This past Tuesday, July 11, 2006, I had the privilege of teaching a seminar on the morals and ethics of organ transplantation to the new group of clinical fellows at the MacClean Center of Clinical Medical Ethics, located in the Division of Biological Sciences at the University of Chicago. In the course of that discussion, some one raised the topic of what kind of screening and counseling should be given to those who are prepared to make a kidney donation gratis to stranger outside the donor’s immediate family. I was startled to hear in response that the sixty-four dollar question posed to these potential donors is this: “Do you know that if you make this particular gift that you will not have a kidney available for transplantation for your child if he or she should need it at some time in the future.?” If you can’t answer that question to the satisfaction of the suspicious interlocutor, then you may not get the transplant program to go along with this altruistic donation.
I regard this approach as an astonishing and destructive ploy that raises far more ethical questions than it eliminates. This tough question was not asked of individuals whose children had some medical condition that could make the need for a kidney transplant imminent or even probable. No big deal. Those folks don’t need to be told to guard their own kidneys. Rather, I gather this question is routinely asked to individuals whose children are as far as any one knew in good health. The question which should ask of the inquiring bioethicist is quite simply this: is this question ethical in that setting?
My answer to that question is, no. The first point to look at is the odds. I am quite sure that hundreds of children may need organ transplants at any given time, but most of those have chronic conditions that are easily identified in advance. Of the millions of children alive today under, say, the age of 15, the odds are miniscule that any one of them will need a transplant, or if that transplant is needed that the putative donor in this case would prove to be a suitable donor down the road. The expected value of the lost donation should be estimated at close to zero. By no stretch of the imagination could that tiny future loss be thought to approach, let alone equal, to the immediate misery that is likely to befall any needy donee who doesn’t get the organ that he or she needs right now.
As we all know, the great difficulty with altruism is that it requires an individual to take a small sacrifice for himself in exchange for a large benefit to another person. In most cases the forces of individual self-interest are so powerful that the donation will not be made even if the gain to the recipient is far greater than the loss to the donor. But on balance we can predict that as kidney transplants become less risky, there will be more altruistic kidney donations (livers, a tougher case; hearts, forget about it) all other things being equal. The new techniques mean that the removal of a kidney is a less intrusive and less dangerous procedure. So as the cost goes down, the willingness to donate should increase. Likewise, better transplantation increases the expected value of the kidney, which is an another reinforcing reason that could tip the balance in favor of allowing the transplant. Holding the cost to donor constant, the greater the gain to the recipient, the more likely the donation. In addition, we know that search costs for suitable pairings are trending down as well. Today all three forces work to an increase in the number of altruistic donations. Even though these together will not solve the ever-expanding kidney shortage, they should dent it a bit. Even one life helped should be the source of social celebration.
Into this framework, this ultimate question about one’s own child can only be understood as a way of trying to raise the costs of altruistic donations to strangers, so as to reduce their flow. The question is, moreover, presented in loaded form, because it suppresses the benefit side in the individual case, and carries with it the implication that the potential altruist is more sap than hero. In addition, it sets up a long-term dynamic that reduces overall organ flow. Right now, UNOS rules allow (as a not-so-“valuable consideration”) organ donors to get to the head of the cadavaric list should they need an organ, a point which this hard-nosed question suppresses. In addition, the discouragement of these altruistic donations systematically reduces the likelihood that others will step forward, thereby accentuating the current shortage.
Think of how much better it would be if the matter were put to the putative altruist donor as follows. “We know that you are making a personal sacrifice, about which you have thought long and hard, and for which everyone is grateful. But we hope that you will lead by example so that others will do the same, so that if, God forbid, your child needs a transfer it is more likely that someone else will step up to the plate on his or her behalf.” The vibes are so much better. Why members of the so-called transplant community wish to follow a different tack to reinforce egoism in ways that add to human suffering is just baffling, especially when it comes from a cohort that is so eager to condemn commodification and markets at the least provocation. The ironies are indeed greater. In dealing with markets, antimarket bioethicists always harp on the dangers of coercion in sales transactions. And heaven forbid that any seller should engage in scare tactics of this sort. Unfortunately, the bioethical questioner of potential donors gives us a text-book example of how to use coercion to diminish the already slender resources of human altruism. This cruel and dangerous practice has got to stop—now.