North American Philosophical Publications

Is a Market in Human Organs Necessarily Exploitative Author(s): Mark J. Cherry Reviewed work(s): Source: Public Affairs Quarterly, Vol. 14, No. 4 (Oct., 2000), pp. 337-360 Published by: University of Illinois Press on behalf of North American Philosophical Publications Stable URL: . Accessed: 05/06/2012 19:13
Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact

University of Illinois Press and North American Philosophical Publications are collaborating with JSTOR to digitize, preserve and extend access to Public Affairs Quarterly.

Public Affairs Quarterly 2000 Volume14,Number October 4,

Mark J. Cherry

a in of market humanorgansfor possibility creating for-profit in manyfeelings deep moralrepugnance. of ignites transplantation Proposalsto brokerorganshave been denouncedby the UnitedStates the the Society, Congress, NationalKidneyFoundation, Transplantation and the American Society of Transplant Surgeons. Professional who were involvedin have resolved to expel members organizations suchdealings(Fox and Swazey 1992,p. 65). As theU.S. Task Force on the summarized objection:"We findthispractice OrganTransplantation and and to be unethical to raise seriousquestionsabouttheexploitation for thepoor"(1986, p. 98). The potential coercionof people,especially in commerce human to whichis perceived underlie organs, exploitation, of the is heldto trump possibility increasing transplants. life-sustaining because they Certainuses of humantissue are morallyimpermissible as as as them things, less thanhuman, human beingsby treating "injure Financial incentivesare objects for use" (Nuffield1995, para. 6.7). believed to undermine consent,to coerce the poor into selling their the to and improperly commodify organs,to violate humandignity, to is The argument thattherichexploitthefactof poverty human body. coerce the poor into selling their organs, which given better the poor would not have done. While such views circumstances summarize the apparent global consensus that marks worldwide of prohibition the sale of human organs, as I will argue, closer examination reveals significant groundsforconcludingthata market thancurrent wouldlikelybe moresuccessfulin preventing exploitation bureaucraticproceduresfor procuringand allocating governmental organsfortransplantation. commercializaIn this regard,RichardTitmuss'sclaims regarding of tion of the blood supplyprovidea usefulsummary objectionsto a in market in market human arguedthata for-profit bodyparts.Titmuss 337

in sonal and professional sanctionsthemakingof profits freedom. is clearthat Titmuss does not bring moreharm the motive leadingto thewise use ofresources.4) limitationson personal on as freedoms. the sick and the inept increasesthe dangersof in unethical behaviour varioussectorsof medicalscience and pracin in more tice. or from a that to which receives A . 2) 3) a lowering of scientific standards. an erosionof a sense ofcommunity. of Such positionsare rhetorically compowerful. the of erodes [Commercialization]. of thiscentral and forceful whichis often heldto exploration objection. In this essay. well as 6) the 5) his between In ofhostility and physicians. limitations professional freedoms.For example. . does as nor regard profit he considerthe market place thatrewardsresponsiblefreedecision a whileproviding the making. 3) coerce the poor into selling organs. . I will focus on such concernsonly as they bear on the particular criticism thata market humanorgansis exin Whilelimiting breadth mythesis. p. between dochospitalsand clinical laboratories.2) benefit whileharming. them the poor. addition. theyoversimplify yet plex issues.338 PUBLIC AFFAIRS QUARTERLY blood products leads to less blood available fortransfusions. lowersscientific limits bothperstandards. tutelage concerning consequencesof one's choices and thelimitations thehumancondition. . be decisive againstsuch a market. The core notionis thatto exploit someone is to benefitby taking unfair advantageof thatperson. market than It on benefit. thesenseofcommunity. significant of blood. or mayexploitpersonsin greatest whether the forbidding sale of organsis itselfexploitative. areas of medicineto thelaws of the subjectscritical social costson thoseleast able to bear places immense marketplace. the of thisallows for careful ploitative.A mayexploitB whenA benefits from transaction is harmful B. 245-246) It is important note the special moralcosts Titmussidentifies: a to 1) decreaseof altruistic sentiments. and categories exploitedhuman of of populations highblood yielders. at best onlymarginally or recipients benefiting. pint . At each step the analysis considers commodify whether and how the market need. represses expression altruism. 246). and imposessocial costs on thepoor (1971. legalization patients that a profit from servicesor 8) criticisms 7) presuppose making hospital from servicesis morally and 9) thattheforces the of laboratory suspect. legalizes hostility torand patient. (pp. will considerwhether for-profit I a commercial market wouldexploitthepooron thegrounds thatit would likely 1) have a negativeimpacton the physicalhealthof vendors. greater a likelihoodof distributing blood contaminated withdisease. vendors. inefficient of a increasein priceper management the available supply. or 4) improperly human body parts.andresults situations which proportionately andmore blood is suppliedbythepoor.

a primaryconcern is that organ sales improperly humanbodyparts. which.For exon is employment injured thejob.Individuals may preferto receive expensive or medical treatment automobilerepairforlittleor no cost. commodify I. such who ask or do circumstances notentailthatphysicians auto mechanics. which gain purchasers in are. is in a way that vendorsbenefit thoughorgan more benefitsubstantially For example. 213). is presumed forpayment. Here. the expectedvalue of such exchangesis negative.1 which ploitative."If a worker severely is we is a net harmto thatworker.even if freely immoral. incentives theconcernis thatfinancial the organsto therich. include:Harmful The possibilitiesformarket exploitaexploitation whileorgan vendors from suchtransactions in tion.if purchasers remainsunfair.Generally. The issue is not ex individual post. Yet. 201). do not say thatsuch employment as harmful a practice" (Wertheimer 1992. adequately but is individual harmed. p.IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? 339 A value (Feinberg1983. ifoffering purchase advantage organs thensuch exchangesmaybe exvendors'impoverished circumstances. gan markethas contransactions beneficial Mostuncontroversial the outweigh benefits. 215). In addition. of takesunfair to or thanvendors. mayexdisproportionate froman exchangewhen B's abilityto choose is ploit B if A benefits even ifB's choice is notstrictly (Wertheimer involuntary compromised.p. Moreover. on but whether balance the costs harmful elements. p. Market by exploitation such thatintrinsically unattractive to thosewho are vulnerable options thebestavailable. consented is fundamentally a from transaction to. Harmful Exploitation requires exploitation organsales involveharmful Assessingwhether an The questionis notwhether orconsidered" an "all things judgment. suchthat ample. will tipthebalance of interests. whether. organsales.Givenconditions inducing poorintosellingtheir to financial incentives undergo the ofpoverty. to is an whether organmarket harmful anyparticular as ex it is typically ante harmful a social practice. inducements often works offering 1992. tain negativeelements. which. poorwill have significant therisksof surgery.on balance. become. and in Moralistic gain purchasers vendors exploitation.harmed. butwhether . Regarding all things considered. advantageousexploitation. is notwhether particular any question on balance. the to evaluateorgansellingas a social practice. exploit for and auto mechanicsmaypermissibly requirecompensation the serthe to the and vices provided that benefits theindividual outweigh costs. thatphysicians it others. Mutually it fromthe transaction.

