The point is moot in any case, since people enter professions out of poverty all over the world all the time which involve them in a statistical certainty of having a lower life expectancy, such as police service, fire service, active military duty, coal mining, etc., and yet these choices are perfectly legal and moral everywhere. Further, if paid donation is so hopelessly harmful in the Third World, why should voluntary donation be any less harmful and any less immoral? "First do no harm" is a foundational principle of medical ethics everywhere, so why do transplant physicians extract organs for altruistic donations in the Third World? Shouldn't the Istanbul Declaration, binding the nations of the world to stop the organ trade, also forbid altruistic organ donations in the Third World as too risky, since they have a net negative utility? Also, how should we measure medical utility: if we can take a pair of patients and extend the lifespan of one by 20 years by giving him a kidney and reduce the lifespan of the other by 5 years by removing a purchased kidney from him, is that a moral gain of 15 life-years in human good or something immoral, given that in the first case there is a net gain in human life and happiness among the pair of people involved in the exchange, especially since the seller announced his preference for the money over the risk of diminished life expectancy? Look at the recent House of Lords decision in Re A (2001), in which conjoined twins sharing a brain were separated so that one twin could live a more nearly normal life at the cost of the certain death of the other twin. Was this immoral exploitation, especially since the murdered twin was an infant and incapable of consent? If this is permitted, isnt' the voluntary sale of a surplus organ like a kidney for a payment which the donor accepts infinitely less morally questionable than what the House of Lords has affirmed is acceptable? Before we start advocating killing dying renal patients by forbidding organ purchases, we should make sure the balance of the reasoning demanding this approach is absolutely clear and not as complex as I have shown it to be.

Since, as Santiago demonstrated, even with the technology of 1972 the life expectancy of renal donors did not decline, I am not sure why you are so sure that the health of Third World donors must suddenly collapse so that they lose their working capacity. I am sure you are familiar with the way nephrons expand their functional capacity to compensate for the loss of one kidney. Since renal donors now have an extra $4700 to apply to purchase the services of an average Third World physician at around $10 per half hour visit, if they have some surgical complication, taking care of it should not be a problem. The additional money from the renal sale should provide improved access to medical care which should in theory make the kidney vendor healthier than the average person in the Third World. Also, a team of French physicians (source available on request) studied the claims of injury to Third World kidney donors and found them groundless. Scheper-Hughes in her "Rotten Trade" article found that most of the donors she had interviewed were eager to make some more money by selling another body part, if possible, so if their experience was so bad, why would they have that view? If the donors misspend their money and thus do not escape poverty, that is not the fault of the organ market.

Are donors really "forced" to sell a kidney or does giving them an additional option to combat their poverty by allowing them to sell a kidney not in fact empower them by enhancing the scope of their autonomy? If a corporation falls on hard times and has to sell its assets at a low price to pay off debtors, those who purchase these assets are not said to "coerce" the sale, since they had no control over the failure of the company. Similarly, if a poverty for which the kidney purchaser has absolutely no responsibility induces a Third World resident to sell a kidney, there is no coercion, because coercion implies that the initial constraint is created by the person who benefits from the sale.

As long as we are talking about the foundational question of what it is moral to buy and sell, why not become more imaginative and dig deeper? We could just as easily say, for example, that it is a case of outrageous exploitation and selfishness for someone with a surplus kidney to refuse to give it for free to someone else who will die without it, and instead to have the unmitigated gall to demand a price for it. This could have been the natural, intuitive response of most people if our society had developed with a greater emphasis on solidarity rather than individuality, but at this ultimate philosophical level of reasoning, we have no reason to start killing desperate renal patients by denying organ sales on the basis of the highly arbitrary way our philosophically unexamined cultural intutions just happen to have evolved. In some legal systems there is a duty to rescue, so that by-standers who refuse to jump into a pond to rescue a drowning person can be punished as criminals. In such systems, it would be perfectly consistent to require everyone with a surplus kidney to give it for free to everyone lacking both kidneys. In the common law world there has never been a legal duty to rescue, but that is just a historical contingency of the common law system, not a universal moral principle that justifies forbidding organ sales.

