Monday, January 25, 2021

If You Can Sell a Kidney to Yourself, Why Can't You Sell It to Someone Else?

Context: Peter Jaworski and I are writing a second, expanded edition of Markets without Limits. This excerpt below (a first draft of an addition) appears toward the end of the book. Having already taken down seven major kinds of objections to human organ markets, we're now considering the persistent belief some people have that, nevertheless, for some hard-to-articulate reason such markets assault human dignity. 

Organ donations are degrading, in a way. We put a person under, cut them open, remove some meat, and sew them up. We would be willing to sell our organs to others for enough money, but we’d prefer not to have the procedure televised. (We’d nevertheless be willing to have it televised for even more money.)

Pope John Paul II viewed organ sales as an assault on human dignity but did not regard organ donations per se as undignified. The Catholic Church’s official position is that living organ donations are compatible with human dignity so long as such donations do not seriously harm the donor in various ways. The harm done is an unintended but foreseen side effect of the donor’s real intent, which is to perform a loving act of self-giving. 

Nevertheless, the church also thinks that it is permissible to buy and sell many forms of labor. We the authors sell our services to a Catholic university. We do value some parts of our jobs for their own sake, but to be clear and on the record, some of aspects of our jobs—such as participating in certain worthless committee meetings—we do entirely for money and not out of intrinsic good will or from acts of self-giving. (Since we think some such activities do not serve Georgetown, either, we do not regard it as possible to do them for altruistic reasons.)


Thus, on John Paul’s view, something about adding money creates indignity where there was none. Giving away the organ for free is not an undignified act. Giving away the organ for a $1 net profit is. So, something about the making of a profit introduces indignity where there was none.

We have already examined why many candidate explanations for this moral judgment fail. We can construct such a transaction to avoid the existence of any exploitation, harm or undue risk of harm, rights violations, corruption, misallocation and so on. We can specify that the donor has good will, if not enough to do it for free, just as we have good will towards our students and genuinely care about them, but not enough to teach for free, or just in the way that typical nurse or doctor cares to save people, but not always for free. We have already explained why pure semiotic objections fail here, so we put them aside. 

What, then, could the remaining worry about dignity be?

We are curious whether it is even the sale itself, or the sale and the transfer to another person. To illustrate, consider some far-fetched but nevertheless easy-to-follow thought experiments involving organ transfers.

Imagine a time machine is invented. Your future self, age 60, comes back in time and indicates that in the future, you suffer from kidney failure. However, you can ensure you live a long life by having your 20-year-old-self donate a kidney to him now. (Readers of time travel fiction or fans of philosopher David Lewis take note that we recognize that if you do give him a kidney, that means the 60-year-old before you already knows that you say yes, and only has one kidney as he speaks.) Here, it seems perfectly permissible to give him your kidney.


What if you sell the kidney to your future self? Suppose you say, “Hey, older me, you have a lot more money than I, younger you, do right now. After all, I am right now putting money into my 401(k), IRA, and other investments, which you are getting to enjoy. You make a higher salary than I do, too. So, why not help me—and help your younger self out—while I help you out. I give you my kidney and you give me, say, $100,000.” Here, this again seems fine. If you can permissibly transfer income and welfare to your future self by investing, then by parity of reasoning you should be able to transfer it backward to your past self. Indeed, your past self needs the money more than the future self. Unfortunately, we simply lack the technology to make transfers backward/pastward at this point. But now, you can! Any principle concerning your younger's self freedom to give or refuse to give the kidney to your older self presumably applies to your older self's freedom to give or refuse to give you money. 


If you want, imagine that your young self refuses to give the older self a kidney unless the exchange takes place. Your young self might say, “Hey, if I turn out to be such an asshole in the future that I would demand a kidney from my younger self but not help my younger self out, then I deserve to die at 60. Shoot, I’ll give my kidney now to someone who isn’t such a jerk.” This position might be flippant, but it seems permissible to us. If the older self can reciprocate but is unwilling to do so, this is a count against providing the kidney, especially since there are others who could use the kidney even more. 


So, it seems that one can indeed sell a kidney without a loss of dignity, because you could in principle sell a kidney to yourself. Otherwise, to avoid agreeing with this, a critic would need to explain why such an exchange is prohibited, which seems to involve defending the weird claim that we may permissibly invest in our own future but not our own past, should time-travel technology ever make that possible. 


Thus, it appears that selling a kidney is not even the problem—it does not strip us of dignity or violate our dignity. What must introduce the problem then is selling to the kidney to someone else. But now we wonder why. After all, the very considerations that count in favor of the permissibility of your older, richer, but sicker self paying your younger, poorer, but healthier self for a kidney seem to count in favor of allowing older, richer, but sicker people pay younger, poorer, and healthier people for their kidneys. Why would it be reasonable for such people to think themselves entitled to a highly profitable gift from the young and healthy, without similarly offering the young and healthy the change to also benefit from exchange, if they can? Indeed, in most cases like this, the seller will gain far less than the buyer gains.