I Don’t Care Too Much for Money, Money Can’t Buy Me Lungs

Is it true that “everyone’s a winner”, as Julian Savulescu suggested recently on this blog , if we price life and body parts? Let’s accept that if there is a valid objection to buying and selling body parts, it must be grounded in the recognition of a harm that would come to some person or group of people. Consider, then, Savulescu’s suggestion that we should price body parts, and engage in buying and selling of them. We could categorize the potential harms that it might generate under the following headings:

(1) Harm to the participants in the transactions: donors, recipients, or facilitators

(2) Harm to specific third parties

(3) Harm to society at large

If we discover that any harms of types (1) – (3) would arise from selling body parts, then we must engage in an ethical analysis to see whether those harms would be all-things-considered justified or not. Savulescu focuses his blog post on harms of type (1), and in particular, on harm to donors: “the objection to selling eggs [and organs] … has to be about doing it in exchange for cash. But the exchange is only wrong if it exploits someone – and that is easily prevented by setting a minimum fair price [to compensate for the small risk involved].” While I think that Savulescu is right that setting a minimum fair price would prevent the economic exploitation of donors by buyers, I retain some doubts about the practice of selling body parts. In this post I want to highlight some potential further harms, not of type (1), to donors, but of types (2) and (3), to specific third parties and to society at large.

If a widespread market for body parts were to develop, donors (or, more accurately, sellers) would presumably be able to earn significant amounts of cash for them, and somebody would need to pay the prices that they would command. Although the state could be the sole buyer of body parts and distribute them according to need, most of those who argue for a free market in organs envisage that those buyers willing and able to pay the highest prices would have the best access. And contra Savulescu’s optimistic claim that each free market transaction would “remove a potential egg [or organ] recipient from the altruistic pool … and there will be more eggs [or organs] to go around to those who can’t afford to buy them”, there is strong reason to believe that the development of a market would tend to undermine the voluntary exchange system that presently exists. Richard Titmuss showed in his seminal book The Gift Relationship that paying blood donors can significantly decrease supply overall. As giving blood becomes commodified, he argued, the existing system of voluntary donations becomes crowded-out, and altruistic motivations cease to have their very important positive influence. Even if it were not the case that the introduction of a market for body parts would similarly reduce the overall supply, it seems highly likely that it would reduce the supply of voluntarily donated body parts. The net effect of the change would then be the accompaniment of any expansion in the overall supply of body parts with a significant reallocation of them from those most in need to those in relatively little need but with a high ability to pay. A useful analogy here is to our existing system of funding for pharmaceutical research: private drug companies spend a great deal of money on research, and arguably it is more money than any alternative system of funding could provide – but the research that is privately funded is heavily tilted toward providing lifestyle drugs for rich westerners rather than cheap drugs with potentially much greater public health benefits for the third world. With the introduction of a free market system in body parts, some of the worst off members of society – those in the highest medical need and also lacking in financial resources – would surely be harmed. Thus we have identified a harm of type (2), to a third party, that must be considered in considering the case for pricing body parts. (Note that this argument may apply to human eggs equally as it does to vital organs if we think that society ought to provide treatment for infertility – the development of a market in eggs could produce a shortage among those who need them most, for example if the available eggs were bought by women who are not intrinsically infertile, but rather have decided to postpone reproduction beyond the natural age of fertility for reasons of convenience.)

There is also at least one important way, I think, in which the development of a market in body parts might harm society at large; a harm of type (3). This is because the development of a market in body parts would change the norms of the relationship of all of us to our body parts, and to each other. And I believe it is plausible to think that we would lose something of significant value about our current relationships with that change. To see why, consider that as things stand, organs do not have a monetary value for their owners. Faced with, for example, a rent demand and inadequate cash to pay for it, a couple of the choices you can make are to sell some of your possessions, or to find (additional) employment and sell some of your labour. One choice that you do not currently have, and therefore do not have to consider, is whether to sell a kidney or a piece of one of your lungs to raise the funds (nor, indeed, the organs of a dying relative, if you happen to have one around). It might first be thought that it can never be a good thing for you to have fewer rather than more options. But I believe that this attitude is mistaken on a number of grounds. For one, consider that others hold you accountable for not making the choices that are necessary in order to fulfil your obligations. As things stand, even if you had no possessions to sell and could not find a job, nobody could criticize you for failing to sell an organ to meet your rent. If a free market in body parts were permitted and became widespread, they would become economic resources like any other, in the context of the market. Selling your organs would become something that is simply expected of you when the financial need arises. A new “option” can thus easily be transformed into an obligation, and it can drastically change the attitudes that it is appropriate for others to adopt towards you in a particular context.

