To Sell or Not To Sell

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					                                                        2 ............................. Compulsory CME       VOLUME 34 NO.7                  J U LY 2 0 0 2
                              3 ............................. Paradigm Shifts in Organ Transplants           M I TA ( P ) 2 0 9 / 0 2 / 2 0 0 2
                                              4 ............................. Spare Parts for Humans

                                                      6 ............................. Sharing Your Liver
                                                  8 ............................. Slim 10: Fat Hopes?
                                      11 ............................. Thinking Aloud One Evening
                                                                                                                                                                     N E W S

To Sell or Not To Sell?                                                                                                By A/Prof Goh Lee Gan

                                                                                                                                                              EDITORIAL BOARD

         ndy Ho’s solution about human           in cases involving organ harvests from                    ANDY HO’S ARGUMENT FOR THE                         Editor
         organs in the 30 June 2002 issue        the living that may carry substantial                     PRO-SELLING STAND                                  Dr Wong Tien Yin
         of the Straits Times is “To save        health risks.                                             Andy’s points are:                                 Deputy Editor
lives, legalise organ markets.” Indeed,               Finally, proponents of prohibition                   (1) Human biological materials (HBM)
                                                                                                                                                              Dr Daniel Fung
this is an evergreen proposal – push it          often dwell on the social risks associated                    are already regarded as commodities
down to the business level of buy and            with the “commodification” of the body.                       so there is no difference between
                                                                                                                                                              Dr Chan Kah Poon
sell, and legalise it to make sure no            They argue there is value in (a) setting                      flesh and flour;
                                                                                                                                                              Prof Chee Yam Cheng
one can take unfair advantage of the             limits to what can be bought or sold                      (2) Basic necessities are subjected
situation. So, why are we hesitating?            in the market as a commodity, e.g.                            to market forces, so why should                Dr Jon Goh
     The arguments in the debate over the        treating flesh differently from flour; and                    flesh be any different from flour;             Dr Lee Pheng Soon
buying and selling (“commercialisation”)         (b) supporting systems that rest on and                   (3) Everybody is paid in the transplant            Dr Terence Lim
of body parts have changed little over           promote voluntary giving, especially                          work, so why not include the donor             Dr Oh Jen Jen
the years. The following is a summary            where the gift is life itself.                                as well; and                                   Dr Toh Han Chong
of the pros and cons from the website                                                                      (4) The market can be tweaked to take              Ex-Officio This is a             PRO-SELLING                                                   out the transactional problems.                Prof Low Cheng Hock
useful website to visit on the subject of        The points for a pro-selling stand are:                                                                      Dr Tham Tat Yean
selling body parts. There are writings           Firstly, in the face of the shortage of                        Andy: “Patients are dying for want of         Executive Secretary
on the pros and cons and you can even            organs and other tissues, with people                     transplants while we resolutely refuse to
                                                                                                                                                              Ms Chua Gek Eng
participate in the debate.                       on waiting lists dying every day, the                     acknowledge that human biological materials
                                                                                                                                                              Editorial Assistant
     Broadly, the views of the pro-selling       proponents argue that the safety                          (HBMs) are, in fact, already commodities.”
                                                                                                                                                              Ms Krysania Tan
and against-selling people have been             risks associated with payment are                              Andy: “Invaluable necessities, like
summarised on the “debatabase” website           outweighed by the benefits of an                          food, shelter and medicine – basic human
into the following points.                       increased supply. Improved screening                      necessities – are subject to market forces
                                                 and testing would in any event ameliorate,                every day...Yet no one clamours to remove
AGAINST SELLING                                  if not solve, the safety problem.                         such goods from the market. Instead,
Firstly, those who call for prohibition               Secondly, according to this theory,                  efforts are made to help the less fortunate
point to the safety risks associated with        it is immaterial that desperate financial                 pay for such goods.”
commercialisation, and offer expanded            circumstances drive people to do what                          Andy: “Everyone is benefiting so why          The views and opinions
                                                                                                                                                              expressed in all the articles
educational efforts to encourage people          they would not do otherwise. If people                    not the donor as well...So denying donor           are those of the authors.
to come forward and donate as an                 are not physically compelled or threatened                compensation does not remove HBMs                  These are not the views
                                                                                                                                                              of the Editorial Board nor
alternative measure to increase supply.          with harm as a consequence of not                         from the market domain – it merely                 the SMA Council unless
Public health concerns clearly motivate          selling tissue, then their choice to sell is              postpones commercial gain in favour of             specifically stated so in
                                                                                                                                                              writing. The contents of
a policy that bans selling of body parts         voluntary and the government should                       healthcare providers down the chain...”            the Newsletter are not to
                                                                                                                                                              be printed in whole or in
and even tissues like blood.                     not interfere. (After all, we permit                           Andy: “In effect, the donor gives away        part without prior written
     Secondly, there is a fear that              people to take life-threatening risks                     property rights to his organ, which then           approval of the Editor.

vulnerable populations will be exploited         for money in other contexts, i.e. choosing                confer significant economic benefits on            Published by the Singapore
(i.e. the poor and others whose social           employment.)                                              subsequent parties...Let us stop fooling           Medical Association,
                                                                                                                                                              Level 2, Alumni Medical
circumstances give them few choices                   Finally, they argue that free markets                donors: Legalise the sale of non-vital organs      Centre, 2 College Road,
                                                                                                                                                              Singapore 169850.
and little medical sophistication, will          are inherently good, promoting the                        by living persons, and all organs by near-         Tel: 6223-1264
become “tissue factories” for the rich).         freedom of individuals – and any limits                   death persons. These markets will improve          Fax: 6224-7827
These concerns are usually most acute            are arbitrary.                                            the quantity and quality of organs available.”     URL:

