Levy Izhak Rosenbaum, an Orthodox Jewish rabbi in Brooklyn, New York, called himself a “matchmaker.” However, he was not arranging dates for his congregants. Rosenbaum is one of five rabbis indicted for brokering the sale of black-market kidneys and livers. He found poor, vulnerable people in Israel and allegedly paid them $10,000 to travel to the United States to sell their kidneys or a piece of their liver to patients awaiting transplants in various U.S. medical centers. For a religious leader, Rosenbaum was quite a businessman. He pocketed as much as $160,000 for serving as a middleman in this organ-marketing scheme.
This is the first known instance of trafficked human organs reaching patients in the United States, but many other cases of organ trafficking occur around the globe. In the past few years, wealthy persons needing transplants have traveled from the United Arab Emirates to Sri Lanka, from the United States to Azerbaijan, and from many nations around the world to Pakistan, Egypt, China, and Iraq in pursuit of kidneys and livers.
In addition to moving sellers of organs to hospitals where their parts can be sold to wealthy recipients, there is also a market in human tissues obtained from cadavers. Corneas have been trafficked in Bulgaria. Skin obtained in the Netherlands has been sold in the Czech Republic. Tissues from Pakistan have been sold for profit in the Netherlands. Bone and fat from the United States has wound up in many nations and is also sent across state borders in pay-for-parts schemes. Brains, bone, and other body parts have been removed without adequate permission at funeral homes and morgues for transplant use, teaching, and research purposes in a number of locations in the United States.
One might think the reaction to this heinous trade in human beings and flesh might elicit strong moral condemnation from all quarters. And, in one sense, these practices do. It is clearly unethical to exploit the living by treating them as nothing more than mobile parts farms—or the dead as a free-fire zone from which those who deal with the bodies of the deceased can make money by pirating pieces and selling them. It is very hard to find anyone willing to defend these black-market schemes, especially when the outcomes for both those who sell and those who buy are much worse than would be expected with legitimately obtained organs and tissue.
But some observers of the extensive illicit trade in persons to obtain organs, body parts, and tissues argue that the problem is not harvesting the living or the dead for money but rather that such activities are illegal. To them, the problem is not paying people for their parts but the fact that the practice is outlawed and thus occurs underground where abuses can and do take place.
Proponents of markets in body parts argue that the only way to counter the shortage of organs and tissues available for transplant is to legitimize the international trade that is already occurring sub rosa in people, organs, and tissues. Given the gap between supply and demand, those in need will do whatever they can to obtain organs and tissues for themselves. Rather than try to battle an underground market, we should simply legalize it and regulate it as necessary.
There are four major problems with the conclusion that the way to combat organ trafficking is to make it legal. First, there is no reason to think that most nations have the resources to regulate a market in organs effectively. After all, even the United States, Britain, and Germany proved unable to regulate their banking, housing, and securities sectors.
Second, there are other ways to expand the availability of organs and tissue that do not involve treating human beings as commercial body-parts factories. Nations could institute presumed-consent policies, asking those who do not want to be donors to carry cards or register their objection in computer registries. When supplemented with appropriate training and resources, these systems have proven very effective in Spain, Belgium, Austria, and other nations.
Third—and perhaps the greatest problem with legalizing organ and body-part markets—is that such markets prey on the grim circumstances of the poor. Fourth, they clearly violate the medical ethics of physicians and health-care workers.
Only the poor and desperate will want to sell their body parts. Faced with fiscal ruin or grinding poverty, it may be a “rational” decision to sell your body parts (or for that matter your baby or your body into prostitution or slavery), but that does not make it a matter of free, voluntary choice.
Having a wealthy person wave a wad of bills in your face while you watch your child go hungry because you have no job is not exactly a scenario that inspires confidence in the “choice” made by those with no options other than to sell vital body parts. Talk of individual rights and autonomy is hollow if those with no options must “choose” to sell their organs to purchase life’s basic necessities. Choice requires information, options, and some degree of freedom, as well as the ability to reason about risks without being blinded by the prospect of short-term gain. If you have no real options, you have no real choice. All markets do is put a polite façade on exploitation.
Selling organs, even in a tightly regulated market, violates the existing bioethical framework of respect for persons since the sale is clearly being driven by profit. In the case of living persons it also violates the ethics of the health-care professions.
The core ethical norm of the medical profession is the principle “Do no harm.” The only way removing an organ from someone seems even remotely morally defensible is if the donor has chosen to undergo the harm of surgery solely to make money. The creation of commerce in body parts puts medicine in the position of removing body parts from people exclusively to abet those people’s interest in securing compensation as well as to let middlemen profit. Is this a role that the health professions can ethically countenance? In a market—even a regulated one—doctors and nurses still would be using their skills to help living people harm themselves solely for money. In a cadaver market, they would risk making families and patients uncertain about the degree to which appropriate care was being offered and continued if a person might be “worth more dead than alive.” The resulting distrust and loss of professional standards is a high price to pay to gamble on the hope that a market may secure more organs and tissues for those in need.
Keeping trafficking in organs and tissues illegal is the only policy option that makes ethical sense. If transplant centers and surgeons are held accountable for knowing all they can about where their donors and organs come from, that will go a long way in making it possible to keep trafficking in check.