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From blood donation to kidney sales: the gift relationship and transplant commercialism

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Abstract

In The Gift Relationship, Richard Titmuss argued that the practice of altruistic blood donation fosters social solidarity while markets in blood erode it. This paper considers the implications of this line of argument for the organ market debate. I defend Titmuss’ arguments against a number of criticisms and respond to claims that Titmuss’ work is not relevant to the context of live donor organ transplantation. I conclude that Titmuss’ arguments are more resilient than many advocates of organ markets suggest, and more relevant to the debate than is commonly appreciated.

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Notes

  1. Titmuss described The Gift Relationship as ‘fundamentally about human values and their relationship to those institutions and services in society with which social policy is concerned’ (Titmuss 1997, p. 219). His decision to use blood donation as a case study reflected his belief that blood provides a ‘sensitive… social indicator which, within limits, is measurable, and… tells us something about the quality of relationships and of human values prevailing in a society' (Titmuss 1997, p. 59).

  2. Two recent papers in Science summarise the current state of the debate (Dhingra 2013; Lacetera et al. 2013).

  3. The claim being made here is that price incentives can erode intrinsic motivations to participate in a particular activity, not that this erosion will inevitably reduce overall supply. Financial incentives may prove effective in cases where they are large enough to compensate for any erosion of intrinsic motivations. According to Gneezy and Rustichini (2000b), the lesson is to ‘pay enough or don’t pay at all’.

  4. Taylor briefly acknowledges that Titmuss wished to promote social solidarity, but argues that a person’s decision to donate their bodily parts or products merely reflects whether they were already inclined to act altruistically (Taylor 2005, pp. 161–162). This point was anticipated by Titmuss, as well as some of his defenders (e.g. Singer 1973, 1985; Campbell 2009). According to these authors, encouraging citizens to give the ‘gift of life’ prompts them to consider their moral obligations to others in a way that a commercial system does not. As Singer explains:

    The idea that others are depending on one’s generosity and concern, that one may oneself, in an emergency, need the assistance of a stranger, the feeling that there is still at least this vital area in which we must rely on the good will of others rather than the profit motive—all of these vague ideas are incompatible with the existence of a market in blood. (Singer 1973, p. 318)

  5. However, it should be noted that the Iranian model of paid donation has not met the demand for transplantable kidneys; there is a significant disparity between the number of transplants performed and the number of patients waitlisted (Rouchi et al. 2014).

  6. As others have noted, any decline in deceased donation would be problematic for an entirely separate reason. If live donor organ markets impede deceased donation, they will threaten the supply of those solid organs that are rarely or never acquired from living donors, such as hearts, livers and lungs (Capron 2014, pp. 60–61; Danovitch and Leichtman 2006; Tilney et al. 2010).

  7. I assume here that Taylor is correct that the health risks of vending are minimal, but this might not be the case. Because kidney vendors are more likely to be drawn from poorer and more vulnerable populations than kidney donors, they may face greater health risks (Koplin 2014; Martin and White 2014).

  8. I have assumed that most participants in a regulated organ market would be drawn from the poorest segments of society. However, some proponents of organ markets have suggested that we should disqualify the very poor from participating in organ markets (Hippen 2005, 2008, 2014). This may mitigate some of the above concerns; if most vendors are relatively wealthy, kidney sales may be less likely to be perceived as degrading, or less likely to promote the view that the poor can permissibly be used as mere means.

  9. This is not to suggest that reciprocal gift relationships are always unproblematic. Recipients of organ transplants often feel that gift of an organ is impossible to repay, and some recipients experience a weighty sense of indebtedness that sociologists Renée Fox and Judith Swazey describe as ‘the tyranny of the gift’ (Fox and Swazey 1992, pp. 39–42).

  10. This is not to say that, given these non-ideal circumstances, the child would not benefit from being allowed to work. The point here is rather that the father cannot legitimately claim to be moved by a desire to ensure that his child’s material needs are met.

  11. This would most obviously be the case in a society that has achieved just social conditions, but it may also be true if political authorities are simply unable to improve the situation of kidney sellers. In unfavorable socio-economic contexts, extreme deprivation may be unfortunate rather than unjust.

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Acknowledgments

I thank Michael J. Selgelid, Justin Oakley, and Jeremy Shearmur for their insightful comments on earlier versions of this paper.

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  1. Centre for Human Bioethics, School of Philosophical, Historical and International Studies, Monash University, Menzies Building, 20 Chancellors Walk, Melbourne, VIC, 3800, Australia

    Julian J. Koplin

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Koplin, J.J. From blood donation to kidney sales: the gift relationship and transplant commercialism. Monash Bioeth. Rev. 33, 102–122 (2015). https://doi.org/10.1007/s40592-015-0035-x

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