Thomas L. Knapp

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Kant get a kidney? No wonder
by Thomas L. Knapp

Last year, I signed up with a project called LifeSharers, and since then I've availed myself of such opportunities as present themelves to encourage others to do likewise.

At the time that LifeSharers founder Dave Undis contacted me about his brainstorm, I had been around the proverbial tree on the issue of organ donation a few times. An article on the subject, written for the Springfield News-Leader, had elicited shrill responses. To be honest, I had become rather cynical about the prospect of bringing market incentives to this vital, life-saving area of medicine.

LifeSharers took a considerably different tack on the issue than my own prescription. Instead of advocating an "organ auction," insurance companies compensating donors' families for the use of organs, or other "direct sale" possibilities, Dave Undis framed the question in terms of prid quo quo:

Indicate your willingness to donate your organs, and receive preference for receiving an organ if you need one.

It's not complicated: register with LifeSharers (it's free). Fill out an organ donor card and power of attorney, and talk with your family about your decision to donate your organs should you die. If, at some point prior to that, you need a new kidney or liver yourself ... you get a shot at it before someone who hasn't done those things.

This, I thought, must be the ticket. No organ tycoons making a quick dime by selling a truckload of suspect corneas. No billboards advertising "same day heart and lung, $99." Just more organs available, more transplant operations, more saved lives. Who could object to that?

Why, "ethicists," of course.

Last week, a reporter for the Kansas City Star called me (Dave Undis had asked if I was willing to speak to her) and interviewed me on the subject of LifeSharers. The interview went well and resulted in an article that, I think, does the idea justice.

I was dismayed -- although, I must say, not especially surprised -- to find that even so sensible and moderate an idea as LifeSharers elicits the same threadbare objections from a gaggle of "experts" on "ethics" whose recommendations substantially control the way organs are allocated to those who require them for survival.

"Dismay at Undis' approach is nearly universal within the transplant community and among bioethicists," writes Star reporter Karen Uhlenhuth. "It runs counter to the philosophy that lies at the very heart of the organ transplant system, they say -- that organs should be allocated based on medical need and how long one has waited for an organ."

That philosophy is known as "altruism." Let's examine what that, in practice, really means.

"It's creating a class of individuals for special consideration in the organ-allocation system," says Mark Fox, who chairs the "ethics" committee of United Network for Organ Sharing, the group which has a stranglehold on methods of organ procurement in the United States. Those methods, Fox claims, are best because they establish a "priority based on objective medical criteria."

Hold that thought for a moment -- we'll be coming back to it.

Another "ethicist," Jeffrey Kahn of the University of Minnesota, allows as to how he might be convinced, if LifeSharers actually increases the supply of available organs, but that the real trick is "to encourage people to donate in ways that are ethically defensible. I'm not sure that LifeSharers is defensible."

Not everyone, even within the "conventional" organ donor establishment, agrees on just what is ethical, of course. At a May 31, 2002 meeting of the Department of Health and Social Services Advisory Committee on Organ Transplantation, one unattributed statement in the "general discussion" section reads as follows:

"If someone signs a contract to donate organs, the individual should receive more points and a higher place on the waiting list should that individual later need an organ. ACOT should discuss this issue."

... and discuss it they did, although without any apparent outcome. That's bureaucracy for you.

Let's cut to the heart (ahem) of the ethics of organ transplantation:

The goal of organ transplantation is to save lives. Not to create jobs for "ethicists." Not to make these "ethicists" feel good at the end of the day for having made "hard decisions" at the expense of others. To save lives.

Kantian philosophy -- the modern and accepted basis of altruism -- doesn't recognize this. It's simply not part of the equation. Neither is the interest of the person who is expected to make it possible to save those lives.

To the altruist, an action is only ethical if it stems from a motive of duty. If the actor is compensated in any way -- if the action amounts to anything other than self-sacrifice -- then it is unethical or at least ethically suspect.

When Jeffrey Kahn refers to the "ethically defensible," that's what he means. For the Kantian, saving lives is way down the list of priorities. As a matter of fact, it can be totally dispensed with if the lifesavers aren't sufficiently pure, having bared their chests before the categorical imperative's scalpel on the altar of "duty."

When Mark Fox refers to a "priority based on objective medical criteria," he's actually referring to a priority based on philosophically acceptable criteria -- altruist criteria. When he complains about "creating a special class," he ignores the fact that's exactly what he does for a living. It's just that the class he creates is a class based on victimization ("sacrifice" and "need") rather than incentive ("supply" and "demand"). The two criteria in question are the "needs" of the patients and whether or not the donors' motives are sufficiently pure. Whether more -- or, for that matter any -- lives are actually saved? That's not a criterion.

If someone needs a kidney, and is able to get one because she has paid a price for it (in the case of LifeSharers, that price being agreement to donate her own organs at death), that's unethical.

If someone agrees to donate his organs at death -- but only on the condition that, should he need new corneas a few years down the road, he'll be able to get them -- that's unethical.

But if someone dies waiting for a kidney because Mark Fox and Jeffrey Kahn are all enamored of The Grounding for the Metaphysics of Morals? No problem. How about 6,000 people a year? Same-same; they're only numbers. And if Joe Sixpack takes his corneas into the ground with him because Mark Fox and Jeffrey Kahn consider it "unethical" to give him any reason not to? De nada.

A certain moral sleight of hand is required for medical "ethicists" to get by with this evaluation of the matter. I've yet to hear of any "ethicist" refusing, on principle, to accept a salary from the hospital or school that retains his or her services. For that matter, I'm unaware of any "ethicist" on staff at a hospital proposing that the doctors, nurses, anesthesiologists, aides, pharmaceutical buyers, receptionists and other personnel who make it possible for a transplant to take place do so without compensation as a matter of hospital policy.

"Ethics," you see, is for those other people. Physician -- er, "ethicist" -- heal thyself.

Some other resources on organ transplants:

Organ Keeper
Organ Selling