I haven’t attempted to show that we should not price body parts; perhaps the harms of the kinds I point to would in the end be outweighed by the enormous benefits that a free market would bring along with it. But I have pointed toward just two examples of the potential harms of types (2) and (3) that may result, and that give me some personal reservations about the idea of introducing a market system for body parts.

Reference:

Richard M. Titmuss, The Gift Relationship: From Human Blood to Social Policy (London: Allen & Unwin, 1970).

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19 Responses to I Don’t Care Too Much for Money, Money Can’t Buy Me Lungs

  • Marco Antonio Oliveira de Azevedo says:

    Simon has a very good and interesting point. But I note with personal surprise that it reminds me of David Velleman’s argument against euthanasia.

    Velleman thinks we have reasons for not having the option of euthanasia, and his best analogy is the case of dueling. He thinks we’d produce a harm to others (in a sense similar to Simon’s: a harm to a “third party” or “society at large”) in creating the permission of dueling; and he thinks the same in the case of euthanasia. I don’t agree with him in the case of euthanasia (and I suppose Simon doesn’t either), but certainly Velleman has a good point in the case of dueling. Since we don’t have the ordinary option of challenging anyone to a duel, we also don’t have any ordinary reasons for dueling or not dueling (for challenging or accepting the challenge). But we can restore (or create anew) people’s ordinary reasons for dueling by introducing a (legal) permission. The problem of dueling is that this practice has undesirable/bad social and third party results. Dueling is not in most (and probably almost all) cases something that is good for duelists (that is, in Crisp’s terms, something that improves duelists’ well-being, or in terms I prefer, something that increases the probability of duelists’ attainment of their own interests or well-being in the long run). But the worst problem is that the person challenged can feel “obliged” (and in most situations not only subjectively feel obliged but be objectively coerced) to accept a duel against his own desires or inclinations. Velleman’s point, I think, is that this would be an undesirable consequence of the “freedom to duel” in societies with some cultural obsession of personal honor.

    I don’t think that Velleman’s argument here can be applied in the case of euthanasia, since, at least in ordinary cases, euthanasia is a reasonable option, for it is the better outcome to persons who are suffering and would not gain any well-being from the prolongation of their lives. Moreover, the possibility of someone being obliged or being coerced to commit “suicide” or “euthanasia” is not only very improbable; it is a contradiction in terms. But Velleman’s points against dueling can be applied in an argument against selling organs. And that seems to me to be precisely Simon’s argument. The permissibility of selling organs (in market transactions) creates the undesirable possibility (for any agent) of having pro tanto reasons for selling his or her organs in situations of serious financial need. Worse, it can create also the awful possibility of having as his or her best option in some circumstances the option to sell one of his or her organs even against his or her own proper wants or desires. Why would it not be reasonable to sell a kidney for the sake of buying a very good house? Since it is prima facie reasonable, now the question is this: which one of these two possible worlds would be preferable to us: one with that kind of option or one without it? Well, having that option would lead us almost certainly to the alternative of selling, for in that case this is the most reasonable choice. Simon points out that those new “options” can thus easily be transformed into obligations, that is, that the person can consider himself obliged of selling an organ contrary to his or her own preferences. Julian’s high minimum price could certainly allow for this to occur without exploitation. But we normally are not inclined to think that selling organs is desirable. Organs are parts of us; they are not simple objects or mere exchangeable things. Simon points out that we have reasons for not permitting the practice based on harms to “third parties” or “society”. But I think we can understand his points in another way, for we can have also some (im)personal reason for not being caught in the awful situation of having those kinds of options in our lives. Even if those options could sometimes be the best available alternatives, when considered “in the long run”, it is best for us individually to not have those kinds of personal options. Setting a minimum fair price doesn’t solve the entire problem (aside from exploitation), but viewed this way the kind of harm is still a type I harm, along with II or III, since it threatens our best common prospects of having a good yet unconstrained life.

    Marco Azevedo, from Methodist University Center (Porto Alegre, Brazil). [SR: Comment edited for readability]

  • Katja Grace says:
  • Simon Rippon says:

    Hello Katja, thanks for the response you made on your blog. I think the same reaction may be common among a number of (laissez faire) economists, so let me quote some of it and respond here. Here’s what you wrote:

    “[Simon Rippon is] right that at that moment where you would normally throw your hands in the air and move on, you are worse off if an organ market gives you the option of paying more debts before declaring your bankruptcy. But this is true for anything you can sell. Do we happen to have just the right number of salable possessions? By Simon’s argument people should benefit from bans on selling all sorts of things. For instance labor. People (the poor especially) are constantly forced to sell their time – such an integral part of their selves – to pay rent, and other debts they had no choice but to induce. If only they were protected from this huge obligation that we laughably call an ‘option’. Such a ban might be costly for the landlord, but it would be good for the poor people, right? No! The landlords would react and not rent to them.

