Sunday, September 30, 2007

Selling Kidneys: Part III - Autonomy

Before exploring the ethical issues of autonomy bout up in selling kidneys it should be reminded that:
Part 1 argued that though alternative procurement methods are available all are insufficient in fulfilling the current lack of kidneys, and
Part 2 living, laparoscopic nephrectomies are adequately safe procedures.

The most common concern for vendor procurement models surrounds the obvious fact that most kidney vendors would be poor. Two concerns come to the fore: 1) vendors will not appreciate or understand the health risks associated with the procedure or 2) that payment will “economically coerce” the poor into the surgery out of necessity.

The first concern should be secondary if we assume that any vendor system would necessarily demand lifelong and comprehensive healthcare for vendors, as well, the practice of full disclosure of medical risks for those who agree to be living donors.

Thus the second fear should be centrally considered. It is perhaps the roadblock for the legal consent for the construction of a regulated kidney market. The concern rests in the understanding of autonomy. I submit three reasons for why autonomy is actually upheld, rather than undermined, when vendoring is permitted.

1) Coercion can only be properly rendered as external and intentional.
2) Laws prohibiting the sale of kidneys are paternalistic and inconsistent toward the poor.
3) The dangers associated with kidney transplantations are comparable to other acceptable occupations.

First, autonomy is defined by the absence of coercion. So to ensure that autonomy is upheld it must be shown that a kidney market will not coerce the poor into selling their kidneys. Coercion can be understood in many ways that are intricately catalogued by James Stacey Taylor in his book, Stakes and Kidneys. It should suffice here that coercion must be both external to the individual and intentional. One cannot coercive oneself, thus coercion is, ipso facto, always an external force. Moreover, the agent of coercion must have an intentionality in the action of coercion. Here the situation of poverty is both rested in the individuality of a person’s situation and has not intentional in colluding for control, thus autonomy cannot be limited by one’s economic situation. As Taylor states, “Given that the impoverished person would thus retain full control over their action even as they (desperately) sell a kidney there is nothing in their economic situation that bars them from being fully autonomous with respect to this sale” (53-59).

Also, if autonomy is understood as the ability to choose compared to coercion as the limit of choice then restricting kidney markets actually offer more autonomy because markets offers more choice.

Second, laws that prohibit the sale of kidneys are both paternalistic and inconsistent toward the poor. The issues concerning the poor as the primary population of vendors for market models need not be the case. Requirements for vending could easily stipulate a certain level of personal, yearly income or some similar financial qualification. However, this would lead to blatant paternalism of the poor. Peter Hoyer states, “A paternalistic attitude to [vendors] implied that they are poor, ignorant and endangering their health.” The issue becomes inconsistent when the same federal system that bars kidney sales out of concern for the poor that may be exploited by the medical community also do not offer sufficient options or programs to the poor to increase their standard of living so that they do not, out of desperation, desire to sell a kidney. Robert Vetch makes this point succinctly: markets are only permissible if one, the society has the economic ability to provide the basic necessities for all their citizens and two, if such a country does not ensure such a minimum standard of living. As he states, “If we are a society that deliberately and systematically turns its back on the poor, we must confess our indifference to the poor and life the prohibition on the one means they have to address their problems [lack of financial security] themselves.”

Third, there are comparative dangers found in completely acceptable occupations, which under the same principles should ethically justify kidney markets. Even the highest mortality rate for nephrectomies (.06%) is lower than for other generally accepted occupations, such as commercial fisherman, merchant seaman, tax drivers, construction workers, and those in armed forces. Thus the same principles that allow for the poor to enroll in the armed forces – a statistically dangerous occupation – would also imply consent to a regulated kidney markets, especially considering the fact that the advent of laparoscopic nephrectomies will further lower mortality rates.

Hopefully this post helped to illustrate why autonomy of even poor vendors would not be undermined by regulated kidney markets. However, the ethical issues surrounding beneficence, non-maleficence and equity must still be considered in later posts.


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