p.The market of be sell. to reduceor eliminate control of or the forcesof market coercionswhichplace menin situations whichthey in have less freedom littlefreedom make moralchoices and to beor to have altruistically theyso will" (Titmuss1971. are likelyto be significantly whenthefullcoerciveforceof the greater is government used to "crowdout" any who maydesireto sell. rich.or those onlythevery withpremiere would be able to purchaseneeded organreinsurance. Policies thatexpandthe number living of donorswouldmultiply availability transplantable the of redundant body to parts. 439. effect" in Indeed. iftheyso will. Expandingthe pool of living organsfrom and cadaverdonorswouldthen save lives and reducesuffering. Prohibition an organmarket can on of of precludesthefreedom all to sell their organs. For example.itseffects "crowding-out operates bothcircumstances. concernis thattheveryexistenceof a The market undermines internal the altruistic of motivations donors(Frey 1998. 242). It the allegedly"limitstheanswers is theresponsibility thestate. if thiscriticism be turned its head.argues thatthereis a "crowding-out withregard blood: thatfinancial to incentives notadd to a fixedsupdo ply of altruisticdonations.Giventhatwitha general prohibition organvending on to onlysome will exercisetheliberty of In the donate.340 PUBLIC AFFAIRS QUARTERLY An initialconsideration whether market humanorganswould a is in lead to less organavailabilityand therefore. for Whyshouldwe give you one?" Financial incentives organprocurementare believed to undermine freedom donateone's organs.but ratherreduce total levels of blood He thatthemarket wouldnotmorethanmakeup availability.forexample.. to more extensivehumansuffering. and narrows choicesforall men. short..familymembers maybe less inclinedto donateto a relativein need. Lepper and Greene 1978). ily "George. Importantly. Otherpotentialrecipientswould suffer and perhapsdie. perhapsinferior. termson waitinglists mightdevelop forthe poor who would Longer thenbe competing thediminishing for number donated less expenof or sive. potential might donorssell exclusively thehighest to bidder. callous individuals a or chiding friend fammember: ownorgan!If youhad savedyourmoney. buyyour for you could have purchased yourown replacement kidney transplant.If the to an organmarket created. presumes forany donationshortfalls. .forexample.once a market exists. p.thefreedom all to sell.Envision. is whileonlysome will exercisetheliberty to the freedom all to donate will thereby wouldalso increaseavailability nonof redundant cadaver limited. organs. effect" Titmuss.. conThe cernremains that market a If decreaseorganavailability.If such a policyencouragedthe familiesof deceased patients makethoseorgansaccessible. placements. ceterisparibus.

theirfamilies. notto be seen as exclusivealternaor directed donation. particular donationto sale) or in relativenumber eral character ( considerdonation. maylead to the parallelstrategies multiple Pursuing thegoal of increasthat It organavailability. beneficence.Regardless. thusreducing ingorgan securedwiththeexistenceof an organmarket. likelyunjustified.Bothpolicies wouldensurethatdonorswerecompensupply whileactively valueoftheir satedforthemarket encouraging bodyparts. Here also. from that thandriven need).theconcern affect health care for the poor. development such a market providesno reason or to stop askingpatients.IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? 341 would lead to less organavailability Concernsthatan organmarket thatthe willingness doto are. relationship particular willingness to are Such transfers unlikely changeeitherin genpatient. a measuresolelyof thewillingAs theexistenceof a for-profit ness to partwithone's organs. and honestly effectively woulddisproportionately thatan organmarket For example..e. The motivations currently becomeother supby are members also likelyto support to donations family family portorgan to organs. healthcare costs..e.rather. incomeor inheritance for These wouldbe governmentally managedmarkets thepurchaseand of organs. however. gratitude. taketax deductions thefairmarket donors.without raising whichwould of a consider system organstamps. loyalty. Organ stampsmightfunction wherethe state or national healthcare entitlements. however. maybe.Indeed.These guilt. direct an increasein available organs. their of utilizea system taxcredits one In oftheorgans. straightforward . one might as create certainwelfareentitlements. availability. donationsfrom living the are suchdonations likelyto maintain same forceregardsupporting market: less of theexistenceof a for-profit love. financial findthepoolingof of the Furthermore. (i.manymay replacement poolingofresources purchase resourcespreferable. those natebodyparts motivated actualrather by to of who are willingto donateoughtto continue be willingregardless market. addition. Here one mightconsider allowing value for to or families. extendsto all possible recipidonorswhose altruism are notgenerally witha their stemsfrom ents. Presuming than is coercedaltruism.those who are willingto donate body mostorgan partsoughtalso to be willingto sell suchparts. might against taxesowed fortheorgan'svalue (Monaco 1990). or the adversely the for numerous underinsured possibilities influencing market. ignores could be utilizedto avoid the need fordirectpayVarious incentives mentsfromrecipientsto donors. ought request tivesto themarket. The motivations donorsare to family members.Addisuchas required tionalstrategies designedto increaseorganavailability. greatest wouldbe more human and suffering. the uninsured. or avoidance of the shame of failingto donate.

. be madeavail"Mother Theresa's able for to thepoor. organmarket In an createsthesocial and politicalspace to exploreadditional opportunities and incentives organprocurement allocation. an empirical or market. Other possibilities ought be considered. realize thegoal Whichinstitutional would moresuccessfully system a of greater of availability organsfortransplantationthefreemarket. short. higher priority courageblood donation to thosewhodonatedorgans(Perry1980. for livermight exchanged a be redundant organs(e. . pp. in altruistic mostblooddonation theUnited thana purely act. Rather Statesis situated within such valuable incentives." brokering pecunious.Insofaras it markets create social space for unencumbered an English trade tingent uponpersonalor family who was not a good tissue matchto donate to his son. concreatea systemof entitlements such stampsmight Alternatively.The organscould thenbe sold to the richto or raisefunds purchase health to care.Forexample. or "MotherTheresa's Non-Profit to the organsfrom poor in developingcountries advantagethosepoor. 63on thewaiting queue. profitinterests. pp. thereby other of incentives and opportunities. ding types One might raiseconcerns the on regarding impact thephysicalhealth of organvendorsin termsof mortality morbidity and risks. placing a fora tradein kind(Sells 1997. a father.Therecouldbe organ envisionindividumuchon themodel of blood drives. for and solutions including forthe so-called "crowding-out" without forbidphenomena. would notprecludetheliberty thealtruistically of inclinedto takecare of others. in kind. case. to als donating rights risks and other healthcare forsurgery minimize guarantee high-quality associatedwithdonation. 1392offered cost neutral option to suchas trading market 1393).andmedicine. blanket question state-regulated prohibition thatdependsin parton the talentsand goals of individuals. Social and politicalinstitutions support rights the that of personsto interact withfreeand consenting others formally are neutralwithregardto theexpressionof a slice ofhealthy not A of healthy kidney). organmarket the an seeking wouldallow private individuals ofcharity sell organsvery out to cheaply to thosein need.342 PUBLIC AFFAIRS QUARTERLY tax health insurance wouldpurchase organs utilizing dollarsforthepoor. system incentives unlikethoseutilizedto enor could give organentitlements. offered one of his kidneysto the Britishdonorpool in exchangefor He his son on the nationalcadavericwaitinglist fora kidney.butare notlimitedto. role could play a significant Churchesand charitableorganizations drives for increating health careresources thepoor.Although . Market-based liberties include.One couldimagine transplantation forthePoor" generating resources provideorgansfortheimto Organs Organs. 71).g. Unlessthestateprohibits practice.Here one might whichwould in organsdirectly local churches.

