Choice, pressure and markets in kidneys

Kidney Sales and Disrespectful Demands: A Reply to Rippon

Simon Rippon, revising an earlier argument against kidney sales, now claims that offers involving the performance of invasive acts, when extended to people under pressure, constitute a kind of rights violation, Impermissibly Disrespectful Demands. Since offers involving kidney sales so qualify, Rippon finds prima facie reason to prohibit them. The present article levels four independent objections to Rippon's argument: the account of Impermissibly Disrespectful Demands implausibly condemns kidney donation as much as kidney sales; the normative importance of having autonomous veto control over bodily incursions does not plausibly underwrite a right to not be extended invasive offers under pressure; Impermissibly Disrespectful Demands can easily be transformed into innocuous offers; and the prohibition has greater welfare costs than Rippon acknowledges.

Unjust organ markets and why it is irrelevant that selling a kidney is the best option

An important argument against prohibiting organ sales is that it removes the best option available to individuals in dire circumstances. However, this line of reasoning fails to recognise that selling a kidney on a regulated market is only the best option in a very narrow comparison, where a regulated organ market is compared with banning organ sales. Once we acknowledge this narrowness, selling a kidney is not the best option. This paves the way for a distributive justice-based critique of the 'best option' argument for organ markets, which illuminates that organ markets should be compared with a broader set of alternatives. If providing the option of selling a kidney is not the best option, but rather the best option we are willing to provide, and one which means that many people will remain in poverty and unjust circumstances, then this reflects poorly on those societies willing to offer only this option and not a better one.

A fair exchange: why living kidney donors in England should be financially compensated

Every year, hundreds of patients in England die whilst waiting for a kidney transplant, and this is evidence that the current system of altruistic-based donation is not sufficient to address the shortage of kidneys available for transplant. To address this problem, we propose a monopsony system whereby kidney donors can opt-in to receive financial compensation, whilst still preserving the right of individuals to donate without receiving any compensation. A monopsony system describes a market structure where there is only one 'buyer'-in this case the National Health Service. By doing so, several hundred lives could be saved each year in England, wait times for a kidney transplant could be significantly reduced, and it would lessen the burden on dialysis services. Furthermore, compensation would help alleviate the common disincentives to living kidney donation, such as its potential associated health and psychological costs, and it would also help to increase awareness of living kidney donation. The proposed system would also result in significant cost savings that could then be redirected towards preventing kidney disease and reducing health disparities. While concerns about exploitation, coercion, and the 'crowding out' of altruistic donors exist, we believe that careful implementation can mitigate these issues. Therefore, we recommend piloting financial compensation for living kidney donors at a transplant centre in England.

The Moral Superiority of Bioengineered Wombs and Ectogenesis for Absolute Uterine Factor Infertility

This paper argues that uterine transplants are a potentially dangerous distraction from the development of alternative methods of providing reproductive options for women with absolute uterine factor infertility (AUFI). We consider two alternatives in particular: the bioengineering of wombs using stem cells (which would carry fewer risks than uterine transplants) and ectogenesis (which would not require surgical intervention for either the prospective mother with AUFI or a womb donor). Whether biologically or mechanically engineered, these womb replacements could provide a way for women to have children, including genetically related offspring for those who would value this possibility. Most importantly, this alternative would avoid the challenge of sourcing wombs for transplant, a practice that we argue would likely be exploitative and unethical. Continued research into bioengineering and ectogenesis will therefore remain morally important despite the recent development of uterine transplantation, even if the procedure reaches routine clinical application.

Exploitation, Criminalization, and Pecuniary Trade in the Organs of Living People

It is often maintained that, since the buying and selling of organs-particularly the kidneys-of living people supposedly constitutes exploitation of the living vendors while the so-called "altruistic" donation of them does not, the former, unlike the latter, should be a crime. This paper challenges and rejects this view. A novel account of exploitation, influenced by but different from those of Zwolinski and Wertheimer and of Wilkinson, is developed. Exploitation is seen as a sort of injustice. A distinction is made between justice and fairness. To exploit someone is to take advantage of him or her unjustly. Exploitation pertains to the nature of actions, interactions, and transaction rather than to their outcomes or to how they are perceived by exploitees. Desperation on the part of one or other of the parties to a transaction does not preclude the giving of valid consent to the transaction. Disparities of power or wealth between the parties to a transaction do not indicate or entail that the transaction will be exploitative. A disparity in the benefits that arise from a transaction between the parties does not indicate or entail that exploitation has taken place.

Understanding choice, pressure and markets in kidneys

Here, I briefly respond to a recent paper by Julian Koplin, in which he criticises my earlier work in this journal. I show that Koplin has misunderstood the distinction I have made between pressure to vend and pressure with the option to vend. I also show that his pessimism about the market regulations I favour is unwarranted.