    In general when negotiating, it’s best to not have options that are worse for you. When the time comes to carry out your side of a deal, it’s true this means being forced to renege. But when making the deal beforehand, you do better to have the option of carrying out your part later, so that the other person does their part. And in a many shot game, you do best to be able to do your part the whole time, so the trading (which is better than not trading) continues.”

    We can paraphrase your argument more clearly, I think, in the form of a reductio:

    1) When you are faced with an existing debt, it would be better for you not to have *any* peronally costly options available to you for paying it off, because then you could declare bankruptcy and escape the debt.
    2)If there were no personally costly options available to people to pay their debts, then we would cease to allow others to incur debts in the first place.
    Therefore:
    3) Market-based exchanges would be severely inhibited.
    Therefore:
    4) The situation would be worse for everyone.
    Therefore:
    5) Not-(1).

    The difficulty for your argument is that I was simply not committed to (1). Observe that I was responding, in the material you quoted on your blog, to the potential objection that:
    “it can NEVER be a good thing for you to have fewer rather than more options”
    In order to respond to that objection, I do not need (1), but only the weaker (1′):

    (1′) When you are faced with an existing debt, it would be better for you not to have *some* peronally costly options available to you for paying it off, because then you could declare bankruptcy and escape the debt.

    But now your reductio cannot go through based on (1′). You can’t derive (3) from (1′) and (2). Maybe you will say that a modified (2) will still allow you a reductio of (1′), as follows:

    1′) When you are faced with an existing debt, it would be better for you not to have *some* peronally costly options available to you for paying it off, because then you can declare bankruptcy and escape the debt.
    2′)If some personally costly options were not available to people to pay their debts, then we would less often allow others to incur debts in the first place.
    Therefore:
    3′) Market-based exchanges would be somewhat inhibited.
    Therefore:
    4) The situation would be worse for everyone.
    Therfore:
    5) Not-(1′).

    But the trouble with this revised argument is that we have no grounds whatsoever for thinking that (4) follows from (3′). It might fit with the thinking of many reflexive free market fundamentalists, but there’s absolutely no evidence for it in practice, nor on the basis of any plausible economic theory.

    The move from (3′) to (4) in fact depends on, among other things, a value judgment about the relative value of being able to engage in a greater number of market exchanges versus the value of not finding oneself socially obligated to do things like, for example: sell one’s vital organs, betray one’s country for money, sell onseself into slavery, sell one’s children or other family members, or engage in prostitution. If you think that the instrumental value of being able to incur these social obligations outweighs the intrinsic value of never being subject to them, you will disagree with me. But then you will have taken up a very implausible moral view.

  • Katja Grace says:

    Your original explanation for why one may be better to have fewer options in this instance applies equally well to all options you could have or not, so if it is correct, so is 1).

    Your last point about weighing up values could differentiate between some options and others, but I see no reason it should draw the line where you say, or that this is the only plausible moral view. Allowing people to decide what debts to incur against what assets on their own seems consistent with most subjective moral views, and under utilitarianism presumably unnecessary organs should be forcibly redistributed if those without will die otherwise and voluntary trade isn’t occurring. Perhaps you could you elaborate on why removing any chance of being subject to having to sell your kidney should be such a huge intrinsic value to so many people, despite the observation that people regularly donate organs.

  • Simon Rippon says:

    Hi Katja, you wrote:
    “Your original explanation for why [it] may be better to have fewer options in this instance applies equally well to all options you could have or not, so if it is correct, so is 1).”

    But my original argument does not entail (1)! All that my original argument entails is that any option can be transformed into an obligation. I never said that the badness of having such an obligation always outweighs the goodness of having such an option (that can be transformed into an obligation). I didn’t even commit in my post to the badness of being obligated to donate organs outweighing the goodness of having the option to do so in the free market.

    You’re right that the line I drew in my reply to you between which market exchanges should be allowed and which should not (with organs on the “not” side) may not be the only plausible one. But I gave some examples in my reply of why there must be a line somewhere, since it’s not plausible that *all* exchanges should be allowed (I’m afraid I’m not sure what you mean in your reply when you talk about most “subjective moral views”, so I can’t respond to that part of your reply. As for utilitarianism, I don’t find it a plausible moral view myself, but I’ll let utilitarians speak for themselves about whether their view requires forcible organ transfers!)
    I do think the burden of proof is still on you to show why you think the (instrumental?) badness of the inhibition of market exchanges in this instance outweighs the obvious and immediate good to the poor of not being subject to forcible demands on their bodily organs.