Organfailure of the population. lack of donor of return patientsto productive lives. fundamental community of benefit a transthepatient if and thecorrupt theunscrupulous we deny the becauseofourfearthat paiddonation indicated is that medically plant is too complexto be regulated" (1990. changeshands. after living-donor such are (Ross et al. the greatfinancialneed of donors (Thiagarajan et al. a liverslice). acknowledge. money.Presuming money regardless whether neutral to ingdonorswill continue be utilized.such as inmorbidity percent cases.selling by ably tissues is less riskythanmanyotheroccupaorgansand regenerative risksexist whenever and tions.therefore. solving the from developing these for Purchasing organs transplantation. family teamsin India docuWhileredundant organsales werelegal. livingdonorsand recipients.000 donors mortality in withothermajorcomplications occurring less than2 (0. can be somewhatmore riskyfor donors to does notlimititself thewealthier (Najaríanet al. even if those donatingare poor members society. Other operations.g.forthcoming). 1992). social goals.03 percent).Provided of and in poorerhealththanmoreaffluent in tissuesare procured suitand regenerative internal redundant organs redundant sterileenvironments. an appropriate subjectforregulatory or in As themarket.. In thePhilippines. focuses on basic humanvalues. of long-term of risks. changeshandseven amongrelated typically nificantly they argue. tarianspare partsmedicine.thepotential to attributable increasedinbenefits againstthe short-and long-term the consider sale of a redundant vendors come.g. Reddyet al. notmereutiliOrganselling. competent surgeons. and assistance in remortality. "We serveonly and connectedness.. it rather. transplant mentedprogramsuccess in termsof graftsurvival.Yet. other sigvaluableinterests. p. organ busimeans to raise resourcesto support to be an important fledgling welfare nesses and to further (Alora and Lumitao. nephrectomy controversial a as harvesting liver slice. 1990). The primary for associatedwith perioperative procedures organharvesting: operative 3 is fornephrectomy approximately deathsper 10. donationamong family or healthier segments is members consideredmorallylicit. Insofaras a disprocess of number poorerindividualswould be exposed to such proportionate harmsof organdonationwould need to be weighed risks.IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? 343 life such costs are likelynotsignificant. to withregard themarket. Long-term lessenedby theremovalof the fordonorsis notmeasurably expectancy tissue internal redundant organ(e. 911). crucialto consider.Such mortality morbidity livingdonors livof are utilized. a single kidney)or regenerative healthrisksforlivingdonorsare those (e. be the While minimizing risksof organprocurement might surgery it is notpersuasiveagainst action. Occurrence creased risk of hypertension or proteinuria. physicians . 1997).

increasedadvantages forchildren.Individualswith whichmay. which in turnare indirectlyassociated with greaterlife and health. giventheforegoing providefurther . of itydiffered. and advantages: higher salary.within in low-income neighborhoods urban Canada thereare higher ratesof infant low birth and turn. of ischaemia. Whitehall an study. to for Organsellingmayeven lead to positivehealthbenefits vendors. and benefit healthof oneselfand one's family. 1989). For example. Similarly.shoulditself economic. lead to indirect that pooropportunity learn by workload are associatedwith and developskills. 563. electrocardiogram employment and morbronchitis. weight.344 PUBLIC AFFAIRS QUARTERLY worldconclude.However. such incentives may be significant. adleads to economic. and less Great Britain. (Wilkinset al. increasein statusas well as increasein salary. p. willgivethem data. 7-8). life expectancyin Canada varies accordingto incomeand status II the et (Iglehardt1990. support among evidencehas accuis perceiveddifferently betweengrades. and functional vantages.i. such as the purchaseof housingor healthcare. pp. higher jobs care coverhealth functional.demonstrated inverseassociationbetween evidence of gradeandprevalence angina. costs and mortality risksvarywith Morbidity incomelevel and professional status. example. Measuredsolelyin terms health of care consequences. 1991. Wilkins al. This circumstance prematurity pointsto indirect healthbenefitsforchildrenassociated withthe incomelevel andjob statusof parents. It would increasethe vendor'soverall social and economicprospects.increaseone's economicand social in keepingwithethicalvalues as well as fundamental commitments medicalcare. and 3) "workenvironment thosewith lowerstatus jobs".Low with in theemployment control closelylinked was hierarchy.p. 1991. organs.2) "patterns social activsocial withclear indication less. the Given thereby indirectly thatsocial and personaladvantageis oftentied to educationand business success. 1392).Impressive to mulated jobs characterized low control.Reasonscitedto account tality to forthesedifferences include: 1) "different attitudes health"such as "thelowerdegreeofbeliefamongthosewithlowerstatus they jobs that a of could takeactionto prevent heartattack".and symptoms chronic of Morbidity werebothaffected employment by grade.despiteuniversal For single-tier age. mayprovidesome withsufficient incentives sell redunto dantinternal It control overtheir ownlives.andhighpsychological et increased ofcardiovascular risk disease"(Marmot al. even short-term welfaremaximization.sellinga redundant be a rational organmay strategy to raiseone's income.reducedinfant expectancy. status incur economic. job position Increase in controlover one's occupation. social.which..e.

is thiscircumstance rectifiable Insofaras it is morally by problematic. frompersonto be difficult measureand may differ to will.Marketincentivesencouragepersonsto raise and goals. 252). 30). 217). to be It remuneration compensate. begs the questionto perhapsheroically. On suchan account. . borne vendors primarily are harms Additional They by psychological. would. increasing for financial standards each organ.p. While sumethatdonorsare notsubjectto similarpsychological causes increased itself somearguethat harm. in whichsome may theirown educato view as attractive. than an value from exchange more command they considerably exploiters while for the exploited the reverseis true bringto the transaction. Similarly.Insofar organvendors or embarrassment. Moreover..g. Feinberg or if is exploitative one of thepartiesreceivesexcessive profit disprothe value from exchange(1986. portionate less are organvenders exploitediftheyreceivesignificantly value from to of thantheworth thetransplant recipients.political. II. however. because even suchan amount tivelylittlemoney. be adequately recompensed. Mutually Advantageous Exploitation a Organ sales may be exploitativeif one partybenefits greatdeal the other. therebyobtaining a net benefit 1992. deep It at some riskto themselves. psychological compensation to the organ vendormay outweighinthe value of the compensation creased psychological dis-value. A resourcesto further personalas well as social interests market humanorganswould create opportunities. incurpsychological distress as (e. motivated organdonorswould presumethatonly unpaidaltruistically as psychologicalharmscan Insofar experiencepersonalsatisfaction. example. an Joel arguesthat agreement (Roemer1985. balancedagainstpsychological at it is implausibleto view organsales as benefiting recipients significantharmto vendors. p. whichset minimum price Such considerations suggest exploitation. loss of dignity). is One possibility statepricecontrols.Marxist froman exchangethatonly marginally advantages focuson thewaysin which for of accounts market exploitation.2 or benefits.and welfareinterests. p. help prevent legislationmay Most vendors thatorgansellers mayface a collectiveaction problem. activity. mayexperiencea organvendors (Wertheimer in for senseofsatisfaction participating a life-saving even.IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? 345 and healthadvantages. secure resourcesfor pursuing tional. an error premay harms. adequatefinancial ingsof violation. feelperson. thetransaction The concernis thatthepoor will be willingto sell organsforrelawill be advantageous. vendor compensation.