somerville

I post this as an addendum to my previous comment, for which I did not cite two sources. The point that those who sell a kidney typically experience such negative consequences from this choice that their free will in electing to make this trade must be forbidden by law is refuted by evidence provided by Scheper-Hughes herself in her "Rotten Trade" article, p. 202. There she reports from her field work that: "In the extensive shantytown of Banion Lupa, Manila ... the majority of young men are willing, even anxious, to sell a kidney and they express few regrets afterwards." Since it is impossible to imagine that this arch-enemy of the organ trade would have failed to notice significant disappointment with the results of kidney sales among the population of Third World vendors she surveyed, the assertion that such sales are significantly damaging can no longer be seriously maintained.

The assessment by a majority of French physicians studying the organ trade that the physical problems it supposedly causes only in the Third World are mythical is mentioned in the book by Sir Peter Morris, 'Transplants,' Council of Europe Publishing, 2003, p. 166.

What we can at least agree on as the result of this debate is that the morality of organ sales is a complex and subtle philosophical, social, and medical issue. If we are in fact in error in allowing organ sales, then we permit people voluntarily to make contracts which are harmful to them, such as happens a million times a day on the stock market. But here the mistake in allowing these contracts to proceed would be more serious, since physical harm could result, such as happens thousands of times a year when patients opt for cosmetic surgery and the risk of injury materializes.

But on the other hand, if we are in error in forbidding organ sales, then according to current United Nations estimates we would needlessly kill 10,000 renal patients a year by preventing them from purchasing an organ for transplant after they have reached the point of medical desperation which drives patients to pay the exhorbitant brokers' fees to obtain one. Since forbidding the organ trade and thus causing a mass murder of this scope as a result of legal policy would be an infinitely worse outcome than mistakenly allowing organ trades to go ahead and thus allowing people to make contracts in which the non-lethal injury to their health exceeded their perception of the financial benefits to be received, the default position has to be to allow the organ trade to proceed.

Anna Bennett

Aggghh. Henry - THANKS - I just spent two hours researching what Dr. Scheper-Hughes has written. (given ANY excuse, I will procrastinate). I owe her an e-mail and she has agreed to an interview for DSEN. Do you have any questions for her before I reach out?

Obviously, you are well educated and PRO organ market. She is firmly ANTI organ market, equally well educated, radical Medical Anthropologist with working native kidneys. I admire her workand even though "Vincit Semper Veritas" - everything is relative. I am willing to be the middle-person in this and I will pose your questions, should you desire.

In my opinion, this is a conversation that we will have for years. Our society is nowhere near implementing an organ market. I know, you and Sally Satel want to do something about that - but sadly, I am the voice of reason who will disappoint you both. The American Health Care System is in crisis and CKD is LOW on their radar - especially when the American government can't be bothered to even prosecute the current black market. A blatantly egregious error IMHO.

I'll leave Peter to the moral issues of Organ Markets - morality has never been one of my strong points. I will always defer to those on higher ground.

Now for a new subject - I am about to write about fistulas (my has failed catastrophically - good that I am currently transplanted). Are you up to debate fistula v. perm cath? That'll be my next topic.

Peter Laird, MD

The moral issues are well documented even by Dr. Sally Satel who readily admits that cash payments may offer too perverse and incentive to people that would be motivated by quick cash for kidneys. That is the entire basis for her in kind rewards of lifetime medical, etc. Even the advocates understand that issue. Otherwise, I think DSEN has made very clear arguments against an organ market with 2/3 arguing from the point of having had renal transplants.

somerville

With respect to Peter's comment, it is necessary to dig down to philosophical fundamentals when we determine what choices society should allow individuals to make and which it should forbid them to make 'for their own good' or for the sake of making them conform to the informal intuitions of the healthy majority, who understand nothing of the reality of renal failure. The objection to organ sales is that people may make the wrong decision if they choose to sell a kidney. But any choice may prove wrong, so we must now ask why the decision to sell a kidney is especially challenged.

