“有人需要肾吗?”或“市场的道德界限是什么?”'
Daniel Mullin

18 April 2013

I'm in the process of looking for work. In the meantime, I'm a bit low on cash. A friend of mine recently joked that I could always sell a kidney. Well, I'm not that desperate (yet), but the fact remains that I can't sell a kidney, at least not legally. This got me thinking: should I be able to do so?

Most people have intuitions about what it's okay and what it's not okay to do for money. Harvard philosopher Michael Sandel has articulated some of those intuitions inWhat Money Can't Buy: The Moral Limits of Markets.Although I haven't read the book, I know he takes up the issue of selling organs and rejects it on ethical grounds. The gist of his argument can be foundhere. I understand these intuitions, but I'm not sure I agree with Sandel entirely. Admittedly, I haven't thought about the issue as long as he has, and my thoughts are still nascent, but I'm going to try to craft an alternative argument and you can judge it for yourself.

To return to our moral intuitions, however, our society tends to frown on people who sell their bodies. This is usually a euphemism for prostitution (which I think should be legal anyways) but we could take it more literally to include the sale of body parts. When it comes to the reproductive system, however, we don't seem to have a problem with it. Men can sell their sperm and women can sell their eggs. A woman can even lease out her uterus as a surrogate mother. But when it comes to the renal system, we as a society draw the line. Why? Granted, there are practical moral issues involved with the sale of organs as Sandel points out. The sellers tend to be poor and the buyers tend to be rich; the movement of organs is usually from the third to the first world. But that might be because these are black market transactions. If they were legal and above ground, a fair market price might emerge. But Sandel is right: the key issue is autonomy. The decision would have to voluntary, not coerced, and determining that in practice isn't easy. Nevertheless, it isn't easy to determine in the case of surrogate mothers or people who are paid to take experimental drugs, yet many of us accept the moral permissibility of these practices.

也许我们抵制器官买卖的部分原因是我们认为免费捐献器官是一种高尚的行为。与其得到补偿,不如把它们送人。再说一次,我们大多数人都承认免费给予和用它换取金钱收益之间的区别。也许正是因为坚持这一原则,我们才会认为器官捐赠是好事,而出售器官是坏事。但我不相信这个原则在这里行得通。原因是,在大多数器官的情况下,捐赠是死后的。想想看,死后捐赠并不需要捐赠者做出真正的牺牲。(这就是为什么我对填写器官捐赠卡的人如此之少感到惊讶。我甚至赞成将捐款作为默认立场,也就是说,你必须选择退出这个项目。)毕竟,捐赠者已经死亡,不管有没有他们的器官,他都将继续死亡。 But in the case of a live donor, as is possible in kidney transplants, there is a real sacrifice. The person is actually giving up something. Isn't such a person entitled to some compensation?

为了更清楚地说明这一点,让我们考虑一个相对没有争议的场景。假设我哥哥需要一个肾。我当然会被合法地允许捐出我的一个,我也会感到道义上有义务这样做。但这并不完全是无私的行为。是的,我会做出牺牲,但我也会获得一些东西,也就是我的哥哥在我身边的时间更长,享受更好的生活质量,这反过来也会影响我的生活质量。所以这对我来说并不完全是无私的举动。换句话说,我得到了某种补偿。在陌生人的情况下,我与他没有家庭关系,也没有任何期望会改善我的生活质量,期望金钱补偿是不合理的吗?

不用说,这个问题很复杂。我甚至还没有谈到这样的补偿是否会解决短缺问题,并增加等待移植的患者的净健康。我不能说我已经在这个问题上确定了完全的立场。我只是试图提供一些思考的食物,并推动我们的道德直觉的新方向。你觉得呢?

Comments(4)


Daniel Mullin's picture

Daniel Mullin

Sunday, April 21, 2013 -- 5:00 PM

Yes, the word 'might' is

Yes, the word 'might' is important which is why I chose it. I don't say that it definitely will emerge. But the surrogate mother case provides a good example, I think. As I guy, I'm running a risk commenting on this because obviously I don't speak from experience, but it seems like there is a fair market price in this case. Surrogate mothers arguably make more than they would in a year at a median-paying job. It doesn't prima facie look like a case of exploitation, but I'm open to being corrected.
Speaking of side-stepping, you kind of talked around the concrete argument and examples I gave. You talk a lot about the generalities of markets and slippery slope-type arguments about where such thinking might lead, but you don't respond in any detail, as far as I can tell, to this specific case or how legalizing the sale of kidneys -- with the appropriate regulatory oversight of course -- leads to the deliterious consquences you envision.
I agree with you, however, that economics is not morally value-neutral. I stated up front that we have intuitions about what it's not okay to do for money. My question is simply why does selling a kidney fall under this heading whereas other examples of 'selling one's body' arguably do not? Your answer seems to be that introducing market forces will make the exchange value-neutral. But isn't that just conceding the point to your capitalist interlocutors? Why not talk about the ethics of markets across the board? The kidney case, then, becomes just one more example, albeit a difficult one, of how we assign value, both moral and economic.