bargaining position appearscomparatively are for 223).p.While a poor individualmaydecide thatsellinga kidneyis to moreattractive thanotheroptions.While coerciveactionsare thosethatplace or threaten place to othersinto a disadvantaged state without justification. are coercive because workers limitedto a choice betweenunpalatable at alternatives: (Cohen 1982. they exploitative. forthe poor. unlikethose betteroff.the restrict options own for the are from utilizing market their fully impoverished prevented advantage.on the otherhand.if thelure of compensation is vendor'schoice.forexample. occupaor construction. 47). p. theyfurther implications. Indeed. or restrict participation organmarkets thosewithhighincomes (Epstein 1997. wealthy an appropriate expression personalfreedom One mustalso distinguish betweencoercionand peaceable manipulation. incentives lowering amountpaid per organ(Radcliffe-Richards the by to in 1996).5 advantaged cion violates the freechoice of Margaret Radin notes. assemblyline tion. example. Michael Walzer. 339).346 PUBLIC AFFAIRS QUARTERLY that wouldbe able to negotiate agreement is less desirablethanwould an as vendors be possibleifpotential collectively a group.4 Analogously.oil platform mustmake the same typeof choice. jobs or starving working low-paying as is donation notregarded altruistic This accounthelpsto explainwhy but it exploitative: is notthatthe exchangeof value is morefair.holds that an should at least approximate exchange "what goes on in the market betweenequals" (1983. meanthattheyare beingcoerced. reducethe financial one might If poverty the difficulty. realizingany value fortheir biddingthem An offer coercive. is though. p.3 that is the themotivation underlying transaction perceivedas morepure. Finanof the compromises voluntariness thepotential and thatoverwhelms cial gain. is unclearwhyengagingin market withthe poor constitutes transactions the use of coercivepower. While such policies may appear less have counterintuitive First. Marxists. peaceable manipulation grounds .Here negotiated thatprohibition one might also raisetheconcern exploitsdonorsby forfrom organs.forexample. the labor or thosewho mustsettleforanyunpleasant morerisky market. 3). thisdoes not necessarily worker. and second. 255). 120).arguethatcapitalistlabor markets p. p.peaceable manipulation does not (Rudinow 1978.while doing so withthemiddle-classor the is of (1996.offers purchasean orgando not on make him worse offif he refusesto sell.such as ditchdigger. peaceable mato nipulativeactionsare those thatplace or offer place othersinto an While coerstateto whichtheyhave no priorentitlement.It is thevoluntary consentof impoverished potential subjugates the vendorsstandto gain so muchfrom sale that because impoverished weak(Wertheimer their consideredan influence donors.

whileaddingto of Opponents organsales mayarguethatsuchoffers. are notgenerally speakingcoercive.If. requiresshowingthat cive. one's list of optionsandprimafacie enhancing too good to refuseand in thatsense are coercive..However. rather disadvendorsinto unjustified such an offer places potential making circumstances. p. line betweencoercion the As Nozick and others is to and peaceable manipulation difficult draw (Nozick 1969). p. vantaged a the is One possibility that lureof financial gain maymotivate deciif he had thought sion thatthe vendorwould have rejected carefully on about its fulleffects his principle. might losophygraduate "Wow! I'm verypleased thathe offered thinking: imaginethe student . longas offers notmakeindividual choice amongpotential costs and benefits and voluntary impossible.giventheperson' value is positive.If a richpatient phione two student milliondollarsto sell a kidney. 347).thus. irrational estedin money as the declinetheoffer. Even if theindividualis so interto thatit would.thechoice to sell a is kidneyin orderperhapsto belie theeconomicstatusof one's family to be coera considered decision without scruples. to evenifit wouldbe rational accept(Zimmerman 1981. 1986.g. 308). The existenceof such miscalculation. are individualfreedom.If an organvendoragreesto sell bethe cause he believesthat expectedvalue of so doingis positiveand the and.thenthereis no miscalculation resulting exists of The possibility suchmiscalculation coercionon suchgrounds.coercion is involved. an offerto purthe because itmanipulates victim's chase an organmayappearcoercive. and in thatsense attempts use himas a meremeans(Rudinow1978.incentivesare. is however. transactions commercial but commercial withevery transaction. permissible (Engelhardt have noted.though.or an employer to donate. deception of contract). forexample. clearly. typically thansimplypeaceably manipulative. preferences.Each instanceis an employeeagrees intodisadvantaged circumexampleof one individualplacing another orbreach force a form unconsented-to of stancesthrough (e.a be scrutiny shownto be in the vendor exaggerates qualityof a kidney orderto obtain knowingly benefitsuntilan withholds contractual a higherprice. What as peaceable manipulation may undercloser mayprimafacie appear a hiddenformof coercion. The intent the offeris to elicit behaviorthatcontradicts to individual'snormaloperativegoals. the of 130).IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? 347 whichindividualsfashioncontheveryprocessof negotiation through As do deliberation sensualagreements. p. an empirical question.If the impoverished then individual'sstatusquo is highlyunsatisfactory. choice is stillplausiblyunderstood freeinsofar an offered impoverished the as he affirms outcome.

" To develop Harry movesthe Frankfurt's if suggestion.. 1973. one would starveor need to take a job thatcarriessubstantial risks(e.Thus. Considerthe circumstance a where.ignoranceas a barrier consentdoes not to the betweendonorsand vendors.but whether tivesto purchase redundant internal organsmakefreechoice impossible It and thereby coerce potential vendors intocomplying withtheoffer. do suchconcerns on familieswho sell organsfrom next deceased or brain-dead recently of kin. if some potential vendorsoughtto be excludedfrom sellingorgansfor reasonsof irremediable disabled). suchoffers notsubtle are threats. however. I could neverrationally refusesuch an offer. theoffer student who is being manipulated thathis first-order volitionscomso as the as pel agreement. Perhaps such offersare coercive relative to a normativemoral baseline. all vendorswill be igprecludedonation. by Thalberg1978). I'm veryglad it was it made.Moreover. actionis stillplausiblyunderstood freeinsofar it is affirmed his second-ordervolitions (Frankfurt 1971. oil-platform conWouldautonomy impossiblein suchcircumstances? be Even struction). shouldameliorate such concerns.without job. On the otherhand. and I wouldneverwantto turn downin anycase.blanket ignorance (e.norwill all be irremediably Adequatecounseling of so.surfrom either concern harvesting for gical risksarenota noteworthy organs brain-dead thatvendorsmayfail to bodies or cadavers. respect distinction Unpaiddonorscan be equallyignorant therisksof surgery ofthepotential serious for of or Insofaras ignorancerules out selling. thethreat significant if of harmincreasesthestandard proofforconsenttoo greatly. The generaldifficulty that questionis notwhether poorare is the the financialincenunfreewithrespectto certainobstacles.concerns understand risks life-threatening do not defeatautonomous participabear significantly tionin an organfutures nor oughtalso to complications.since theydo not deprive as the potentialseller of any preexisting optionsand rationalchoice remainspossible. of It prohibitions problematicto describesuch offers coercive.g..thereis a difference betweenhavinglimitedoptionsandbeingunableto choose rationally one's bestinterests in among theoptionsavailable.then . The poor generally have feweroptionsavailable amongwhich to choose. thementally do not servetheinterests liberty. If thereexists a moralobligationto provideassistance. not withdonors. is autonomous unclearthatan organmarket would fareworse regarding consentthanotherorganprocurement On strategies. raises of this the concernthatotherimportant freedoms will be ruled out as well. is.g.348 PUBLIC AFFAIRS QUARTERLY me two milliondollars. therefore. norant therisks. theone hand.Whiletheymaybe seductive.

