A couple of months ago, I wrote a piece supporting the sale and purchase of organs. I argued that allowing for a market for organs would get rid of the lack of supply of organs that are desperately needed to save the lives of those in need of an organ transplant (the literature tends to agree, as does empirical evidence from Iran). Every year, tens of thousands of people (about 100,000 in the U.S. alone) in need of new organs must wait because there lacks a supply of healthy organs available to them, and thousands more die because of this shortage. Every year the shortage continues to rise (demand is increasing faster than supply is). Healthy organs abound, but the shortage arises from the fact that it is a crime to sell or purchase organs. The altruistic donation of organs, while undoubtedly saving many lives, simply does not come close to supplying the necessary amount of organs. The logical conclusion seems to suggest there ought to be a market for organs.

Some people, however, detest this notion. In a recent post on his blog, Dr. Filip Spagnoli makes several nuanced arguments against free organ trade. The main arguments he makes, insofar as I understand them, are that the poor, qua the poor, will be desperate for money and therefore forced to sell their organs; the wealthy, qua the wealthy, will be able to disproportionately afford the organs and therefore be unfairly benefited; organ transplants are dangerous; solid organs donation is nonrenewable and therefore decidedly and relevantly different from blood donation; organ trade is tantamount to commodification of the body; and an opt-out system is the best solution to our problem.

King Banaian, a professor and chairman of the economics department at SCSU, made an argument similar to first listed above, back in 2005. The poor are desperate, goes the argument, and so it’s unfair they would end up selling organs (i.e. they lack informed consent). The basic underlying premise of this argument is that the poor are irrational, incapable of thinking for themselves. The government, therefore, knows what’s better for them than they themselves do. That is, they have to be protected from themselves (because they’re poor). I reject that argument. If the premise is true for the sale of organs, then it would be equally true of other economic decisions they make, including the sale of their labor or their purchase of goods. That doesn’t seem to be the case and, if it is, we certainly don’t restrict completely their involvement in the market (and even more certainly not the involvement of others).

So the argument seems to be that, if it weren’t for the money incentive being offered, the poor wouldn’t choose to donate their organs. But that’s true of basically all people. Economic agents would not do many things if it were not for the money incentive. Dell wouldn’t sell me computers if they weren’t being compensated for it. Is that exploitation (of their want for money)? I don’t think so. That’s called trade, and both the seller and buyer are made better off by it. So what the detractors have failed to explain is how the poor are made better off by ensuring they are not able to receive money that would help alleviate their predicament.

The second argument is that the wealthy, because they obtain more wealth, “will be able to benefit disproportionately from the market because prices will be high …” Dr. Spagnoli says this is true because society is aging, but admits prices will fall because of competition among suppliers, particularly from poor places like Africa. Still, the fact that the wealthy can disproportionately afford things does not suggest to me there ought not to be trade. So long as the distribution of wealth is unequal (which seems to always be the case), some people will be able to afford more than others. That doesn’t mean we outlaw trade. (The wealthy can afford more food and labor than the poor; do we therefore outlaw the sale of food or labor?) That seems to be punishing the rich merely by fact that they’re rich. And in this case, the punishment is death. Detractors of organ trade fail to explain how outlawing trade benefits the less-than-wealthy who are in need of an organ. It seems to me that as the wealthy begin to demand less organs, prices will begin to fall (allowing even the poor to afford to buy organs). By outlawing organ trade, detractors are (at best) disallowing some people from buying lifesaving organs merely because of their wealth.

The next argument is organ transplants are dangerous, so they should not be allowed. It’s true that all surgery, even the most benign, carry risk (including death). That reason alone is not enough to outlaw transplantation of organs. If it’s dangerous to sell organs for money, then it’s equally dangerous to donate organs altruistically. But we allow the altruistic kind. Clearly, danger is not the underlying factor here. Moreover, the dangers are overplayed, I think. The death rate for liver transplantation in Japan is at 0%, and 0.3% in the United States. These rates will continue to decline as advances in medicine continue and as surgeons progress along the learning curve. Kidney transplantation is even safer (people who donate kidneys live longer than those who don’t). Remember, it was Joseph Murray who won the Nobel Prize in medicine for completing the first kidney allograft in 1954. The patient in that case is still alive. While there is serious risk in many activities, including surgery (or timber cutting or smoking, which are both legal), that’s not enough to outlaw the practice.

Another argument is that blood (or sperm perhaps) is okay to sell because it’s renewable. The only defense here is that the distinction between renewable and nonrenewable is “relevant,” but without any further explanation. How is the distinction important? The fact that some goods are scarce doesn’t tell me a lot (other than that their price is going to be higher). Furthermore, modern liver transplantation in live patients consists of removing only a portion of the liver from the donor, which will regenerate and return to full functionality within a matter of a few weeks. Does the detractor now accept the trade of livers? (Similarly, the sale of bone marrow, which is just as renewable as blood, is a serious crime in the United States.)

A very common argument that also comes up is that the trade of organs is tantamount to the commodification of the body. I say, So what? It saves the lives of real human beings. That’s what matters. “Commodification is dehumanization,” they say. I counter that there is nothing more dehumanizing than simply letting people die, which is precisely what you do when you outlaw the trade of organs. So what is worse: that people might sell parts of their body or that hundreds of thousands of people are unable to get organs that could save their lives? Supporters of this argument also fail to explain how blood, bone marrow, sperm, ovarian eggs, or bearing children (all of which have markets) do not constitute commodification. Or, if they do, do they believe these practices ought to be outlawed? It’s also worth mentioning that even in altruistic donations, people are still profiting from it: the doctor, the nurses, the hospital, and so on. That is, everyone except the donor.

They might respond, We’re not letting them die because we have a solution, which is the op-out system. Opt-out, also called presumed consent, begins with the assumption that all people wish to donate their organs upon death. If you do not consent, you must specifically tell this to the state. (My contention is that this is akin to saying the state owns your body by assumption.) This is opposed to the opt-in system, like in the United States, where the assumption is that people do no wish to donate their organs upon death, unless it is otherwise specified. In that way, the hope of opt-out supporters is that people are not altruistic, but rather lazy or ignorant. I find that deeply unethical, but Dr. Spagnoli points to several studies from his country, Belgium, which show opt-out is providing an ample amount of organs (that is, people seem to be lazy or ignorant). (The rate of “donation” is marginally higher than that of the U.S.) A lot of the scholarly literature, however, does indeed seem to suggest opt-out provides higher rates of organ “donations” than opt-in. If this were necessarily true, though, Sweden and Israel (opt-out states) would not have such low donation rates. A study published in 2005 further shows that opt-out systems do not guarantee higher donation rates. The authors find that, when correcting for mortality rates, the apparent efficacy of opt-out disappears. Perhaps better than opt-in or opt-out, a better choice would be mandatory choice. All competent adults must choose whether or not they wish to donate their organs or not. Family decisions (which negatively affect the efficacy of both opt-in and opt-out) must not override the individual’s choice.

Still, it seems giving enough of an incentive to potential donors is the key to finally getting rid of organ shortages, which cause unnecessary deaths each year. As I explained earlier, Iran has been successful in accomplishing this. If detractors are unwavering, however, then perhaps markets are not necessarily the correct solution. Instead, I might propose a system wherein the government pays for the organs and then distributes these as equitably as possible. This removes a lot of the fears detractors have of unfair market allocations. Others, unfortunately, might reflexively bash the idea because it relies on (*moan*) the government. But I ask these people the same question as before: What is worse—that the government might be involved in the trade of organs or that thousands must die needlessly each year because they are unable to procure necessary organs?