Welcome to the global market of commodities. Think corn, computers or cars -- wherever they are made, it is not in the United States. When demand outstrips supply, as is usually the case for a commodity, the usual method of distribution -- the most efficient one -- is price. When we whip out Visa for a television, we don't ask who made it, or whether they worked under environmental, fair-labor, or minimum wage-strictures.
The global market now embraces organs. Scan "transplant tourism" under Google to see the possibilities. One village in India is dubbed "transplant village" because so many residents have sold kidneys. Newspapers in the developing world advertise "willing donors." China sells the organs of executed prisoners to cash-toting tourists. In Israel, some insurers will pay for transplant operations done in China: it costs less than an operation in Israel. Thanks to the Internet and jets, the world is increasingly one market. The organ-market is not a black market; in the world of commodities, it's simply a global market.
And the rules of the market that govern who gets the best computers now govern life itself.
Ethicists recoil at this price-based distribution system. When the commodity is an organ, the market no longer seems the ideal arbiter, even in so ardently a capitalist nation as ours. The wealthiest among us can buy the most comfortable lives. But should the rich be able to buy life itself? By commoditizing organs, letting the market decide who gets the scarce ones, we are saying "yes."
In 1968 ethicists in the US crafted a system for the harvesting and distribution of organs that injects values, not money, into the mad scramble.
We have rules for harvesting. We encourage would-be donors to sign "in the event of" cards authorizing the donation of specific organs. Without express permission, physicians do not take organs. We don't take organs from prisoners or homeless people without families. We don't allow patient-customers to pay donors, or donors' families.
We have rules for state-based distribution, which rank would-be recipients by factors such as illness, and time on the waiting list. The federal Uniform Anatomical Gift Act rationalized the distribution of organs.
But demand outstrips supply. Each day about 14 people sign on to an organ waiting list. Depending on where they live and how ill they are, many face poor odds.
It is time to modify our rules, to inject some realeconomik into this system (analogous to the realpolitick we reluctantly injected into our diplomacy). Everybody on the waiting list is desperate. But with enough money a person can up his odds by taking a trip to China, or e-mailing that willing donor in Bosnia. For many people, the global market has rendered our ethically crafted system irrelevant.
Four states (Virginia, Idaho, Utah and South Dakota) have passed legislation to bolster the supply by changing the rules for donation. Half the other states are considering the legislation. (Rob Stein, Washington Post, April 4, 2007)
The new law would remove some barriers to donation.
First, even when people have signed "organ donation" cards, at the time of death relatives can, and often do, rescind that order. Even if the person, while living, agreed to donate his organs, a bereaved spouse or child can stop the transfer. The moribund patient who is waiting for the organ dies. The legislation would let the decedent's wishes prevail.
Second, the law would clarify the clash between two desires: the desire to donate organs, and the desire to eschew mechanical life support. A donor might need to be on support, briefly, to maintain the health of the organ. Yet when surgeons start to hook the donor up to a machine, the family objects. The donor dies without mechanical support. But a patient needing an organ also dies.
Objecting to this bill, some ethicists fear a slippery slope, where rabidly eager physicians trample over the wishes of patients and families -- a science fiction nightmare.
Yet the global market already distributes organs the way the market distributes computers. A commodity-based approach dooms people who are not wealthy.
This legislation won't stop the market. The disparity between supply and demand will persist. Transplant tourism will flourish. The bill, though, will shrink that disparity, by increasing the supply of organs in this country, thereby improving the odds of life for people who are not wealthy. Surely that is a pragmatic -- and ethical -- response.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.
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