A actuallyproposesto makeB worseoffif B does not to A.or a dutyto help others need. to do something morally injurious III. is difficult counta policyas exploitative as in the if. need. Moralistic Exploitation: ImproperCommodification are is beAn additionalpossibility thatorganmarkets exploitative that human For cause moralharm. ConNozick's example:B is drowning. example.theoffer coercive. Pace theoften cited urewho are analogous to Nozick's drowning will exploitthe poor. 207). or is holdthat there something must intrinsically wrong debasingin sellone evenifone does thisfreely. absentprioragreements special it moralobligations. is unclearwhythose withhealthyorganshave a In to moralobligation donate. shouldnotbe commodified.In orderto see such circumstances might cause they argue On organsshouldnotbe maybe thatit is patients organfailman.this analysissugconcernthatan organmarket the the to in geststhat offering sell organs poormaybe exploiting illness or of the rich forpersonalgain. Nozick concludesthatthisis an example to B's ofcoercion.WhileAprimafacie offers improve situation relative to thestatusquo. it increasesthenumber options as one to individuals.whichsusis tainssuch a moralbaseline. do circumstances not improveif organs are purchasedfor ploitative . 449-450).6 short. has beenbrought so ingone's organs.IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? 349 to demanding compensation fulfillone's dutymay be coercive. ifB A to siderRobert agrees to pay him $10. eitherforno cause A has an independent less (1987. pay the $10. Patientsdyingof organfailurewould not usuallybe describedas havingspecial moralobligationsto providepotential organ withfinancialincomewithout vendors askingforsome good or service withend-stage in return. and of the resources thusin morethreat exploitation: poorwhoneedfinancial or therichwho are dyingof organfailure. such an account. offers rescueB. Indeed. pp.a marthatwhich because it commodifies ketin humanorgansis exploitative exInsofaras such a view is sustainable. Insofaras there or compensation forconsiderably in to existsa right be rescued. adequatelyto assess claimsof coone mustalso inquireas to who is in greater ercive offers. bemoralobligationto save B.000 relativeto whatB has a right expect from Alan whilethiscase maybe properly holdsthat described Wertheimer similarly but as coercivethisis notbecause B has no acceptablealternative. p. organsales.000. of case of legitimizing open organsales. thatthisanalysisclarifiesthecase of human It is unclear. Yet. Both knowthatA is the only prospective rescuer(1969. that to oneself. it to In general.

For example.fungias "fullyinterchangeable with no effecton value to the bility (i. Incommensurability a represents concernthatthe values at stake cannotbe relevantly incomsummed and compared. treat 2) thatthevalue of items. commodify such transactions shouldbe prohibited. argues. valPerhapsorgansales involve an exchangeof incommensurable ues.commensurability that"values of things as a function one continuous of variable"). Opponents organsales mustarguethat of human suchtransactions 1) organsby treating inappropriately objectify human them objectsrather as thanas partsof subjectsor agents. initialchallenge regarding and of foropponents the market thatorgansare infact manipulable is withothersof the same kind.whichincludelove.and monetary equivalence (i. Both market and non-market is based strategies procurement transplantation similardiffiand face for culties. though. that deception or other formsof coercion are not and thateach is satisfied withthevalue to be received. The mensurability of transactions does not requirethatthe goods permissibility market be precisely transbut that commensurable. farebetter worse or The question.By itself.e..thatoccurs"whenone party a transaction oriented toward exchangeof 'giftvalues'. she to is exploitation. whether is organmarkets An commodification thanotherstrategies. "ascription by objectification at sense of something thatis manipulable the will of persons"). 4) that valuecan be givena monetary and this expression.This exchangeable. meansthatwhatis receivedin return worth least as muchto the is as as thatwhichwas given. rather theparties exchanged act voluntarily. commodities marked of statusas a thingin the Kantian (i. appreciation Gift and .. p. "the continuousvariablein termsof whichthingsare rankedis dollarvalue") (1996. holder").it is argued. 118).gratitude. are As Radin maps the conceptualgeography. values. presume 3) organsas fungible the organto the vendoris commensurable the value of the organto to thepurchaser. ElizabethAndersonsuggestsanother Thereis a kindof possibility.This is the veryreason interchangeable thattransplantation medicallyviable. 218).one can buyor sell "priceparty less" Monêtswithout value of the or claimingthattheaesthetic historic is "commensurate" withthe moneythatis paid (Wertheimer painting 1992. are goods through If organsales improperly humanbody parts. p. can be arrayed (i. others not.e. whiletheother the opparty erates in accordance with the norms of the marketexchange of commodities... This capturesthe intuition thatwhile some significantly are appropriately distributed the market.e.350 PUBLIC AFFAIRS QUARTERLY moremoney.e. will not establish that organ sales are illicit.All treat humanorgansas exchangeableobjects.though.

often of The pursuit self-interest requiresthatone advancethebest inbenefits ways other in thandisinterested of terests others providing by to At commitments civic dutyor generalizedsolidarity. is typicallynecessaryto maintainlong-term concurrent commitbusinessgenerally a successful requires Achieving and of satisfaction to theprovision qualitygoods and ment customer to notesthiscirand services(Engelhardt Rie 1992). reputational poorlyproin duces thesame incentives auctionmarkets (1997. 103). p.and others tals.transplant specializedservices. However. timesone party sell value as to an exchangemaydeliberately goods forless thanmarket that valuescan be brought Such considerations a subtlegift. p. incentives virtuous for significant provide and as wellas vendor recipiand service medical suchas quality is in the titlecompany'sbest interof and skilledtransfer real estateownership. is One might expression an inapgivingorgansa monetary arguethat propriateway to value humanbody parts. the intoplay in the market. of of customer satisfaction. neceswherevendors and recipients in "spot markets. mustoften and personalrecognition theother. Similarly. can Virtue be seenas a profit-maximizing entsatisfaction.17). realization of profits. cultyis relevantif and only if such a dichotomy intentions the value of humanorgans Personswho negotiate regarding fairmarket such conceptualdissonance. will notlikelyexperience one cultivate virtues the In orderto do well in themarket. in is "To failto valuethings appropriatelyto embody one's lifean inferior . Conceptions human flourishing typically shouldbe valued. meetonlyonce.For example. treating impact who perform teams. kindness. an ests to effectuate honest from others The reputational hospipoorlyon surgeons. p. suggest gift Even if Andersonis correct. 89). Here the concern is that to discourseand market exchangeswill encourageindividuals property ineconomic terms as valuethosegoodsregarded "property" (Gold solely underlie ideals of 1996.Cultivating how certain thatsupport things capacities to appreciateaestheticand historicvalues enrichesand elevates life. ElsewhereAnderson withauction markets. independently thegoal to maximizeprofit." involvementprovides considerable incentives for sary third-party virtuous behavior.will in tendencies an organmarket.this oversimplifies. diffiof exists. strategy. of The goal of giftgiving. customermarkets cumstancewhile comparing are like whereauctionmarkets structured one-shot dilemmas.IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? 35 1 or cannotbe bought obtainedthrough of others. piecemealcalculations of individualadvantage"(1990. prisoners' like are markets structured indefinitely whilecustomer prisonrepeated forfuture Where ers' dilemmas. though. parties cooperation provide opportunities incentives respecteach to withmarket-generated markets in customer of others effects treating the other'sinterests.

