Body Values: The Case against Compensating for Transplant Organs

By Joralemon, Donald; Cox, Phil | The Hastings Center Report, January-February 2003 | Go to article overview

Body Values: The Case against Compensating for Transplant Organs


Joralemon, Donald, Cox, Phil, The Hastings Center Report


Proposals to compensate families for transplantable organs are gathering momentum. The proposals assume that the body is dissociable from the self and can be treated like property. But such a view is out of step with the rest of the culture.

The issue of financial compensation for organ donation is back on center stage as a result of legislative proposals in Congress and recommendations adopted by the American Medical Association, the United Network for Organ Sharing, and the American Society of Transplant Surgeons. Recently introduced Congressional bills relating to organ donation include two that would authorize tax credits for cadaveric donations. (1) Another bill, by some readings, would grant authority to the Secretary of Health and Human Services to override the prohibition against donor compensation in the National Organ Transplantation Act of 1984 so as to support pilot studies assessing the impact of moderate incentives (such as funeral benefits) on donor rates. (2)

The AMA's House of Delegates, at its Annual Meeting in June 2002, approved a recommendation from the organization's Council on Ethical and Judicial Affairs to encourage pilot studies of compensation for cadaveric donations. (3) The studies would have to include consultations with the population affected, their methods would have to pass scientific muster and be approved by oversight bodies, and they could use only "incentives of moderate value and at the lowest level that can be reasonably expected to increase organ donation." (4) The studies would involve only cadaveric donations, not donations from live donors, and they would not sidestep the present organ allocation system (as governed by UNOS). UNOS and ASTS quickly responded to the AMA action with supporting resolutions. (5)

The AMA proposal is based on a utilitarian ethic that is especially clear in the following passage: "Whether or not [incentives] are ethical depends upon the balance of benefits and harms that result from them." (6) A number of opponents agreed with past AMA President Lonnie Bristow when she said, "Please do not be seduced by the idea that the ends justify the means." (7) Rex Greene, an oncologist and a delegate to the AMA's House of Delegates from California, made a similar point when he said, "I would state that, no matter what the outcomes of these studies, it does not answer ethical questions." (8) Despite this strong opposition and in the face of a negative recommendation from the Reference Committee on Amendments to Constitution and Bylaws, the proposal passed.

These are only the most recent episodes in a two-decade-long discussion about whether organs and money can ethically be mixed. (9) The combination of legislative proposals and aggressive support from medical societies indicates that proponents of incentives believe the time is right to move the discussion from the pages of bioethics journals to the public arena. In doing so, they seek to inoculate their proposals against attack by claiming the moral high ground--they ostensibly seek only to advance the interests of desperate patients on waiting lists--and by minimizing the scope of the actions proposed--they propose "incentives," not payments, and only "pilot studies," not policy changes.

This paper responds to the most frequent criticisms of the present altruism-based system, and elaborates on the case for keeping the cash out of transplantation. The arguments canvassed here refer variously both to the cadaveric organ acquisition addressed by the AMA proposal and to the use of live donors--or vendors--which is known as "inter vivos" donation. Although the AMA proposal is only for cadaveric organ acquisition, a natural next step is to consider employing financial incentives for inter vivos donation.

The major alternative schemes proposed for organ acquisition range from fully voluntary to coercive, where "coercive" plans are those that attempt to encourage or force people to do something that they would not otherwise be inclined to do. …

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