FOCUS | March 7, 2008 | PUBLIC HEALTH: The Organ Trade: Right or Wrong?

In the late 1700s, before the invention of the porcelain denture, wealthy Europeans flocked to surgeons who would replace missing or damaged teeth with fresh ones bought from another person. The sellers were typically the poorest of the poor and, for this reason and others, the practice, though fashionable, faced criticism. The 18th century caricaturist Thomas Rowlandson expressed his disdain in his famous drawing, “Transplanting of Teeth,” which depicts a soot-covered chimney sweep sitting amid a gaggle of bewigged surgeons and patients. One surgeon is removing the poor sweep’s tooth while, nearby, a ruddy-cheeked woman impatiently awaits its delivery into her vacant tooth socket.

Courtesy Wellcome Library, London

The English caricaturist Thomas Rowlandson shows healthy teeth being extracted from the poor to create dentures for the wealthy.

Another critic, the great Prussian philosopher Immanuel Kant, was so repelled by the buying and selling of teeth that he declared it was under all circumstances immoral, said Samuel Kerstein at a recent symposium, “The Ethics of the Organ Bazaar.” Modern dentistry has rendered the market for human teeth obsolete and yet as participants at the symposium, which was held at HSPH on Feb. 8, made clear, the selling of human body parts is a booming global industry. Over the past decade, patients with end stage renal disease have been traveling to remote corners of the Earth, where they are fitted with new kidneys, a phenomenon dubbed “transplantation tourism.” Though the organs are usually bought, occasionally they have been taken without permission—essentially stolen—from the bodies of unwitting donors.

Human Boundaries
Last year, China declared the organ trade illegal, and India is seeking ways to stem the practice. Governments and non-governmental organizations have been holding meetings with increasing frequency to discuss whether to curb if not outright ban the international sale of kidneys and other organs. The symposium, which was organized by Daniel Wikler, was intended to provide a glimpse of the dilemmas facing this burgeoning movement.

As Wikler, the Mary B. Saltonstall professor of population ethics at HSPH, made clear in his opening remarks, while transplantation tourism is being driven by huge demand—over a million people have end stage renal disease—it is forcing a transformation of what it means to be human.

“Everyone’s body suddenly contains something of enormous value that might be taken from them for money,” he said. The most impoverished person suddenly became “someone carrying around gem stones.” Though we admire those who offer their precious organs for free, we tend, like Kant, to condemn those who sell them for profit.

Like the chimney sweep, these sellers sit at the center of a swirl, in this case of negative public opinion. “Being perceived merely as a commodity can harm you through stigma, social exclusion, shame, injury to self-respect, neglect, violence,” said Nir Eyal, HMS instructor in social medicine. And the censure can radiate outwards, affecting family members, in some cases jeopardizing their ability to get jobs. “The consequences of donation for people universally are loss of health and income and stigmatization,” said Luc Noel, of the World Health Organization.

One of the key questions asked at the symposium was, Is moral repugnance enough to ban the sale of organs? “There’s a great balancing act here to be done between the obvious unseemliness of the whole thing on the one hand and the fact that for the people who get these organs it can mean the difference between dialysis and no dialysis. For many it’s life and death,” said Wikler.

The Morality of Repugnance
The symposium, which was organized into two halves, presented its own balancing act. The first half outlined the pressing realities of the organ trade and described efforts to curb it. Noel detailed how transplantation tourism is expanding across the globe, taking advantage of the most destitute of people, such as those affected by the recent tsunami. Francis Delmonico, an HMS clinical professor of surgery at Massachusetts General Hospital, described how in one slum in the Philippines more than 3,000 people sold one of their kidneys. The plight of this so-called “Kidneyville” and other hard-hit areas will be on the agenda at a summit meeting, organized by Delmonico, to be held in May in Istanbul.

“Everyone’s body suddenly contains something of enormous value that might be taken from them for money.”

In the second half, speakers presented the ethical arguments for banning or allowing the organ trade, a discussion that occasionally veered to the esoteric. Taking as a general point of departure Kant’s dictum that selling organs is an intrinsically immoral act—and arguing specifically against the claim by Harvard economist Alvin Roth that some markets like the organ trade may be deemed impermissible because people find them repugnant—Julio Elias, an economist at the State University of New York at Buffalo, argued that moral repugnance is a variable that can change and can even be manipulated. “We know repugnance will shift—for example, if you or a relative are on the waiting list,” he said.

Eyal argued that whether the organ trade is repugnant depends, in large part, on the eye of the beholder. “Because we perceive trade in kidneys as incompatible with dignity, a state that carries out trade may causally reinforce the dehumanizing perception,” he said.

Kerstein concurred: “Whether selling organs is morally wrong depends in part on the cultural and historical context.” To illustrate his point, he showed Rowlandson’s print of the once-common practice of tooth transplantation.

From these rarefied positions, both he and Eyal drew real-world suggestions. “Should we ban organ trade?” Eyal asked. “Not necessarily. Trade can benefit buyer and seller a lot. You can do trade without being seen to do trade—without doing harm to dignity.” This could be accomplished through concealed payments, such as airline tickets.

Kerstein suggested that instead of opting in to organ donation when applying for a driver’s license, people be given the choice to opt out.

Organ donation “is a civic gesture that should be taught at school,” said Noel.
In a conversation after the symposium, Wikler, a former chief ethicist at WHO, made another suggestion for increasing the number of donated organs. Years ago, while serving on a committee to advise then Secretary of Health and Human Services Donna Shalala, he was struck by the disparity between the rate of organ donation at different transplantation centers around the country. “It really did seem to come down to having a dynamo of a director. There are some people who are fantastic at this,” he said. “How can we train people like that, give them incentives?”

—Misia Landau

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