as equal withthebasest commercial He commodity.of Cal.. p. Arabianconcludedthatmarket in normsinherent property discourseare incompatible withopen discussion of non-market. 89). of hold equallyagainstsystems donahowever. bodies. something is bothusefuland financially Such considerations. asks much"(Moore v.or fortheirloved ones at death.. ReHe commingle gentsof theUniv. donationsupopen-ended. "Sexual or reproductive the enter market as comprostitutes modities.352 PUBLIC AFFAIRS QUARTERLY of (Anderson1990. thereby over .are seen as scarcelife-sustaining medicalresources. . Monetary oughtnotto be attached thepresence of a spirit altruism. whiledonations gifts more as are and as such defysuch minimization. social solidarity.As organtransplantation became thestandard care.withits important minister fundamental of and is set symbolism love. all women's for bodies will have a price. analogousclaimfororgan The once sales is that pacities there a market human is in all organs.. Organ and posedlyaffirms community solidarity expressesthebeliefthatit is to to humanneeds. solidarity social beneficence to values. fellow-feeling.The concernis thatthemarket would so affect altruistic impulsesthatit would starkly limittheexpression altruism thereby of and lead to far-reaching moral costs to community and (Titmuss1971. 198). 207). non-monetary. p.p. conception human flourishing" in Moore v.and those who do not sell theirredundant organswill be viewed as hoardersof that valuable. 36). surSara Ketchem arguedin thecontext commercial has of Similarly.organswere of recastas merethings (Fox and Swazey 1992. Concerns avoid to withholding as collectionsof sparepartsmustbe addressedunder recasting persons of and any system organprocurement transplantation. 290).it is argued. Regents the University California. p. because it wouldhave a deeply Perhapsorgansellingis exploitative effecton altruism. once thereis a market women'sbodies.. tion. of The contention thatmarket is relationships minimize moraland social dimensions. urgesus to the sacred withthe profane. 51 3d at 148). or One beneficence.. It treats cawomen'sreproductive financially as commodities.. p. entreats to regard humanvesHe the us for sel . debilitating would be corrupted the veryexistenceof might arguethataltruism by themarket. Justice Arabianarof of gued that treatingcertain things as commodities may be morally "Plaintiff asked us to recognizeandenforce right to has a inappropriate: sell one's bodytissue profit. For example. Donation. . philanthropy that wouldbe sulliedby greed. organswill havea price. that ofthemarket use of recaststhemeaning nature women's and rogacy . friendship.and the womanwho does not sell her body becomes a hoarderof something thatis usefulto otherpeople and is valuable" (1992. values (Gold 1996. Personswho do not donate while living.

of and drugs procedures theadvent immuno-suppressive transplantation and survivalrates. ety." calling into thereby gans one legislatesthenecessity than Rather of character suchtransactions. than on blanket current prohibition selling. largeorganizations. whethercurrent practices of organ procurement and donation beneficence. to and even strangers make theirorgansavailable to members family the othersif needed. as well as a sense of community: market commitments In to civil dutyand social solidarity. socialbeneficence. organ availability. First. sustainable. describescurIt is unclear.that"altruism" accurately With the documentedsuccess of rent organ procurement policies. tip one To assess such criticisms adequately. againstthesupposedly and impersonal bureaucracies. whenever to ment be offered medically in Thismedicalshift language. of thecommunity.the ways in whichthe free thanthe market. 117).forexample. system's and reduces altruism. thegeneralpubthatincreaselong-term lic quickly changed their view of organ transplantationfrom an successfultherapy to (Fox surgicalprocedure a medically experimental to alteredmedicalsocial reality and Swazey 1992. personalrealtruism. successfully with choicesofindividuals. the binding question "altruistic" in as and donors recipients. . their disinterestedly it It to as families "accessbarriers" be overcome. shape thecharacter interacting one another.However. of goods and principles foran alternate This is a search interpretation that the by whichgoods are to be distributed "capturesmorefaithfully of our mostdeeplyheld ideas about the meaningsof those complexity justice" (Murray1996. maybe that is the grieving that rather themarket. addition reducing organavailabilof and social solidarity a society of weakening theverymoralfabric ity. This shift as has thatorgantransplantation come to be regarded a treattheextent are Humanorgans often indicated. wellas their physicians. thesolidarity potential are human social valuesand caring of shared dying patients relationships. community encourage of and societymore lationships. staveoffthedepersonalization modern and second. 8-30). p. moralcosts might thescale againstthemarket. as construed a "scarcemedicalresource. market relations.physicians. such If to is argued be theprobablecost of an organmarket. pp.IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? 353 forcesof mass socialienating depersonalizing. and recastas "sources"of bringing considerablelegal forceof of to bear againsttheverypossibility sellingone's orthegovernment of the"donation." and practiceplaced a greater perceivedmoralburdenon expectation. At stake goods and about distributive of are the ways in whichindividualfreechoice shapes the character a will altruism benefiand and whichstrategy lead to greater community to or the cence. mustconsidertwo interrelated issues.

unlessone specifically taking forceof thestateto choice implements significant the whilemandatory or coerce one intochoosingwhether notto "donate. one's organsat death. consistent expression beindividualswho standto be financially neficence. U. goods. increasing et al. and between cal companies. 117). 1320a-7b(b)). limits to forbidden waive are whoacceptMedicarepatients generally physicians even if the physician as of thepatient'sco-payment a matter kindness. thedevelopment significant of if such altruism reduces the depersonalization the modernbureauto cratic society.braindead. hospitals highly inequality profit.p. wouldallowforaltruism fororgan both donation allocation. is himself the sole bearerof such costs (see U. and contrast. Moreover. Organ donationappearsto invert of those who would otherwise recipients be beneficence intothosewho mustagain sacrifice (Epstein 1997. that market. taken Requirements organdonation altruistically or wouldruleoutanyschemeofpresumed consent mandatory seriously. p. example. and thepoorwho donateorgans.yet.Presumed deniespermission. personal solidarity.354 PUBLIC AFFAIRS QUARTERLY if that be motivated. consentlegalizes simply choice. Indeed.Rather beingseen as thosein need of kindnessand support. friendship.This cirsurgeons compensated cumstance raisestheadditionalquestionof who shouldbear theburden of fostering altruism: thosein need of transplants requirecare and support. specterof organdonationrecaststhebethe reaved familyas gatekeepers of a scarce medical resource. building even of and relationships. policies. reciprocated be one's intentions to failing donate(OTA 1987. supported than"kindhave other motivations by a personneedingan organmight on be to ness" fordonating a too do the familiesof the dying. Medicare statute 42. legislated"giftgiving"constrains an otherwise commercial wheresurgeons.S. market the mayenhance anddrawtogether moral a for communities. or recently deceased potential than organdonors. Ratherthanerodinga sense of community. as well as manydonations.and ministers basic humanneeds. Those who shouldbe recipients charity confronted of withtheaddiare tionalburden organprocurement of in The commercial market."Neither policyis of altruistic with"giftgiving"as a voluntary. How puremust as an altruistic act? Even if it is truethataltruso as to transfer organs social moral blockofbeneficent ismis a necessary communities. pharmaceutisetting.C. guilt. 260). it is unclearwhy for national "altruism" a depersonalized or either bureaucracy legislated wouldpossess or foster ofthese and distribution any organprocurement thanthe rather legislation. nurses.Otherdonations might premised for not or concern to be stigmatized love. is oftenstatebureaucratic in For altruistic behavior. in individualaltruism Moreover. opening opportunities building .S.