                                                                                                                                             Page 10

        Page 1 – To Sell or Not To Sell             objections continue even beyond death             to health care, selling kidneys would
     THE COUNTER-ARGUMENTS                          of the seller.                                    put transplants out of reach for many,
     TO ANDY’S POINTS                                                                                 and allow the rich to outbid others and
     Limitations on flesh as commodities            People doing transplantation work                 jump whatever queues might exist.”
     About flesh as commodities, a quotation        are providing a service                           (Source:
     in a paper from the University of              Why deny the donor compensation when
     Houston Law Centre gives us some               all the others connected with transplant          MAKING SENSE OF THE
     perspective: “...Presently, many countries     work are paid? The argument is that               OPPOSING VIEWS
     have laws in place flatly prohibiting the      the services involved in providing the            Both the pro-selling and against-selling
     purchase or sale of body parts. U.S. law       transplantation work come from people             sides have a common end-point – namely,
     has tended to divide body parts into           who can be deployed to do other                   have more organs available. The means
     categories. Payment for non-regenerative       work and provide other services if                to achieve that is of course different. The
     or non-renewable tissues used in               there is no transplant work. Hence, the           against-selling side achieves the numbers
     transplantation, such as hearts and kidneys,   argument of benefiting these people is            through encouraging people to donate.
     has been prohibited. However, payment          not valid. Transplantation work and non-          The pro-selling side achieves it through
     for renewable tissues such as blood,           transplantation work are still services           fiscal means. What stands in the way of
     hair and semen has been permitted.             rendered and these should be paid.                either side are the physical, social and
     The National Organ Transplant Act,                                                               moral risks. Finally, there is the question
     which applies to any transaction that          Market imperfections                              of flesh being different from flour,
     affects interstate commerce, prohibits         Can the market look after itself? The             and should therefore not be treated
     payment for solid organs. These include        market can look after itself if it is a perfect   commercially in the same way.
     organs derived from a fetus as well as         market. However, the buying and selling
     skin, bone and bone marrow. The federal        of body parts, if allowed, will be conducted      The Gift of the Magi
     law, like many state laws, includes            in a market of imperfect information.             At the end of the day, it is the question of
     imprisonment as a possible sanction.           The quantity of organs for the poor may           values we attach to the different risks
     The exception to the no payment rule,          be made fewer and well beyond their               to the individual and society. The best
     mirrored in many state laws, permits           reach. The quality of organs may be poor          way out of the difficulty may be to go
     reasonable payments associated with            as sellers try to sell off what they can          back to the big value of giving. Read
     the transplant process itself (e.g. organ      exchange for money. Or, the organs may            the “Gift of the Magi” by O Henry to
     retrieval and implantation) and payments       have been procured by violent means.              be moved. The message is there.
     to cover the expenses of the donor                  The laws can never deal with the
     such as travel and lost wages.” (Mary          complexities of transactions. Hence, the          The Nicholas Effect
     Anderlik, 1998.)                               oft-quoted saying that “the law is an ass”.       To be more direct and specific, there is the
                                                    It is safer to avoid the slippery slope           Nicholas Effect coined by Reg Green, the
     Basic necessities and body parts               rather than to try to stay upright on the         father of a little boy of seven, Nicholas, who
     Is selling flesh the same as selling flour?    slope. Imagine trying to stay upright             died in a car hijack in Italy while on holiday
     The argument is that basic necessities         on a mountainside covered with moss.              from California. The parents decided to
     that keep us alive are different from flesh         On the market perspective, Jeffrey           donate his body parts to seven Italians.
     that come from human beings. The sale          Kahn from the Center for Bioethics,               This led to an outpouring of love by the
     of body parts renders the seller less          University of Minnesota, has this view,           people of Italy and a sharp increase in
     intact. The harvesting of such desired         “We have made a decision not to allow             organ donor rates. The father wrote the
     tissues for the buyer may leave the            a market in human organs for a number             experience in a book called “The Nicholas
     donor more vulnerable to disease or            of reasons. For living donors, we have            Effect”. You can buy it from
     injury and sometimes the risk of death.        focused on two main issues. First, we             It is a touching and transcendent book.
          One may argue that all the risks          are concerned about the exploitation of           As one book reviewer puts it, “Here is
     will be removed if one were to give            potential donors. Everybody has a price,          a book that will make you cry, make
     orders to sell the desired body parts          and it is unethical to create situations          you glad you’re a human, and make
     after death and instruct the payment           where people overlook the risks of                you want to do something great.”
     to be made to individuals mentioned            donation to themselves and their family
     in the will of such a seller. Well, it will    (pain, disability, long term effects,             BEYOND MONEY
     still have to counter the argument             and even rarely death), for monetary              It is good to know that there are some
     of human dignity, and the moral                inducements. Second, we have decided              things that are shared not by dollars
     hazard of being killed for the body            as a society that it is unfair to base access     and cents, but by love. So should we
     parts by unscrupulous individuals who          to a scarce health care resource on               not continue to ban the selling of body
     stand to gain from the killing. So, the        one’s ability to pay. Even with access            parts commercially? s

     S M A N e w s J u l y 2 0 0 2 Vo l 3 4 ( 7 )

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