The error behind this reasoning comes from assuming that it is the human body which is so sacred that it can only be used in transactions if these are first 'purified' by being altruistic transactions rather than monetary ones. But in fact what has been recognized as ultimately sacred ever since the work of Kant in the late 18th century is human freedom, human autonomy, not the mindless lump of flesh which forms the substrate of that freedom. It is only a philosophical anachronism, a hold-over from the days of sacred saints' bones and relics, that regards the human body as more sacred than the human will and as morally entitled to make claims to restrict the interests and choices of the free will of the body's owner. A rule of the Jesuit Order forbids its members ever to strip naked because God has made their nakedness sacred, but this is clearly the antique reasoning of the prude and totally divorced from modern public reason, which holds that humans should be entitled to do whatever they perceive as furthering their own good with the agreement of those other humans they affect, rather than cowering in superstitious terror at the prospect of touching their bodies in a spot made sacred by some value system which cannot, in turn, objectively and positivistically explain its value to tangible human interests, such as health, life, and freedom.

It has been estimated at least in the West that donating a kidney is as dangerous as drving 16 miles a day to work over the course of an ordinary working career. If it is twice as dangerous as that in the Philippines, should American companies be forbidden by law from hiring any workers in their branch plants there who might have to drive farther than 8 miles to work? The point is that society allows as moral and legal all sorts of health risks which people judge to be to their ultimate utilitarian benefit, so the controversy over kidney sales must arise from deeper, less well-understood, and probably less rational roots.

Applying the modern philosophical perspective which puts respect for people as free over respect for people as flesh to the problem of organ sales, we can see that causing the utter extinguishment of the human body which sustains human freedom by denying a dying renal patient the option to purchase a replacement organ, for no other reason than to preserve from sale a part of another human body whose removal in no way destroys the material platform necessary to sustain the free will of another, and whose sale indeed fulfils the free will of another to sell, in fact profoundly denies respect for human freedom, which is generally recognized as the highest moral value of soceity ever since Kant. Indeed, the whole line of philosophers from Kant to Hegel, Schopenhauer, Sartre, and Heidegger have recognized respect for human autonomy as the key to morality.

To re-emphasize a point I earlier made, this is obviously a complex issue requiring medical, philosophical, and legal knowledge to argue fully, and it is likely that errors of analysis may creep into any position advanced. But since this is the case, we must obviously err on the side of life rather than on the side of slaughtering 10,000 innocent dialysis patients for some seriously disputed moral value allegedly superior to life.

I am thus dismayed at the utter inhumanity displayed by those writers on this subject who, with obviously very little technical knowledge of medicine, philosophy, or law, and with no understanding of the personal reality of dialysis, leap into print and with a shrill, murderous ignorance scream out for the mass murder of dying dialysis patients, and watch them suffer and die with the cold recommendation that they try to show a little dignity in suffering and grace and dying, just before these writers print off their screeds and return to their healthy lives.

Anyone should feel free to communicate my views to Scheper-Hughes.

somerville

Anna, your observation that the U.S. government, like many other jurisdictions, declines to enforce its laws against purchasing a kidney, is significant for both legal and moral reasons. Fortunately the law has built-in protections to keep its operation from becoming as viciously inhumane as the hysterical public often demands that it be, and one of these protections is the 'defense of necessity.' This defense allows anyone convicted of violating a statute to demonstrate that the harm that would have been done in obeying the law so far exceeds any material benefit that would have accrued from observing the law that the law should not be obeyed in that instance. If this demonstration is successful, the person charged is either declared not guilty of the crime or is declared guilty but excused from punishment, according to the jurisdiction. The typical case in which such defenses has been advanced is when an isolated mountaineer is lost in snowstorm and has to break into someone else's cabin to obtain shelter and nourishment. Although breaking, entering, and theft are all committed, there is no crime, because the defense of necessity operates, since the law recognizes that it is better for someone to live than that the doors, windows, and food supply of a cabin be preserved from damage or theft.