developing and personalrelationships. solidarity.and recipients procurement we someone Moregenerally. theprostitute Satz arto the statusof a thing"(Satz 1995. and to i. makespace in practiceforthehumansubjectas a person(Radin 1996. expressing providing thefundamental needsof others. Expressionsof altruism mayexistside in markets humanorgans.Instead of encouraginga hostile relationshipbetween physiciansand would meet who are potential donors. This degradation.though. As alreadynoted.arethefinancially organ the exploiting poor to assuage theirown feelingof is for to to for altruistic a parent sell a kidney pay fora life-saving to operation a in 1996. a surrenders certain other merely instrumentally.By forbidding sales. Compare organ gradingto vendorsand thereby "In now values the sex. transplantation oralike objectify and allocationagencies. Forbidding market humanor(Radcliffe-Richards from withothers pool financial to persons joiningtogether gansrestricts It resourcesto purchaseorgansfortheimpecunious.if it is by side withfor-profit to altruistic a parent donatea kidney a childto save his life. p. 392). 155). p. procedures and in encouraging altruism community choice.shelter. prevents altruistic donationof organsto non-profit groups.IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? 355 for sense of social solidarity. is also objectification. therichand able-bodiedunderthiscircumstance the be exploiting poor so as to be able to have the poor not challenge theirview of propermoralconduct. contrast. ketrespects Prohibition. datory of Another maybe depossibility moralharmis thatsuch a market violate theirdignity. The customer only is cedes herbody:theprostitute degraded of amount cash.As alreadynoted. social exploitaraise additionalconcernsregarding Such arguments secureandable-bodied tion. a failureto respectin theory gues.surgeons. themunable to makemoraldecidemeanthepoor by considering may sions abouttheirown fates. each party selling to prostitution: commercial . for altruistic as well as forcharitably for sentiments..vendorsand physicians patients. . humanorgansis notan obvious violationof theKantianmaximto treat that absentadditional showing arguments personsas ends in themselves The organmareven consensualsellingof organsis morally injurious. andtreat gans of Commodification as merely a means if he consentsto be so treated.. do nottreat as them thatthey have saved thepoorfrom that themwell at night can sleep thinking they would selves? Thatis.some may find .For example.who could thensell such parts or to raise fundsto purchasefood.e. in donors. in as and vendors persons moralagents. market human organswouldlikelybe more thancurrent nationalized bureaucratic successful each ofthesegrounds on suchas presumed consent manand or other proposed policies. A in on a moreequal footing. healthcare forthepoor. 73). p.

returning matter considerationsotherthanexploitation. huimproper particular on to mandignity. thepoor thisopportunity choose freely the denying how best to advantagethembasis of theirown judgments regarding in selves. If one and heteronomous the distinction betweenautonomous this oftenmeans thatpersonsare being thatX is exploitative.indeedvaluable. busiin on their by repulsive misery ourattention engaging thestrikingly or ness of sellingpartsof themselves repairthedeficiencies therich" to is 1996. In that improperly a choice. While "at leastthesepeople will despairand die quietly. 2) to whichtheyhad no independent for existsindepento theyare required engagein activities whichthere dentgroundsforholdingthatit is immoral(e. justifiedinthe act involvesheteronomous sense. Therefore.). (Radcliffe-Richards p. of an is vocation a viewthat offer exploitative dependson an independent to argument show thatthe action would 1) illicitlyviolate the natural the good of maintaining bodyas a whole.3) improperlycommodifythe human body. IV. argues is so to giveninducements act in a waythat heteronomous that1) though a claim. thenthe purchaseof organs from poor will be exploitative and onlyif either1) suchindepenthe if dentgrounds impropriety be established 2) thepolicyon balance of can or will cause moreharmthanbenefit thepoor.2) involvea violationof human dignity.However.356 PUBLIC AFFAIRS QUARTERLY sale of a redundant organto be an acceptable. responsible Saint Edward's University .g. ways and the poor will not force to and less offensive the affluent healthy.language regarding exploitation appears to be parasiticon choices. for assessingthis latter condition will require that recognizing allowingthepoorto choose on theirown view of the good both protects poor from the being demeanedby being considered unable to make moralchoices abouttheir ownfuture helpsto educateindividuals their and in faculties freeand of choice. thereby. 406). or 4) is the to justifiably morally repugnant.. theoutcome robustly paternalistic.meansof The their circumstances opportunities. Some Final Reflections on Exploitation In part.3) theyare offered good. such actionsviolate humandignity. Which is to say thatif thereare not independent moralgroundsto show thatthe sale of organsis immoral. commodification. the commodify humanbody. richand ablelife and improving bodied by forbidding organ sales exploit the poor to supporttheir or views on moralpropriety.etc.

or social objective. Given state-legislateddonation. short.recentempiricalstudiesreveal feelingsofduressand dissatisfaction satisfaction among both paid and volunteer donors (Puig et al. Similarly. means to improveone's life circumstancesand opportunities.IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? NOTES 357 1. 1996). 4. a smalleropportunity For example. emotional. . p. "if some of the unemployedcould get a large sum of money and theirfamilies instead of living on the dole. Withregardto an organmarket. family. while "I was manipulated" generallydoes not (Rudinow inappropriate 1978. 225). 176). Gerald Dworkin (1982) has argued thatin some contextsit is false thatbeing providedwithmoreoptionsleaves one at least as well offas whentheindividualhad a way analogous to thieves and theirvictims(Steiner 1984. Dworkin's concernsmay suggestthe need forcaution. Paternalistically only closes a protecting poor froma humanorgan market of To miserable range of options still further.but theydo not appreciably supportprohibition. in India researchersdocumented and thatself-respect social respectincreasedbothbecause of thesaving of another's life and of theabilityof one's familyto prosper(Reddy 1991. poor individuals may find thatothersbegin demandingtheirorgans as a condition for access to certain goods. 55). 339). 389). Psychological. In valuable. where Titmuss argued that the social conditions of blood vending conduced to among vendors. p. Family membersmay agree to donate organs to avoid or confrontations to satisfy some personal. Consider the ways in which "I was coerced" providesone withan excuse for behavior. one' s bargaining powermaybe strengthened the ifone cannotmake certainconcessions. demand on family members to transplantation donate organs to each otherbecame perceived as partof one's obligations. but anything a huge increase in theirself-respect internal Some mayfindsale of a redundant organto be an acceptable. a means by which to fulfillthemselves(1994. The effects payingblood donorsmaynotbe as appreciable as Titmuss of "crowding-out" asserted. 96). 3. indeed p. would therebe startagain.""mutually advantageous. p. Helena Ragoné reports thatmanycommercialsurrogates view theirworkas a vocation or calling. This is to especially thecase ifthealternative theproposedprocedureis thedeathof a loved the one. as well as a desire to please othersmay influenceone to donate organs (OTA 1987. p. Will creditors demand theredundant organs of the poor as collateral formakingloans? Yet. The categories of "harmful." and "moralistic" (1992. exploitationare borrowedfromWertheimer 2. As RadcliffeRichards argues. 1995). For example. the dreadfuldifficulties povertyis added state coercion thatremoves an option thatpotentialvendors may see as the best theyhave to bettertheirlives. p. supporting and therespectof others?"(1996. 5. concern is thatonce the floodgates are open. Once became a successful procedure. and medical needs. such difficultiesare independent of the existence of a market. Many not may have preferred to have had to make thischoice. it is more likely less fair since the donor for receives no compensationin return thevalue of his organ.

