In the discussion, Virginia wonders what I think of Etzioni’s view. In his letter to the New York Times, Etzioni decries the prospect of market incentives in organ exchange and proposes this alternative:
Actually, what we need is more, not fewer, evocations of our moral responsibilities. Currently most states essentially leave it to each individual — if and when she renews her driver’s license — to indicate whether she is willing for her organs to be harvested.
If, instead, whenever people fill out forms in doctors’ offices, clinics and hospitals, they were given a form that would remind them of the suffering of the many thousands who are dying for donations and would tell them how much we all hope they give that which they cannot take with them — many more organs would be available. Such a clear articulation of what the community considers good citizenship would be further enhanced if donors were listed on a Web page, a sort of honor roll.
Let me make three points in response. First, as I argue in the book, it’s important to realise that prevailing beliefs about the moral responsibility to donate are themselves in large part the outcome of a long-term effort by the transplant community to create a viable “cultural account” of donation. In the early 1970s, organ donation was an experimental therapy often lumped together—in terms of its potentially negative effects—with still-controversial things like genetic engineering, cloning, assisted suicide, and so on. In their effort to build a viable supply and exchange system, transplant entrepreneurs did a great deal of work to develop the idea of organ donation as a “gift of life” which people ought to feel morally obligated to give. So I would question the implicit premise in Etzioni’s argument that organ donation, as such, is something we should straightforwardly see as a moral responsibility. To the contrary, many communities—political and especially religious—had strong doubts about the morality of donation because of the way it threatened to interfere with the rituals of death and mourning. Far from being a straightforward moral obligation that people need reminding of, transplantation might easily have been seen as a brutal, scientized invasion of the sacred values and ritual practice of families and communities. (Indeed, something like this was the case for many years in Japan.) The moral order of the gift of life itself rests on concerted efforts to overcome people’s reservations.
Second, Etzioni argues that if only people were constantly reminded of the need for organs and the expectation to give, then “many more organs would be available” thanks to this “clear articulation of what the community considers good citizenship”. I suggest this is a mistaken picture of how people tend to react to such appeals. As Albert Hirschman remarks, appeals of this sort “exhibit a complex, composite behavior: they atrophy when not adequately practiced and appealed to … yet will once again make themselves scarce when preached on relied on to excess.” My view is that we are much closer to the second tendency than the first in this area. Moreover, in the case of cadaveric donations the decision to donate is typically made by the next-of-kin or donor family under very stressful circumstances. The fine grain of how organizations handle this process is extremely important to its success, and demanding the fulfilment of a moral responsibility in such circumstances is not a good approach.
Third, there is the question of market incentives for living kidney donors. Here the situation is different from cadaveric donation because the exchange can be made directly with the donor. What would such a market look like? There’s little doubt that it would have some unpleasant aspects: there would certainly be many cases where a wealthy individual bought a kidney from some much poorer person, and that sort of exchange – where the poor are literally giving up their bodies to the rich – is enough to turn many people off the whole idea. But if you feel such exchanges are exploitative, there are only two solutions: the first is to ban them; the second is to redistribute bargaining power so that people will not need to enter into exploitative contracts. (Note that this is not the same as saying we want to arrange things such that no-one will ever want to sell a kidney.)
The problem with the first solution is that it risks consigning people to an even worse fate than being exploited. The problem with the second is that it raises questions of social and distributive justice that go well beyond the narrow question of marketizing a particular good. While the vice of the anti-market side is to settle for the warm moral glow that comes with opposing a market like this, the vice of the pro-market side is to ignore the structural context in which particular markets are embedded and which may guarantee unfair or exploitative exchanges.
At present, the closest analogue to a prospective market for kidneys is the market for human eggs. In this case, it turns out that the organizations brokering sales retain many elements of gift-exchange in the process, and also do a considerable amount of work to socialize donors into thinking of the exchange in gift-like terms. Whereas the donors often come forward because they want the money, the egg-donation agencies work to get them to see the exchange as more than just profit-motivated. (Rene Almeling as a very nice paper forthcoming in ASR on this topic.) A real market for kidneys might look quite similar to this. Payments might primarily take the form of reimbursement for time and inconvenience, a distinction which might sound pointless from the point of view of sheer incentives but which in practice turns out to be quite important to people.
At bottom, I think, monetary payments and financial incentives are simply not incompatible with the kind of moral obligations that Etzioni has in mind. We might want to idealize the distinction between morally virtuous gift-exchange and selfishly-motivated market transactions, but this boundary is crossed too often in practice for us to draw a bright line. Moreover, it is crossed in both directions: gift-exchange is often made a vehicle for self-interest; market transactions routiney have strongly moralized or normative aspects. Empirically, I would have two expectations for a viable market for kidneys. First, it would immediately incorporate a great deal of the gift form in order to legitimate itself, with market-matching between donors and recipients working largely at the back-end. Second, it would probably stratify itself in a way that reflected the structure of the U.S. health care system in general, with all that implies about the bottom-end of the market. In that sense Etzioni’s concerns are valid. But those inequities apply also to the communitarian alternative. Why should people feel any moral obligation to participate in a system that does not serve them well in other respects? To think otherwise is a kind of gift fetishism – the belief that we can guarantee the fairness of an exchange simply by insisting that it take the form of a morally obligatory gift.