Obviously, since it is an infinitely better outcome for humanity, life, and human freedom if the voluntary choice of the organ purchaser and vendor is allowed to proceed, since a life is saved, human free choice is promoted, and the seller can be rescued from poverty, every jurisdiction with a defense of necessity knows that its anti-organ market statute would be struck down as soon as it attempted to enforce it. Since everyone coming up on that charge would have the same defense, the statute would become useless, and whatever deterrent value it now has to those unaware of the defense of necessity would be lost.

For those opposed to the organ market to succeed, they should press to have the defense of necessity repealed by statute in order to remove this ancient protection, available in English law since the days of Bacon, against the potentially murderous, extreme viciousness of the law. Though perhaps, since they would have to take this drastic step against the traditional humanity of the law to make their favorite statute operative, they might want to take a good look at themselves in the mirror first.

Anna Bennett

Henry, you shine when you write about the history and ethics of the law. I am never going to be opposed to a perfect world. I don't think I'll ever see one, but if I should wake up tomorrow in that perfect world, well, I'd be a happy camper. Until then, I'll continue to write about what I see today. Society and medicine have advanced since the days of Bacon (mmm... Bacon - sorry, I couldn't resist) but human nature has not advanced. Until we have a fair and just world, there will be abuse, coercion and exploitation - which is what is happening today in the black market of organ trafficking.

For now, I want to see exploitative organ traffickers behind bars. I want to see altruistic donors cared for, and I want to see my peers in CKD5 getting every currently legal avenue for optimal health open to them.

somerville

My initial statement urged the creation of a legal, well-regulated organ market, but most opponents of the present black market oppose a legal market as well, for the usual idiotic arguments which assume that the sacred intactness of human flesh is a superior value not only to human autonomy but even to life itself. However, to join with you in your realistic approach, I would note that since a society which neither understands nor cares about people dying of renal failure is also determined to do nothing to rescue them, you have to balance the thousands of deaths and the infinite human suffering caused by this government indifference against what you imaginine (though the sources I cite disprove) to be the social costs of buying kidneys in a poorly-regulated but still voluntary market. Unless you are prepared to murder 10,000 dying dialysis patients a year by closing the market because you think those deaths are less important than the morally superior goal of stopping a poorly-regulated but voluntary trade, then your views are irrational. It seems morally bankrupt to me to slaughter 10,000 people a year to prevent poor people from voluntarily making choices for money which may have negative but not lethal effects on their health. Unless you are prepared to kill 10,000 people a year because you think it should be illegal for poor people to take the safety risks of driving more than 16 miles a day to work over a working career, to join the military in wartime, to join the fire or police service, to work in a coal mine, or to become prize fighters, then your opposition to what you believe is the dangerous health choice of kidney sales is indefensible. Since all these activities listed are as or more dangerous than organ donation in the Third World, yet are universally recognized as legal and moral, your position simply makes no sense, and yet still you persist in it, even though in doing so you make common cause with the effort to commit mass murder against dying dialysis patients. I am really at a loss to comprehend what is going on.

I also have to wonder why you rushed into print in your original post to support this mass murder when you admit that, golly gee, like I don't really understand the moral issues involved, so I guess I'll just have to leave that to other folks to discuss. How can you advocate policies which will involve so many deaths without feeling the least duty of doing all the required research, moral, social, legal, and philosophical, to ensure that you are not in error in your analysis? This is the same question I have of those who, like Scheper-Hughes, are so profoundly ignorant of dialysis that they imagine that it can only be 'commodity fetishism' which drives people to buy a kidney; that kidney patients, many of them perhaps on the verge of death from lack of dialysis access, only resort to the black market because they want 'the best kidneys'; that her entirely uninformed belief that slaughtering infants and those over 70 living on dialysis by denying them access to transplants would make any real difference in the lethally long waiting lists for a transplant; or can be so blinded by her bias that she cannot draw the natural implications of her own fieldwork demonstrating that most Third World poor people who have donated a kidney are not only not crippled and disappointed, but eager to donate another organ, if only they could. You would think that a trained anthropologist would be sufficiently aware of the widespread cultural phenomenon of irrational hatred of the sick by the majority of healthy people in each society, which leads to them being regarded as cursed by the gods, so they must be banished from the community or killed, so that she would not fall victim to the same irrationality herself.