    You also wrote:
    “Perhaps you could you elaborate on why removing any chance of being subject to having to sell your kidney should be such a huge intrinsic value to so many people, despite the observation that people regularly donate organs.”

    Why think this observation relevant? The fact that people regularly do something voluntarily (e.g. having sex, having children, refraining from having children, getting married, sending birthday cards, eating spinach), does nothing at all to show that there is no intrinsic value to them in not being *forced* to do it.
    I suppose I should also say that I think that, if organ selling were allowed, it is unlikely that the system would or could in practice be properly regulated to maintain a minimum fair price. There is an intrinsically limited demand (from people who could benefit from a transplant and who are rich enough, or live in societies rich enough, to pay for it), and an almost infinite supply of organs available, in principle, from the poor. So in all likelihood, I think a market in organs would exploit many of the poorest without making them any better off financially – or at least not significantly better off financially – in return.

  • Robin Hanson says:

    I’m with Katja; the form of your argument applies equally well to any thing one might sell or donate, and you haven’t said what is different about organs so that we should treat them differently from the rest.

  • Simon Rippon says:

    Hi Robin, in one sense you’re quite right: my argument applies (in principle) to anything one might sell. It says that having freedom to sell it may result in being obligated to sell it (in some circumstances). And this may be a bad thing for many people.
    It’s highly implausible to conclude from that argument that we should not be free to sell anything at all. As Katja pointed out, it would be very bad for us if we were not free to sell anything. It’s likewise implausible, as I argued in my reply to Katja, to conclude that we should be free to sell everything. Now, if on this basis I want to draw a line between some things we should be free to sell, and some other things we should not be free to sell, then I must hold that it is *worse* to be obligated to sell some things than it is to be obligated to sell others. But isn’t this self-evidently true? It’s much worse to be obligated to sell your labour *every* week of the year than to be obligated to sell your labour *some* or even *most* weeks of the year. That’s exactly why most industrial democracies (rightly, in my view) legally mandate minimum vacation time for employees (and analogously, limits to hours of the working week, and so forth). Isn’t it similarly obvious that it’s worse to be obligated to sell a second home, for example, than to be obligated to sell the shirt on your back? Isn’t it obvious that it’s worse to be obligated to sell your children than to be obligated to sell your unnecessary car? And isn’t it obvious that it’s worse to be obligated to sell your organs, than to be obligated to sell (for example) a 40-hour week of labour?

  • Robin Hanson says:

    Simon, being allowed to sell those things is a long way from being obligated to sell them. It is not obvious to me that it is bad to let people sell any of those things, nor even that some of them are worse than others in the directions you postulate. Really, you’ll need *arguments* to make these distinctions.

  • Simon Rippon says:

    Robin,

    1) You wrote: “being allowed to sell those things is a long way from being obligated to sell them.”

    Where is *your* argument? My entire argument was about the way in which a permission to sell something can result in an obligation to sell it; have you read my post? If you’d like to point out you think where the weakness lies in the arguments I’ve given in the post (and continued in comments) I’ll be glad to consider it.

    2) You say that it’s not obvious to you that, e.g.: it’s worse to be obligated to work 52 weeks a year than to work 50, it’s worse to be obligated to sell the shirt on your back than a second home, it’s worse to be obligated to sell your children than to be obligated to sell your unneccessary car, and it’s worse to be obligated to sell your organs than to be obligated to sell a 40-hour week of labour.

    I could give an argument for these claims, but it would be long and off topic I’m not going to do so here. I’ll simply invite you to agree if you happen to share any semblance of a normal value system with me. Most readers, I confidently predict, will accept my invitation.
    If you had instead said that it’s not obvious to you that a contradiction cannot be completely true, I would be entirely unable to give a non-question-begging argument for my view. But I would still be unperturbed by your objection. Asking for arguments starts out as a sound skeptical methodology, but it can end up as just anti-social behaviour.

  • Robin Hanson says:

    Simon, yes permission to sell something can end up leading to an obligation to sell, but the connection is hardly direct or reliable, so it makes little sense to evaluate a permission to sell primarily via evaluating the corresponding obligation to sell. For example, in marriage one “sells” one’s sexual exclusivity, and an obligation to sell this would clearly be very bad, but it hardly makes sense to ban marriage on this basis.

    it seems to me that you are just like most folks who have an intuition that such sales are bad, and you’ve added a lot of commentary but ultimately you just fall back on the fact that many people share your intuition.