D." and Frey. R. "Non-coercive Press. 12." Essays on and ed.voice and valuesin ecovol. 27-35. University Cambridge pp. pp. D. and Gold. 437-461. New York:Oxford Society. on 1997. 4. and Engelhardt. pp. "Freedom theWill and theConceptof a Person. 1992. Minneapolis: Sartorious. Values. and PublicAffairs. Studiesin than Less?' Midwest G. Feinberg. Beyonda Western Press. A. Alora. LIST OF REFERENCES Bioethics. pp. 1990.B. "SellingVirtue: in Journal Healthand of Strategy HealthCare Delivery. University Washington. Frankfurt. and J. Moral Peril: Our Inalienable Addison Wesley. 1986. to R. Ben-Ner L. 132-164. Economics. Rie. "Institutions Morale:The Crowding-out and and ed. as as the of others from paying owner theorgan much itis worth forcibly prevents (1984. pp. London: Routledge of pp." vol.Significantly. 1973. 1997." Maximizing vol. 5-20. University of H. 1992. Social Policy. T. andSwazey.. S. While secondis often the throughviolation rights. T. KeganPaul.G.pp. 1996.pp. To extend analysisfrom an ownership of different monopoly from overhis healthy is ownership natural organs crucially is the a of secured resources. 1983. Lumitao. Oxford University Ethicsas a Profit H. A.R. 72-85.E. PublicAffairs. M. It aboutexploitation. R. H. Reading: ed. and E.SpareParts:OrganReplacement American Press. Jr. Jr.HarmstoSelf New York:Oxford University In Effect.: Georgetown University Washington. Journal Philosophy.C.. in of brings intervening thecommerce thefirst exploitation. of In H. University pp. of Engelhardt. Cambridge: in J. Organizations. 101-105. Putterman. 1982. 3-33. Right HealthCare? Epstein. Fox. nomicinstitutions'" of Unireedom. Press. "Comment Dawson's 'Exit. "Is Women'sLabor a Commodity?' Philosophy vol. In J. A. Anderson. "Is MoreChoice Better vol. ofMinnesota 201-235. Philosophy. 1982. 239). "The Structure Proletarian vol.: Georgetown Materials. Honderich." Paternalism. Dworkin.C. 1971. T. 1986. Biological . 21. A.BodyParts:Property of Rights theOwnership Human Press. "Coercionand Moral Responsibility. first in of whileintervening thecommerce thesecondcan prevent not.47-61.New York: Press. person'smonopoly 6. Press. Frankfurt. Exploitation.Forthcoming.Philosophy Cohen.358 PUBLIC AFFAIRS QUARTERLY a Hillel Steiner. 1998. 7. 13. The Foundations Bioethics. Freedom Action. 68. and Economics Philosophy. p.

vol. "Transplantation: The State of the Art. pp. Proceedings. R. 1996. 1990. and theGiftof Life. 340. S. "Manipulation. ContestedCommodities. S."lnfusionsther Transfusionsmed. pp. 1978. L. J. Holmes and L. . Iglehart.vol. and Matas. Ketchum. Moral Arguments. Dossetor. and Greene." In Feminist .ed. England Rudinow. Monaco. Nozick.." In Organ ReplacementTherapy:Ethics. vol. 1991." Proceedings. pp. 1996. ed. "Ethics of a Paired-kidney-exchange Program. 22. 1980. 30-65. C." Lancet. Land and J. 1978. Martin's Press. vol. pp. 336. 1996. "Canada's Health Care SystemFaces Its Problems. 88. Government Printing and the Open Market. et al. Cambridge:HarvardUniversity Press.C. 1992. J. 1990. 1995. Years or More of Follow-up of Living KidneyDonors. Berlin: SpringerVerlag." In Philosophy. 337. 338-347. Radcliffe-Richards. P. Hillsdale. Ross. J. 1992. in Renal Transplantation India.B. Office. 1752-1755. 910-911. 896-901. "Unconventional Reddy. Chavers. 1997. "Should Marxists be Interested in Exploitation?" vol.: Lawrence Erlbaum Assoc. "Human Organs Puig. 1969. S. vol. pp. Transplantation Roemer. The Hidden Costs ofReward. 21. W. Youngner et al.S. 1987. L.Commerce. M. A. C. Purdy Bloomington: Press. vol. M. 1990. et al.vol. pp.. et al. F. 322."New Journalof Medicine."Ethics.Justice.J." In Organ Transplantation: Meanings and Realities.S. 1387-1392. 14. of Madison: The University Wisconsin Press. Murray. B. New York: St. A. Philosophyand Public Affairs. Washington. Marmot. New Developments in Biotechnology: Ownership of Human Tissues and Cells. "Organ Donation for Consideration. pp. 22. A. Radin. E. et al. N. D. 807-810. E. C. pp. pp.ed.IS A MARKET IN HUMAN ORGANS EXPLOITATIVE? 359 J.A. London." 375^16. Transplantation T."Ethics. vol. 44-72.D. "Health Inequalities Among British Civil Servants:The WhitehallII Study. and Method.J. "Coercion. Perry. "NephrariousGoings On: Kidney Sales and The JournalofMedicine and Philosophy.ed. "Organ Vendors. Reddy. McHugh. G. 562-568.M. pp. "Satisfaction of Paid ThrombocyteDonors with InstrumentalThrombocytapheresis.Families." K."Lancet. pp. Indiana University Lepper. NuffieldCouncil on Bioethics. vol. 1991. Human Tissue: Ethical and Legal Issues. pp. 1985. 63-71. S. 1995. "20 Najarían. J. M. K.. J. pp. 14-18.Science. H.. 22.: U. "Selling Babies and Selling Bodies. 173-180."New England Journalof Medicine. Perspectivein Medical Ethics. Morgenbesseret al. Office of Technology Assessment.

H. 1978. C. Coercion. Department Health and Human Services. 1989. "Birth Outcomes and vol. F. 912-914. vol." Ethics. Thalberg. "Changes in Mortality by Income in Urban Canada from1971 to 1986. "Two Questions about Surrogacyand Exploitation. 211-239. 121-145. pp. pp. Dordrecht:Kluwer. Adams. R. Sells. pp.. StatisticsCanada. 1981. 337.C. D. S.Washington. and Brancker." In Mental Health: Philosophical Perspectives. Exploitation. pp. A.I. by 3. et al. vol. 1. Ethics. .. "A Liberal Theoryot Exploitation. 94. 63-85. O. vol. 1996. Walzer. Wertheimer. D. Titmuss. 1991.1986. Princeton:PrincetonUniversity 1992." Health Reports. 1984. 1990. Infant Mortality Income in UrbanCanada." Transplantation Transplantation Proceedings. and Best. Engelhardt. United States Task Force of on Organ Transplantation. Sherman. Office..vol. 1971. "Markets in Women's Sexual Labor. 21." Philosophy and Public vol. Zimmerman. T. U. R.A. New York: Basic Books.S. 1983. Government Printing M. F.G. Organ Transplantation. Press. 106.Princeton:PrincetonUniversity Wilkins. 225-241. Spheres of Exchange. 22."Phivol." New England Journalof Medicine. 1392-1393. pp. M. vol. 1997. "Paired-kidney Exchange Program. 10. P. Affairs." Health Reports.Jr. "Motivational Disturbances and Free Will. Steiner. 1986. Wilkins. Press.R. 1995.360 PUBLIC AFFAIRS QUARTERLY Satz.. The GiftRelationship.: U. "The Practice of UnconventionalRenal (UCRT) at a Single Center in India.New York: Pantheon.and S. StatisticsCanada. A. "Coercive Wage Offers.R. A. losophyand Public Affairs. 1987.éd. Thiagarajan.pp. 201-220.D. pp. Spicker.H.