Throughout this discussion, I have never seen at any single point any sustained, logical, factually supported engagement with the extensive arguments I have presented, and yet all my opponents persist in their now vigorously attacked and still utterly undefended positions. One wonders if the motivation for these positions lies in darker sources than can be reached by rationality.

Anna Bennett

(I just said "HUH?" aloud)

You wrote:

"Throughout this discussion, I have never seen at any single point any sustained, logical, factually supported engagement with the extensive arguments I have presented, and yet all my opponents persist in their now vigorously attacked and still utterly undefended positions. One wonders if the motivation for these positions lies in darker sources than can be reached by rationality."

Henry, we are not in a courtroom. To me, our discussion is simply a few people who can't pee on their own sitting at a keyboard, opining to a minuscule audience of people who also don't pee on their own (and those who love them).

"now vigorously attacked and still utterly undefended"

I don't need to defend my position. It is my position. I own it. I don't feel attacked. I like reading your dissenting opinion. And your research is vigorous, I appreciate that - it sets the bar high. You make me extra vigilant for typos... but I keep it in perspective - really, what influence do any of us have? A state ratified organ market is well beyond any of us (and far beyond my government's current capability). You won't start one, and Peter and I won't stop one.

In my opinion, as far as impact - it could be legal organ markets or we could be discussing speed limits on the moon. Neither are going to happen in our lifetime.

What are we doing here? We are writing to each other and that aforementioned minuscule audience. If they actually click on the comments, we are forcing them to think about organs, organ procurement and their own lives. People will garner from each side of the coin, and then make their own choices - that is critical thinking at it's finest. Or they can just write us off as crackpots - whatever... I just hope we are entertaining if the latter - I like "entertaining crackpots". You can debunk Dr. Scheper - Hughes, and I can laud her. People can read about her and decide how they feel.

I'm too lazy to look for sources - aside from actually going to the presentation originally, and reading some of your citations. I have other fish to fry. I appreciate the time and energy that you put into your thoroughly researched and professionally presented opinions though. You do encourage me to think. But even with your citations and your expert opinions, I can't agree. I can't intellectualize myself over the hurdle of the potential for exploitation in any organ market, and that for me, is a deal breaker.

As far as winners or losers in this debate? We all won, because by whatever means - we are alive, with the time and energy to have this discussion.

Seriously, I look forward to future discussions with you Henry. We have plenty to disagree about, and I couldn't disagree with a more agreeable foil.

somerville

While I entirely agree with you, Anna, that the impact of our discussion here on real world renal policy will no doubt be minor, you cannot excuse your shouting encouragement to the lynch mob which is urging policies to slaughter 10,000 renal patients a year in order to preserve the 'infinitely higher value' of not allowing another 10,000 Third World residents voluntarily to risk injury for money by pointing out that your voice can hardly be heard! Especially when it comes to endorsing polices which demonstrably kill people, it is the most profound of all human duties to keep silent unless you are absolutely positive that your contribution, however small, to the discussion is 100% accurate in promoting the greater human good. You cannot just shrug, say aw shucks, and leave the morality of the issue to Peter, as you say. Individual guards at Auschwitz have been prosecuted for war crimes, even though their contribution to the tragedy was minimal.

Miriam Lippel Blum

Somerville,

While your arguments are passionate and well-researched, to compare people whose opinion differ from yours to Auschwitz guards is outrageous and totally inappropriate.

Anna Bennett

Henry, I will "awe shucks" you until the cows come home. It is fun, and your clearly academic view and dense writing style needs a bit of levity and fun (it lightens up the whole "Organ Market" subject - don't ya think?). I remember once, years ago, you told a joke in a post - it was GREAT.

