The organ business: second thoughts on transplants

Christian Century, July 3, 2002 by Jennifer Girod

Raising the Dead: Organ Transplants, Ethics, and Society.

By Ronald Munson. Oxford University Press, 288 pp., $30.00.

ARE WE MORALLY obligated to extend every life that we have the technological or medical ability to extend? The claim that we are underlies Ronald Munson's book. He provides a fairly comprehensive survey of the ethical issues involved in organ transplantation in a lively style, relying on current, historical or fictional cases to illustrate many of the ethical and policy issues. He also integrates relevant medical and scientific information into the discussion.

Munson's background makes him the right person to write this book. He is a professor of philosophy of science and medicine at the University of Missouri-St. Louis, has served as a medical ethicist on a National Institutes of Health study and a human subjects review committee and has written three novels. Yet his book is not definitive. We need to think more broadly and deeply about some of the issues he raises.

Munson makes three major claims: that we ought to increase the organ supply, that donors and recipients should be protected from exploitation, and that telling stories about individuals is morally helpful in assessing the complex issues associated with transplantation. The logic that underlies his first claim is familiar and easy to understand. Organ transplantation saves lives, even though it is a complicated practice that leaves chronic disease in its wake even in the best of circumstances. Thousands of people die every year because of the scarcity of available organs. Thus, we have a "prima facie obligation to shape policies and practices to save their lives."

So distressing to Munson are the looming deaths of those with organ failure that he favors nearly every innovation intended to increase the organ supply, including the sale of organs. The following fictional case represents Munson's ideal scenario for organ sale. Alice Cushman's daughter, Karen, needs a kidney transplant. Karen's father is dead and her mother's kidneys turn out to be too scarred to be usable. Meanwhile, Betty Burke's son, Chris, needs a bone marrow transplant. His insurance will pay only 70 percent of the $300,000 treatment, so his mother must raise the remaining $60,000 herself. Luckily, Betty and Alice meet in the hospital waiting room and devise a plan in which Betty pretends to be a long lost cousin and donates her kidney to Karen for the $60,000 she needs for her son.

Munson considers this an ideal case. His argument is that selling one's nonvital organs to achieve a chosen benefit is merely an extension of allowing individuals to make decisions about the course of their lives and the risks they are willing to take. We allow people to race motorcycles and climb mountains for recreation, so we ought to allow them to take similar risks for more noble purposes such as securing needed medical care for a loved one. According to Munson, there is no moral difference between giving a kidney to one's child and selling it if the money gained is used to secure other necessary health care for that child. "Except that money changes hands, the consent, risks, and motivation in [the Cushman-Burke] transaction are the same as in the trading and in the donation." Munson also supports the sale of organs for other reasons, although he doesn't make an extended argument for this position.

Munson grants that there may be risks associated with the sale of organs, including exploitation of the poor, decline in the quality of organs, decline of altruism in society, and the detrimental effects of commodifying the human body. However, he finds these insufficient deterrents when balanced against the "gain of saving thousands of lives." He dismisses similar objections against policies of accepting donations by children, use of anencephalic newborns as donors, and use of animal and mechanical organs. After all, what "repels [opponents of these policies] may result in saving or prolonging the life of a sister, a mother, ... a child."

Although the logic that underlies Munson's arguments is well accepted, it bears further scrutiny. The fact that people die because they can't obtain an organ does not in itself prove that we have a duty to increase the organ supply. A significant increase in organs available for transplantation would have mixed results. Its positive consequences would be that more people would receive transplants, some of whom have the potential to respond very well to a transplant. In addition, some difficult allocation decisions could be avoided. For instance, we wouldn't have to decide whether smokers should compete equally for lung transplants with nonsmokers, since there would be enough for both groups.

But increasing the organ supply would also mean that many individuals who are now considered questionable candidates would be accepted at transplant centers, and their care would be more expensive and their outcomes less satisfactory than current cases. In addition, the cost of significantly increasing the number of transplants is potentially extremely high; scarcity is now the only factor that controls the cost of these medical procedures, which range in price from $100,000 to $400,000. These costs would further burden the strained resources of private and public insurance agencies, thereby decreasing the amount of money spent on other goods (medical and social).