Settling the Final Reckoning for Organ Donors

In the news this week, the Nuffield Council on Bioethics suggests that the NHS should test the idea of paying for the funerals of organ donors who have previously signed the organ donor register, in order to try to encourage more of the public to sign up. When I was asked to write about this proposal for the BBC’s web site, I found with surprise that I could think of no plausible ethical objections to it. This despite the fact that I’ve previously written here and elsewhere about the dangers of introducing a cash market for donor organs, and even about the dangers of other kinds of non-cash incentives. If the council’s proposal were found in trials to be both practically effective in increasing donations, and also affordable, then my clear view is  that it should be implemented in the UK.

I have reached what at first sight appears to be a puzzling ethical position:  endorsing a kind of organ bartering, but drawing a line between some goods that may, and others that may not, permissibly be offered in exchange for organs. How could it be that we ought ot allow the NHS to offer funeral expenses in exchange for organ donation, but not cash, or other non-cash incentives such as free higher education, health insurance, or a trust fund that would provide security in retirement?

To explain, I must first return to the objection I raised previously to permitting a free market in organs. In fact I raised it as an objection to permitting the selling of live donor organs rather than organs taken after death, but I think it reasonably could be applied to the latter as well. . My objection was that in a free market, the donatable parts of our bodies would become economic resources like others (namely, our property and labour) and could therefore not only be used to provide us with opportunities that we may not have otherwise had, but could also be treated as a means we have of paying off debts, or of meeting our own basic needs or those of our families. Along with the ability to do something comes accountability to others for either doing or not doing it. An opportunity to legally sell an organ in the free market can therefore all-too-easily be transformed into a socially enforced demand to sell one.

I think there is significant intrinsic value in not being subject to certain kinds of demands, where our having control over the thing in respect of which we may incur demands is particularly important and meaningful to us. Our bodily organs, I believe, fall into this category, and it would be extremely bad for us to be forced to sell them. A free market in organs would fundamentally, and detrimentally, change our relationships toward each other and the parts of our bodies.

Much the same argument holds against the idea of non-cash compensation for organs where the compensatory goods comprise things like health care, education or security in retirement: the kinds of things that conservatives would like to privatise, but that many of us regard as basic needs best provided for by the state. I don’t want to live in a society where you’re expected to sell a kidney in order to get yourself a decent education, health care, or a pension, if you’re poor and can’t earn more from your labour.

So where do I see the moral difference between the above cases and the Nuffield Council’s suggestion that the NHS pay for donors’ funerals? Well, here in Britain, the government already makes funds available to pay for funeral expenses for those in poverty. So long as this benefit is maintained, there shouldn’t be anyone who needs to donate their organs because it is the only way they have to pay for their funerals. And this is important because donating your organs should remain a fully free choice; never something that one is forced into.

There’s one more important consideration here which the Nuffield Council and others cast sometimes as an ethical one: that of altruism. Some people think that organ donations ought not to be compensated because they should be purely altruistic. The council argues that because funeral expenses payments really assist surviving relatives rather than donors themselves, any donors motivated by them will still have purely altruistic motives. I think this is clearly false: some donors might be motivated by the thought that they will get themselves a grander, more opulent funeral by donating, and this is not an altruistic motive. However, as valuable as altruism is, it is surely not more valuable than human lives. While we should applaud purely altruistic donations, if we can also encourage additional partially altruistic or non-altruistic life-saving donations, we should surely do so.

There is still a potential practical problem that consideration of altruism raises: Richard Titmuss has shown that incentives can “crowd out” altruistic motivations for acting and produce exactly the opposite behaviour to that which classical economics predicts, given the presence of the incentive. This occurs because an incentive sometimes acts as a signal that something has a price. If kidneys were to sell on an open market for five thousand pounds, then the gift of a kidney would be equivalent to a gift of five thousand pounds (the amount for which an equivalent could be purchased). This would change the nature of what is currently a priceless, life-saving gift, and quite possibly reduce people’s altruistic motivation to provide it. If payment of funeral expenses were similarly to act as a price signal for donor organs, this problem might arise with them. But this seems unlikely: funeral expense payments would be likely to be seen less as full compensation for providing an organ than as a symbolic recognition of the donor’s generous gift. In this sense, funeral expense payments do indeed maintain, and even support, the essentially altruistic character of the relationship between organ donor and health care system; a character that may well be necessary if donation rates are to be maintained and improved.