I do not and I will not debate morality with you or anyone for that matter. If my morals are not clear through my everyday words and actions, then I have no morals. I do not need to explain my morals, they should be evident. I should not have to debate my morals, for they are my own - I do not project nor to I proselytize.

I have a schizophrenic who lives in my building. Every morning, as I am at the computer, he stands in the vestibule and screams obscenities at me through my closed and locked apartment door. Not a great way to start the day (for either of us) BUT, I know that he is mentally ill, I ignore his delusional ranting and I pity him.

Slaughter, lynch mob, Auschwitz (yeah - like ANYONE would trust me with a gun! HAH!)... those are words that are used to push buttons. I have no buttons to be pushed.

Henry, you want me to be silent unless I am sure that I am "....100% accurate in promoting the greater human good."

Now that is one loaded statement. Rest assured, I won't be silent. I like this little corner of the web. I like having my name and opinions out there when someone Googles "Anna Bennett, Dialysis". I am brave enough to pull back the curtain of anonymity and post my opinions. What about you Henry? Pull back your curtain of anonymity and jump in. Be brave with your real name attached to the comments that you make.

For the record, my sole beliefs, pertaining to the post that is now so far above all of these comments, are:

1.) Today's Black Market Organ Trade should be stopped. People are being exploited.

2.) Dr. Nancy Scheper-Hughes is a firebrand medical anthropologist who has made strides in exposing the horrendous exploitation in today's Black Market Organ Trade. I applaud her.

And with regard to the comments, I have refined some of my beliefs, based on your research Henry:

3.) I do not believe that I will live to see a legal organ market in the United States and I feel that it is fruitless to debate it ad nauseam. The energy for debate should be harnessed and used for optimizing and improving the systems that currently exist.

Henry, I am all for letting you have the last word on this. When I write next for DSEN, it will be about fistulas, and I know how you feel about them - just givin' you a heads up buddy!

Until then,

Anna

somerville

The discussion has clearly reached an impasse, primarily because no one has chosen to meet my detailed argumentation with anything more than blank repetitions of their starting positions. This is not how informative dialectic operates.

But the moral issue implicit in the discussion is more salient. Since all humans are doomed to die eventually, all murder has to be understood as subjecting people against their will to conditions which will shorten their lives. In the case of the organ market, if we allow sellers to make their trades, we fulfil rather than impose on their will, and all the scientific studies I have cited, even from 1972, demonstrate that this choice is either not life-shortening at all, or it merely risks a loss of life expectancy which is well within the range of risks which all societies find moral to allow people to make freely for financial gain. The old legal maxim, "Volenti non fit iniuria," or "to the volunteer there can be no injury," applies in this case, since there can be no 'murdering' of anyone who consents to a trade which he finds to his benefit. Murder requires not just killing, but also killing against the will of another, and murder is the greatest evil our society recognizes -- not, as you incorrectly assume, a theoretically exploitative market.

But at what price do we purchase the legal prohibition of what you believe is an exploitative market? Clearly, we buy it by committing the greatest evil possible, for statistics demonstrate that denying dialysis patients transplants greatly shortens their lives, and for those with failing vascular access this denial can nearly immediately kill them. Diabetics on dialysis aged 20 to 39 can even triple their life expectancy with a transplant. (G. Danovitch, Handbook of Kidney Transplantation, Philadelphia: Lippincott, 2001, p. 15) So the first criterion of murder is met by prohibiting the organ market.

But in opposition to the case of purportedly exploited renal vendors, in the case of prohibiting the market the second criterion of murder is also fulfilled, since we impose this curtailment of potential life expectancy on these people against their will; we compel them to die by our policy, rather than allowing them to take the risk or not, at their option, to donate an organ for money, which is a health and life expectancy risk significantly less dangerous than motorcycle racing, military service, coal mining, lumber work, etc.