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Daniel Mullin

Sunday, April 21, 2013 -- 5:00 PM

格鲁,谢谢你的链接。I

格鲁,谢谢你的链接。我以前可能听过那一集,但有机会我就会记起来。
With respect to Richard's comment, it probably warrants more by way of response than I gave it the first time around. In retrospect, my response seems a bit terse. I was writing in a hurry, but I wouldn't want that to be mistaken for dismissiveness on my part.
显然,我还没有把我的初步建议的具体安排好。那不是这篇文章的目的。我只是想搅局。当然,如果“卖给出价最高的人”是唯一的选择,这个提议就会有问题。但将肾脏出售给出价最高的人——我认为这是最不可取的安排,而且最有可能被滥用——并不是肾脏出售和分配的唯一方式。如果政府器官银行设定市场价格,只在稀缺的情况下才鼓励出售,会怎么样?再说一遍,我只是提出一些想法。
我对把人看成商品的担忧也很敏感。大多数道德敏感的人都有这样的直觉:把人仅仅视为商品或达到目的的手段是错误的。但我不完全确定这一原则在这里如何适用。“出卖身体”的行为本身是否在某种程度上贬低了这个人?所有情况都是这样吗?具体在这个案例中?如果一个人如此自主地做这件事,是否仍然如此有辱人格以至于国家有压倒一切的利益来阻止它?这些都是与这个问题相关的问题。在我看来,这就变成了一种练习,就像随意画线一样。我们在其他地方所依赖的一般原则在这些情况下有用吗?
Also, are there cases in which compensation can actually affirm personhood? Whether we like it or not, the way our society assigns value is through money. Perhaps I'm sensitive to this because over the past five years I gave a lot of myself to a job for which I wasn't fairly compensated. This has a profound effect on one's sense of value and can rightly be described (I think) as a denigration of one's personhood. I don't know if this principle applies here, but there's a fine line between volunteerism that's noble and volunteerism that exploitative. I can envision scenarios in which 'giving out of the goodness of one's heart' or out of a perceived sense of obligation, are more exploitative than setting up mechanisms of fair compensation. Again, whether this applies in the kidney case is debatable.
P.S. I hope that, ultimately, this will be a moot issue, as medicine advances and we can clone replacement parts in the lab. But, still, the process would likely be expensive and may still cost the recepient some money. Would this be less morally objectionable, however?

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Daniel Mullin

Monday, April 22, 2013 -- 5:00 PM

I suppose I'm curious about

我想我很好奇是什么让代孕案例和你的肾脏案例不同?为什么女人的子宫是市场的合法领域,而不是某人的肾脏?
I think we might also be in danger of talking about "something called 'the market'" in too abstract a way. Markets can be very complicated entities, but the basis for markets is relatively simple: property rights plus contracts. We generally think this is fine when the arrangement is voluntary and we generally acknowledge that individuals have a high degree of sovereignty over their own bodies. Again, people already sell blood, sperm, eggs, wombs, etc. This at least sets the stage for extending markets to cover kidneys.
The only real issue that I can see -- and I think that this *is* central to both Sandel's and Satz' position -- is the problem of weak agency. In other words, are the persons giving up their kidneys doing so in an informed, voluntary way and not being coerced by some external agency or circumstance. I acknowledged in the original post that these are practical worries. But there are at least two responses available: 1) these worries may be overcome by regulatory oversight (we shouldn't generalize from black markets to regulated markets); 2) the problem of weak agency applies also to donation (as opposed to sale).
But these are all arguments on the individual autonomy side. You rightly bring up the issue of our collective concerns. Well, how about the argument that allowing a market in kidneys would increase supply and reduce the suffering and death of 75,000 Americans on waiting lists? This is a social welfare argument and I think it ought to give us pause. We can talk idealistically about some things being too precious to be reduced to market forces, but in the meantime there are a lot of concrete cases of suffering that go unanswered. It's an exercise in utilitarian calculus, I know, but it speaks to the 'greater good' aspect of the argument.
In any case, it's good to bear in mind the bigger picture, because our moral intuitions may lead us astray. The idea of using someone, even if they are fairly compensated, for spare parts rightly causes a twinge of conscience. However, we typically don't feel that same twinge of conscience in the case of the tens of thousands per year who die awaiting a transplant. This is the problem of silent suffering and it looks suspicously like a cognitive bias in our moral reasoning.
At the end of the day, I suspect that one's position on this issue comes down to how much weight they place on individual autonomy and how much weight they place on the aggregate suffering of those on wait lists. Clearly, kidney markets aren't ideal and aren't without their problematic moral consequences, but we're seldom given the luxury of choosing between ideals. The pragmatic question, then, is "are kidney markets better (or at least no worse) than the alternative?" Tentatively, I still find myself saying 'yes.'

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