To the Editor:
For more than 25 years, health authorities around the world have expressed concerns about the harmful effects of commercializing organ donation from living as well as deceased donors. Through a series of resolutions, beginning in 1987, and then with the adoption in 1991 of a set of Guiding Principles for Human Organ Transplantation, the World Health Assembly strongly urged its member states to prohibit organs sales and brokering, while at the same time promoting voluntary, uncompensated donation through better organ procurement laws and management. In May 2010, the World Health Assembly reaffirmed its opposition to organ markets, noting especially that monetary “rewards” or “incentives” are as objectionable as financial payments (1).
Nonetheless, proponents of organ sales have persisted in urging that prohibitions be replaced by a “regulated market” (2) based on arguments that are both empirically and ethically unconvincing (3,4). In November 2010 a number of well-known proponents of financially incentivized organ sales chose to travel to the Philippines, funded in part by Filipino organizations that have favored organ sales to foreign recipients, to develop “international standards.” The resulting article in the February issue of the AJT (5) makes no attempt to justify departing from the consensus embodied not only in the Declaration of Istanbul (6) and the WHO Guiding Principles but also in existing law everywhere but in Iran. Rather, to support their proposed “incentives” for living organ “donation,” the authors repeat familiar arguments that have been thoroughly discussed and rejected in light of decades of abuse (7).
The Manila “Meeting Report” is problematic on many levels. For example, the contention that financial incentives must be “fixed” from one locale to another is belied by the reality of markets (as evident in Iran and elsewhere) that it is impossible to set prices for organs; those eager to obtain a kidney willingly pay extra to obtain “better” organs or to undergo transplantation more quickly. The Manila report authors contend that a regulated market is needed because the present prohibitions cannot be enforced; yet if that is true, how will their proposed “regulations” be enforced? Furthermore, asserting that a “trial” of an organ market is necessary to determine its efficacy is akin to suggesting that countries conduct an experiment in fixing a price for “voluntary” slavery, whereas in reality countries prosecute criminals to stop human trafficking.
Any thought among the AJT’s readers that the mechanisms for governance and non-corrupt enforcement of the law, much less the transparency or level of economic development with which they are familiar, would prevail if regulated organ sales were implemented in the Philippines or other developing nations is naïve or worse. For the standards proposed in this “Incentives” article to work—whether in Manila or Minnesota—you would have to accept that it is ethical to build a medical procedure on permitting the poor and vulnerable in any community to part with a kidney for the wealthy sick.