Even if you measure the issue in purely utilitarian terms, the total amount of human life and happiness on Earth from allowing these trades to proceed, with 10,000 dialysis patients' lives saved every year, with 10,000 people restored to health and productivity from a life of suffering, and with 10,000 Filipinos now in possession of $4700 each in a country with no free public schools, with few social services, with a 25% unemployment rate, and with a per capita income of around $2500 a year, their lives are enriched as well, or at least so they say, according to Scheper-Hughes' own research which I quoted in an earlier post.

When you post a message on a controversial topic on a website which invites feedback from readers, it is implicit in your initial choice that you are prepared to discuss and defend your views, rather than just stubbornly persist in them while offering not a single fact or argument in their support. Your excuse seems to be that so few people will read this discussion that it hardly matters that you may be contributing to policies which will certainly kill people by your comments. But nothing vanishes in cyberspace, and with sophisticated search functions many of those who now prowl the world under the banner of 'Organs Watch' may well cite your views and use them to shriek that "Even renal patients think it is better for them to die rather than allow an unregulated market!!" True, the overall impact of your statements may be small, but since human life is infinitely valuable, and we have to multiply that value by 10,000 unnecessary deaths a year for the indeterminate future, then even if your contribution to those deaths is materially minimal, it still multiplies out to a morally highly significant evil. Frankly, your willingness to accept this evil without being able to offer here any reasons for that view makes me wonder why you are not as afraid of contributing to unnecessary deaths as I always assumed every moral being would be. That is why I still insist that unless you can clearly demonstrate in a public forum that your rational and factual reasons for forbidding the organ market actually outweigh the moral evil of killing 10,000 dying renal patients a year, you have no right to say things which contribute, even in small dimension, to the infinite evil of causing unnecessary human deaths. Have you ever considered that you owe it to the dialysis patients you may help kill by your recommendations to enter a public, rational debate in order to clarify your thoughts through the eristic arts to ensure that you have given these people every benefit of the doubt before leaping in to promote their death? Or perhaps you are, as you earlier suggested, just too 'lazy' to investigate the arguments for and against the death of so many renal patients before adding your voice to those who would condemn them without giving an adequate hearing to their case? Where human life is at stake, no one has a right to lazy opinions.

Zach

Of those 10,000 dying renal patients per year, what percentage would be approved by a transplant team to receive a kidney?

Is there a breakdown in their age groups?

Anna Bennett

"But nothing vanishes in cyberspace, and with sophisticated search functions many of those who now prowl the world under the banner of 'Organs Watch' may well cite your views and use them to shriek that "Even renal patients think it is better for them to die rather than allow an unregulated market!!"

Comeon Henry, now state my view correctly. I am a renal patient who is opposed to the current Exploitative Organ Black Market.

I not only encourage people to read my opinions, I freely share them. Did you see me in the New York Times? Google it. That's me, my picture, my voice and my words. I'm proud of them. If you feel I am a murderer, well, so be it. I have been tried and judged in your court.

I encourage you to do the same. You put up a great argument. Own your words and opinions. Sally Satel needs you.

I'll be more conscientious in my writing thanks to these comments.

My laziness is a time management issue. I just don't see this as a productive debate. The current Organ Market is wrong. A future state regulated organ market is not going to happen. I want to spend my time where I can make a difference.

somerville

Anna, my objection that your views could have a negative impact on peoples' lives and thus should be more carefully examined before being promulgated was initially countered by your assertion on May 24 that "our discussion is simply a few people ... opining to a miniscule audience of people." After I responded to that by pointing out that a small influence on a life and death matter can still be morally significant, you changed your facts and announced that your views have a huge public impact via the New York Times, etc. So which is it, "a few people ... opining to a miniscule audience" or lethal policy agendas being pushed in the New York Times?