  • Simon Rippon says:

    Robin: First, I think it’s pretty obvious, when you read it, that I don’t rest my argument on any intuitions about what things it is bad (or not) to sell.
    Second, a normal western marriage, as far as I’m aware, doesn’t involve the selling of anything sexual. But I suppose that if you fill in some background about the dowry system, gender discrimination, poverty, etc, then maybe you would describe a kind of marriage that does involve the selling of sexual favors and exclusivity, and that may often also become obligatory for financial reasons. If so, it’s not implausible to say that that kind of marriage should not be permitted, and that it should be prohibited precisely because the system in which it exists forces women to effectively sell their sexual services!

  • Robin Hanson says:

    Simon, when you make a deal with someone, you are “selling” the parts of the deal where you constrain yourself in a way you would not if there were no deal. When two people agree to be sexually exclusive with each other, they are each “selling” that exclusivity in trade for the exclusivity of the other, and the other parts of the deal. Not all “sales” involved cash.

  • Simon Rippon says:

    Robin, you have not argued that “selling” in your artificially broad sense is linked to obligation in the way that I have argued financial transactions are, and that permitting a type of this “selling” (i.e. permitting marriage) generally licenses others to criticize you for failing to “sell” (to someone not of your choosing) in order to meet a broad set of further obligations to unrelated third parties. So, you have not given any argument to establish that permitting marriage harms anyone. And neither have I.

  • Robin Hanson says:

    Simon, imagine a poor single mom struggling to make ends meet, with an offer of marriage from a rich man. Wouldn’t your argument suggest she’d feel some pressure to accept this offer? Should we then forbid poor women from marrying rich men?

  • Simon Rippon says:

    Robin, thank you. Does anything in my previous argument commit me to forbidding poor women from marrying rich men? No. Should we forbid poor women from marrying rich men? I don’t know, let’s consider the issues involved in the particular proposal. Would this policy protect some poor women who would find intrinsic value in not being obligated to marry rich men? Yes, perhaps. How many, and how much intrinsic value would they find in this? I don’t know. Would the policy harm some poor women who want to marry rich men out of their free choice, and not because they are coerced? Definitely. How much would it harm them? Quite a bit, since it seriously interferes with one of their most significant life choices. So is it plausible that a policy forbidding such marriages would be a good one? Probably not. Is there a strong analogy with the case of organ selling vs. donation here? No.

  • Robin Hanson says:

    Simon, we lose something when we sell anything, else why not give it away? So anything that we might sell has the downside that we might then have to sell it should we ever get desperate. So should we ban selling it on this basis? You suggest the heuristic of banning the selling of a thing if we’d lose a lot from selling that sort of thing. But this neglects the fact that we’d also tend to gain a lot from selling such things. More valuable things to sell also tend to be more valuable things to buy, and so command higher prices. They are also plausibly where lie the most gains from trade. So banning the sale of high cost, high value, high gains-from-trade things seems to me a bad idea as a general rule.

    On marriage, you again seem to just pull an intuition from the air, that some things seem to you on net bad to allow sales in and other things not.

  • Simon Rippon says:

    Hi Robin,
    “anything that we might sell has the downside that we might then have to sell it should we ever get desperate.”
    Exactly my point in the post, glad you’ve found it for yourself.

    “You suggest the heuristic of banning the selling of a thing if we’d lose a lot from selling that sort of thing.”
    No I don’t. You’d lose a lot (and gain a lot) from selling a piece of prime real estate in Manhattan, but my arguments did not imply we should ban selling such a thing. My heuristic, so far as I have one, is that we should *consider* banning the selling of a thing if *never being obligated to sell it* has great intrinsic value. For example: our children, our sex lives, our organs.

  • Robin Hanson says:

    Not sure what you mean by “intrinsic” value. Why isn’t there great intrinsic value from not being obligated to sell prime Manhattan real estate? The land has a lot of value, and if you valued it a lot you’d lose a lot from selling it. How is that not comparable to losing a lot from selling an organ?

  • Simon Rippon says:

    Marco Azevedo: I recently returned to this post and I want to thank you for pointing out how my argument here is parallel to Velleman’s on Euthanasia (in his “Against the Right to Die” (1992)). I think you’re exactly right about the close parallel between the arguments, and I’m disappointed to find that Velleman pretty much got there first (he in turn cites Gerald Dworkin (1982) and Thomas Schelling (1960) as having pointed out that having an option can sometimes be bad for you).

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