Wednesday, February 04, 2009

Brother, Can You Spare a Pancreas?

Despite the questionable and declining quality of my internal parts, I am registered as an organ donor. Every few years, when I go to renew my drivers license, this decision seems like a no-brainer. Now, I'll admit that it may be the case that my organ-altruism is really motivated by self-interest, since I am a Type 1 Diabetic and secretly covet my neighbor's pancreas... but the truth is that I don't think that's the reason I sign on the Organ Donor dotted line. For me, it has more to do with my awareness of the limited resource of healthy organs and my empathetic substitution of a first-hand experience with the misery of unhealthy ones. And it probably also has to do with some basic metaphysical/religious views that I hold about the human body and "personhood," and when they can be separated from one another. In sum, I think that organ donation is primarily a practical issue (hey, I'm not using them anymore!), secondarily a social/political issue (the hoarding of any kind of wealth undermines social cohesion), and only tertiarily a moral issue. That said, I am still very aware that, for most people, the decision to be or not to be an organ donor often comes down to a matter of ethical conviction.

And that kind of moral ball-and-chain is exactly the problem with our organ donation system in the United States, according to Sally Satel (resident scholar at the American Enterprise Institute, an important biographical note to which I will return in a moment). In her recent essay, "When Altruism Isn't Moral," Satel argues that the current practice of allowing only "gifted" organs for transplants fails both the donor and the recipient. She writes:

The woeful inadequacy of our nation’s transplant policy is due to its reliance on “altruism.” According to the guiding narrative of the transplant establishment, organs should be a “gift of life,” an act of selfless generosity... Yet, it is lethally obvious that altruism is not a valid basis for transplant policy. If we keep thinking of organs solely as gifts, there will never be enough of them.

Through the use of a couple of heartwrenching anecdotes, Satel speculates that our current "altruism"-based policy puts medical professionals in a quandary; they would rather see both potential donor and potential recipient die before accepting an organ for transplant that is not a "pure gift." So, what should we do instead? Here's where Satel shows her ideological (AEI) cards, when she proposes the following solution:

We need to encourage more living and posthumous donation through rewards, say, tax credits or lifetime health insurance.

Of course! It's the go-to anwer for all conservative think-tanks (like Satel's employer, the AEI), where everything can be solved by repeating the well-worn mantra: incentivize! incentivize! INCENTIVIZE! To be fair, Satel's essay is surprisingly well-argued and solidly grounded in philosophical arguments for and against the incentivization of organ donation. She considers both "arguments from corruption" and "arguments from consequence" (Michael Sandel's terms) against incentivization, and even takes seriously Marcel Mauss' formulation of "the gift" as always contaminated by some logic of exchange. But, in the end-- as is almost always the case in AEI-ish arguments-- moral considerations are but ruses, paid a perfunctory lip-service but easily expendable or coopted into broader justifications of free-market economies. Again, from Satel:

Simply look at our daily lives. Financial and humanitarian motives do not reside in discrete realms. Moreover, it is unclear how their co-mingling is inherently harmful—the goodness of an act is not diminished because someone was paid to perform it... The desire to do well by others while enriching oneself at the same time is as old as humankind.

As someone who is very sympathetic to Satel's basic instinct-- that is, to see organ donation policy as a social and political issue and not (primarily) a moral one-- I am nonetheless disheartened by the ease with which she completely collapses the two "realms." Or, rather, I am deeply skeptical of the elision between what Satel calls "the desire to do well by others" and the desire to "enrich oneself." I am much more inclined to suggest, admittedly with some reservation, that we are better off grounding organ donation policy in (philosophical, metaphysical) arguments that undermine the tendency to see body parts as "personal property."

That said, if any of you are willing to part with your healthy pancreas, I'll enter the bidding.


Ideas Man, Ph.D. said...

A part of me wants to turn Platonic and replace voluntarism or incentivization with gold ole' state mandates...

Did you read much about the controversy a few years back about the professor-turned-real-estate-developer-turned-extreme-philanthropist who gave a kidney to a stranger? He did so on strictly utilitarian grounds, and many ethicists were therefore appropriately appalled...

anotherpanacea said...

I'm a fan of incentivization for a lot of things, but when it comes to organ donation I think the standard should be choice architecture: make donation the default, and make it difficult-but-not-coercively-so to not-donate. That way the incentive isn't a payout but rather convenience.

DOCTOR J said...

Ideas Man: No, I haven't heard this story. And I'm all for state mandates in this instance, as well.

AnPan: Really? I'm surprised to hear your support of "incentivization for a lot of things." Makes me wonder which things. But since you are so inclined, I can spare about 50 bucks for your pancreas. I'm also willing to sign onto a payment plan... the way I figure it, if I gave you the same dollar amount that it costs me every month to be diabetic, you could easily take that as a regular monthly income and devote yourself to working out your incetivization issues.

anotherpanacea said...

I have a friend who needs a new liver and to whom I regularly consider donating, and when I saw your post my first thought was: what's the deal on live pancreas donations? (It's still really scary experimental, sorry.) I certainly wouldn't charge you for it!

My only real objection to signing you over the postmortem rights for my pancreas right now is that I'm not sure it's really fair. To give these amazingly valuable things to friends means sidestepping the UNOS process where my pancreas ends up going to whoever is most deserving, probably a stranger, rather than to whomever I like best.

Anyway, I get the sense from your comment you're worried about organ markets, not the legitimacy of special duties to friends and loved ones. Here's the thing: not all incentives are financial. Defaulting to organ donation is a kind of incentivization that avoids the market. Instead of a cash incentive, it uses an inconvenience disincentive. You ought to have to jump through some bureaucratic hoops if you really want your organs to go into the ground rather than where they belong.

I also think some things are best organized around market incentives. For instance, I favor incentivizing seat belt and helmet usage: make insurance more expensive for people who've been cited for failing to wear a seat belt or a helmet. My dad rides his motorcycle without a helmet (legally and without cost), and I can't stand it. I nag him mercilessly to disincentivize it for him, and it often works. So I'm a fan of that kind of (heh) paternal incentive, and it doesn't bother me much that poor people would be less able to go seatbelt-less with impunity than rich ones. Nobody ought to do it, but if anybody's gonna die it ought to be the rich guys who drive around feeling invulnerable. The same thing goes for incentivizing health insurance, education, or a host of other things.

I doubt you disagree, but there's something about the AEI way of arguing things that leaves a bad taste in my mouth, so I'm guessing you're feeling the same way and all markets sound equally gross right now.

Dave said...

About 50% of the organs transplanted in America go to people who haven't agreed to donate their own organs when they die. As long as we let non-donors jump to the front of the waiting list if they need a transplant we'll always have an organ shortage.

There is a simple way to put a big dent in the organ shortage -- allocate donated organs first to people who have agreed to donate their own organs when they die.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.

Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

John said...

My instinct would be to try to bring out the weakness of Satel's argument, as well as the forces that require such an argument to exist. I think that an excellent starting point for identifying the flaw as well as the bad faith implied in "receiving by giving" is Derrida's Given Time: Counterfeit Money.

It also provides some way to appropriately ask (seriously) how much trust we as individuals have in a health care system, and in what sense we are being selfish, selfless, or some perceived combination of the two in doing so.