I accept your concession that you will try in the future to be more careful before promoting policies which will certainly mean many deaths. But if you were pushing these views before a large audience, I would have thought that a decent respect for the lives of other people at stake would have caused you to pause and make your arguments as philosophically rigorous as possible before rushing into print.

somerville

Miriam, I am sure you realize that your rhetorical point against my arguments is a profound misrepresentation of what I was actually saying. I was not comparing everyone who opposed my views to the perpetrators of Auschwitz, but rather, making the very specific point that since even those who made a very small contribution to the Holocaust were still subject to prosecution as war criminals, Anna's defense that her comments promoting the death of renal patients were essentially innocent because of their minor contribution to that outcome was incorrect.

somerville

Hi Zack! Since the organ trade is a black market, I doubt that there exist any reliable data on the number of those purchasing organs on this market who could have been medically eligible for a transplant at home. The issue of medical eligibility is largely moot, however, given that the shortage of donor organs means that even many of those who are medical candidates for transplant die waiting. Also, the organ shortage even feeds is cruel logic into the notions of medical eligibility, since waiting lists are kept artificially short in order to give those waiting some hope, but at the cost of excluding people who could benefit from a transplant. The recent discovery that advanced age is in many cases not a barrier to successful transplant has revealed how arbitrary the determination of the list often is. The great variation in the percentage of dialysis patients advanced to the waiting list in various countries also attests to the arbitrary nature of this determination, and many illegitimately subjective factors have also been identified as motivating medical decisions to list people or not. Insurance coverage, family stability, subjective assessments of maturity, the patient's ability to comply with fluid restrictions which have nothing to do with the ability to comply with immunosuppressive pill taking, and other utterly ridiculous criteria which amount to grossly immoral and irrational reasons for deciding who lives with a transplant and who dies without one plague the legal organ allocation system, but a market avoids all this cruel idiocy. Thus the current 'moral' and legal organ allocation system is itself morally questionable, and this has to be factored into the assessment of any alternatives. A further immorality unique to the legal organ procurement system is the persistent question of what brain and cardiac death really mean and how they are to be assessed, and whether there is any sensation with the removal of organs from the nearly but perhaps not really dead type of 'cadaver' which is the only source for viable transplants. A further problem with the legal allocation system is that it increasingly relies on altruistic living donors, who may be subject to a familial, emotional coercion to surrender a kidney which is a trillion times worse than the pressures of Third World poverty. But in the kind of blinkered thinking which predominates among the organ trade opponents, none of these factors is properly weighed.

Opponents of the market often complain that only the wealthy can rescue themselves, but in this they forget that every person removed from the waiting list moves the rest up by one, so the rich can only benefit by helping the less fortunate ones remaining on the list, which fulfils John Rawls' famous 'difference principle,' which he views as the foundation of ethical distribution principles in society.

But don't get me started ... .

Bill Peckham

The problem with your position sommerville is it's reliance on strawmen. The point DSEN has made repeatedly is that you shouldn't conflate an organ market and a kidney market. That is what you are doing.

It's this conflating that is so frustrating because as you write, again and again and again, transplant is an excellent treatment for too little dialysis. A good kidney transplant cures too little dialysis. Of course readers of DSEN know that more dialysis also cures too little dialysis. You've never engaged that point.

Don't you think the analogous situation is prostitution? Some people may base their objection to legalizing prostitution on the body's sacredness (and maybe some people who object to a kidney market do too) but society's interest is in society, not your body. Society's interest is in manifesting the world people want to live in - when you allow the sale of kidneys you change the way our world works.

Maybe being able to sell a kidney wouldn't change people's willingness to donate livers/hearts/lungs postmortem, or maybe it would. Because that is an open question it is reasonable to call for a "controlled study".

Bill Peckham

Oh and the problem with those donor followup studies is that they are making the health comparisons to population averages. While the people in question, as organ donors, are part of a very select group. For a valid comparison you'd have to compare people who donated to people who were medically eligible to donate at the time but did not.

Emma

Just an excellent blog you have here. Its very information and enjoy reading it. I try to visit your blog about twice a week just to see what you have posted :) Keep it up. I was wondering if you can exchange links with me, my blog is http://dialysis-patient-care.blogspot.com, it will really help our Google PageRank and at the same time increase our visitors. I would love to share you stuff to my readers. I went ahead and added your blog to my blogroll, hope you can also do the same.

Sincerly,
Emma

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