Pecuniary and Non-Pecuniary Incentives to Increase the Rate of Organ Donations from the Living: A Moral Exploration

摘要

This paper examines the morality of schemes of payment to live donors/sellers of organs for transplantation. Following empirical and historical evidence, it is argued that consent to sell organs is substantially different from consent to ordinary business transactions and that legalization of exchanges of organs with financial benefits deviates significantly from the scope of liberal toleration and liberal conceptions of human rights. Although altruistic giving is commendable, it is immoral for society to benefit from them without conferring to the donors benefits such as health and nursing insurance for life. Non-alienable and non-fungible benefits of this kind are moral as incentives to organ donation/giving.Keywords: Organ transplantation, live donors, financial incentives/rewards, market in organs, altruistic donationINTRODUCTIONEvery day patients die while on a waiting list for kidney transplantation. Many cadaveric organs are not transplanted because of legal constraints or refusal of next of kin. Anybody who is committed to the value of life and human dignity cannot accept this grim situation.In many places of the world, money is offered to healthy people in exchange of a kidney donation. Similar schemes might be conceived regarding lobes of lung and liver. The probity of pecuniary payments, compensations, or incentives offered to such so-called donors is hotly debated worldwide.Language is a central player in the debate, as the very vocabulary used predetermines much of the discussion. Therefore, in this paper I use words such as “donors” and” sellers” as synonyms, and instead of the terms “compensation” and “payments” I speak about “pecuniary incentives”, having in mind all sorts of cash or liquid benefits that are offered to people in order to encourage them to give a kidney for the sake of transplantation in a needy patient.In the forthcoming discussion I will argue that fungible incentives are immoral and should be prohibited even if they are likely to increase the rate of transplantation and of health indexes overall; and that society should offer some non-fungible incentives or rewards to every live donor regardless of the motivation or whether he or she asks for it.This paper discusses kidneys, because kidney transplantations considerably outnumber other forms of organ transplantation. The discussion, however, is relevant to any form of transplantation that may originate from live donors. Kidney and liver lobes are two notable examples.AN OVERVIEW OF DIFFERENT MODES OF ORGAN PROCUREMENTOf all possible schemes of organ procurement, only one benefits from public consensus – altruistic donations (including presumed consent to donate altruistically) from either the living or the dead. Consensus prevails also with regard to two prohibitions – against non-consensual harvest from live donors and against consensual but harmful removal (e.g. a parent with a single kidney who wishes to donate to a child). Although the ethics of one scheme may depend on the morality of another, the academic literature on organ procurement tends to focus each time on a single scheme. For example, it seems reasonable to assume that the morality of markets in organs from the living may depend on whether non-consensual harvest from the dead is practiced first or whether all potentially eligible cadaveric kidneys have been used. But publications promoting markets in organs ignore this approach (e.g. Cherry1).Currently, there is some literature in favor of non-consensual harvest from the dead; more intense is the debate on markets for organs from the living. The two approaches aim at expanding the availability of organs, but they are not conceptually compatible with each other. Support for non-consensual harvest from the dead is based on utilitarian considerations, whereas libertarians typically respect every personal choice including the choice to sell one’s own kidney at “market price”. The utilitarians are committed to the fair promotion of p