It says a lot about the poor state of medical ethics that the University of Pennsylvania has accepted Frances Kissling as a scholar in bioethics.

Why? Because Kissling, (to use her own words) has been

a public voice and made a modest contribution to a better world. Twenty-five years giving the Vatican and the U.S. bishops a hard time for treating women like dirt had helped build a feminist movement in the Catholic Church

“Treat like dirt”? I don’t think so.

Now, you may not agree with the various ethics and moral teachings of the Catholic church, but these teachings are well thought out, politely written, and quite nuanced.

In contrast, Kissing is a firebrand given to rhetorical hyperbole and distortions of Catholic teachings–not exactly what one expects as a scholar in ethics at a major university.

Up to recently she ran an “astroturf” organization set up to oppose Catholic teaching which was funded not by it’s members but by secular foundations like the Ford Foundation.

But now to the real subject: paying “compensation” to organ donors.
Kissling needs a new kidney, at age 65. She rejects dialysis pointing to the “4.5 year average life span” for those her age. So she has decided she needs a kidney transplant.

Yet that “4.5 year” life span data is a bit misleading: most of my dialysis patients over 65 had diabetes, and died of heart disease or other complications of their diabetes. Indeed, that is why we hesitated to transplant them: because of these other medical risks.

But if Kissling has no other major medical problems, transplant would be an option: even 75 year olds who have no other major medical problems are getting transplants nowadays–something to remember the next time you read about the shortage of organ donors.

Of course, some bioethicists would say that in these days of high health care costs, a 65 year old shouldn’t even be considered for dialysis let alone a transplant. But that’s another story altogether.

So Kissling then goes on to tell her story of realizing that the waiting list for kidneys is long, so she began pressuring a lot of her friends to donate a kidney to her. Well, it worked: a few people “volunteered”, and maybe one has been found. The others? Too old, other medical problems or didn’t match.

Again, this is alas a common problem with my patients. sigh.

But Kissling, who is not a nuanced person, has a solution: her solution is to pay for a donor: or rather a big government program to reimburse donor’s expenses long after the donation, which is pretty close to the same thing, except that Uncle Sam pays the bribe instead of the donor.

And Kissling blasts those who dare say the “B” (bribe) word:

Far more disturbing is the attempt by some transplant professionals and ethicists to so constrain government benefits to potential donors that the large number of low-income and minority candidates for transplant are almost automatically precluded from receiving kidneys while they are healthy enough to benefit from them.

Well, part of the reason that minorities get so much kidney disease is the lack of good medical care to minority communities. But another reason is the distrust of “big medicine” by many minorities, who don’t quite trust the system. So often they don’t get treatable diseases like high blood pressure or diabetes diagnosed until complications have already set in.

It is a problem of money, but also of prejudice, and a lack of public health outreach at a grass roots level. It is not, however, due to a lack of altruism.

Why is it that rich white people think minority patients families and friends don’t care for the sick patient, but would donate if bribed/paid to do so?

She is also blind to the subtle “slippery slope” of paying for organs.

As Bioethicist Arthur caplan warned:

It is hard to imagine many people in wealthy countries eager to sell their organs upon their death. In fact, even if compensation is relatively high, few will agree to sell. That has been the experience with markets in human eggs ….

Yes, that’s why a lot of surrogate eggs are bought from Eastern Europe, and why the South African Catholic bishops recently protested the exploitation of poor women there who are paid to donate eggs for research.

Selling organs, even in a tightly regulated market, violates the ethics of medicine. The core ethical norm of the medical profession is the principle, “Do no harm.” …

In a market—even a regulated one—doctors and nurses still would be using their skills to help people harm themselves solely for money. The resulting distrust and loss of professional standards is too a high price to pay to gamble on the hope that a market may secure more organs for those in need.

Summary: buying or “compensation”, which is about the same thing probably won’t increase the willingness for rich Americans to donate to strangers, but it will have a subtle effect on the medical ethics of donation because you now have replaced altruism and “do no harm” with the ethics of the free market.

And once you have a free market ethic of organ donation, can globalization be far behind?

There is no easy answer to the shortage of organ donors, but introducing money into the decision changes the ethic of altruism into the ethics (or lack of ethics) of the market, where the rich and the middle men are the real winners.

Perhaps I’ve lived overseas too long , but it’s pretty obvious that breaking the money taboo in organ donation will quickly increase pressure to legalize the black market in buying organs from poor people outside the US.

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Nancy Reyes is a retired physician living in the rural Philippines. She writes on human rights at Makaipablog

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