Stakes and KidneysWhy Markets in Human Body Parts are Morally Imperative 1/26/2006 |
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Book Review James Stacey Taylor’s book Stakes and Kidneys is an important contribution to the political debate surrounding markets and organ trade. While this book is an attempt to defend the moral legitimacy of markets in human organs, its real achievement is to offer more secure foundations for understanding the relationship between autonomy and poverty, in response to those who would argue that individuals' actions are dictated by their economic circumstances. In Stakes and Kidneys, Taylor thoughtfully and informatively addresses numerous arguments that have been made against markets in human organs including issues such as: the effect organ markets might have on human dignity, the question of whether kidney vending would be too risky to be permitted, what effect such markets might have on the quality of transplantable organs, etc. It would be impossible to treat all of his arguments equally in the scope of this review. Instead, we will focus on Taylor’s two central points: (1) a discussion of the nature of autonomy, and (2) a claim that human organ markets should be regulated. Is the Typical Kidney Vendor Forced to Sell?
Most of the book is committed to addressing the issue of whether or not vendors of their own body parts would be forced to sell their organs in a legal market. Taylor broaches this question by examining the work of Gerald Dworkin, who has written on both autonomy and organ sales and who is “well known for arguing that allowing persons to sell their kidneys is required out of respect for their autonomy” (p. 30). In his work Markets and Morals: The Case for Organ Sales, Dworkin concludes that respect for an individual’s autonomy requires that all voluntary transactions regarding a person’s body parts ought to be permitted. As Taylor points out, however, this assumes that organ sales are voluntary, an assumption many of those who oppose markets in human organs argue vehemently against. These opponents argue that vendors would be forced to sell their organs due to their economic circumstances. Moreover, Dworkin’s own theory of autonomy from his earlier work Acting Freely, implicitly supports the idea that someone can be coerced by his or her economic situation. Taylor offers various interpretations of Dworkin’s theory of autonomy, attempting to reconcile Dworkin’s ideas about autonomy and his approval of organ markets. Building on this discussion, Taylor offers his own theory of autonomy by refining Dworkin’s views. He then uses this more refined conception to answer the question of whether or not a kidney vendor (in a legalized market) would be forced to sell. The view of Dworkin that Taylor uses to build upon for his own argument states that if someone endorses his own “first order desire” to sell his kidney, which arises from himself, with a “second order desire,” meaning that upon reflection he condones his first order desire, then he is autonomous with respect to that action. If, on the other hand, he would wish not to act in accordance with the first order desire, he is not considered to be autonomous with respect to the action. Taylor gives an example of someone who compulsively washes his hands but who wishes he could escape such a condition by not acting according to this desire (p. 39). Taylor shows, however, that this would lead to a strange conclusion. If this interpretation of autonomy was sufficient, then someone who endorsed their urge to comply with a highwayman’s demands, that is to say that upon reflection they valued their life more than their money and believed compliance to be the right choice, they would be considered “autonomous” with respect to this action. In response to this strange conclusion drawn about autonomy, Taylor forwards an improvement on Dworkin’s theory of autonomy. He argues that, while Dworkin is right that it is necessary for someone to condone his desires and actions in order to be autonomous, it is not a sufficient condition. Someone who condones his own desire to obey the highwayman is not autonomous. Taylor explains that since the satisfaction of the first order desire to comply with the dictates of a coercive agent requires “relinquishing a degree of control to the threatener over what action is performed and when, a person suffers from impaired autonomy with respect to the coerced action” (p. 57). Thus, one loses autonomy when one surrenders the lead in one’s own decision making to another agent who intends to and can direct one’s actions. Once Taylor establishes this description of autonomy, he analyzes several specific examples of the arguments that attempt to show how economic impoverishment would force people to sell their organs and subsequently shows how each fails. Taylor argues that, unlike the victim of highway robbery who becomes passive to the definite demands of another agent, the kidney vendor remains in the active role with respect to decision-making. When one is being robbed, if one is passive, one’s “default action” is to follow the dictates of the robber, that is, to allow him to take one’s money. If one is passive with respect to pursuing or ignoring the offer to sell one’s kidney, one’s “default action” is not to have one’s kidney removed, rather, one must actively pursue this option. Taylor stresses that this distinction between the active and the passive activities demonstrates that any formulation of the idea that economic pressures in some way force people to sell their organs, or take away their autonomy with respect to the action of selling their organs, is false. Thus, he shows that a legal market in kidneys does not undermine the autonomy of the vendor. The Conditional Nature of Taylor’s Argument Taylor emphasizes many times that the arguments in this book are aimed at those who already have a sense of why autonomy is valuable and who believe that autonomy is the relevant value to judge a proposal for a legal organ trade. As he explains clearly from the outset: My arguments in this volume appeal only to those values that are shared by the majority of contemporary bioethics, namely, personal autonomy and human well-being. If I can show that these values morally support a minimally regulated, current market in human organs, then the legalization of such a market should be accepted prima facie by all who accept these values (p. 19). That Taylor directs his arguments to this narrow audience may leave the lay reader disappointed, since Taylor gives no account of why autonomy is valuable or why it is the relevant standard by which to judge the moral legitimacy of human organ markets. Nor does he give a summary of the relationship between well-being and autonomy. In fact, Taylor explicitly avoids giving a positive account of why one should value autonomy. He writes: At first sight, it appears that the proponents of any argument that is based upon a claim concerning the value of personal autonomy must provide some indication of its value…Yet although this autonomy-based pro-regulation argument appeals to a view of the appropriate value of autonomy, given my aims in this chapter my development of this argument can progress without the provision of a positive account of this. My purpose in invoking the value of autonomy in this way is solely to establish that…for the defenders of autonomy respect for autonomy justifies the regulation of markets in both labour and kidneys (p. 98). It may seem to the reader from statements like this that Taylor is engaging in a mere exercise of constructing an argument, positing that autonomy is “valuable” and subjecting anti-market arguments to the logic that follows. Moreover, Taylor often uses the phrase mutatis mutandis to indicate that his “arguments could be adapted so that they are grounded on concern for values other than personal autonomy” (p. 112), that is to say, “you may place your own value here.” This makes autonomy analogous to a mathematical variable in the eyes of the reader. Taylor’s arguments take on the form of equations, rigorous with respect to their internal relations, but resting on variables that the reader might not be entirely sure about.
A sense of why one ought to value autonomy, however, would be valuable. Such an account might give the reader an idea of what is gained and what is lost in a move to a legal organ trade. What is it that we desire from autonomy? If autonomy is for the sake of something else, following autonomy may not necessarily be the best means to achieve this other value. Without an indication of autonomy’s value, one may be left wondering whether what is lost in a move to such markets is actually what we wish to achieve by preserving or expanding autonomy. Of course, if it were indicated that we should value autonomy absolutely and for its own sake this question would dissolve. This, however, is not Taylor’s position. He recognizes a number of times that “autonomy is not the only value that is relevant within this debate—and it might be outweighed by competing values” (p. 70). Yet, without an account of the value of autonomy, there is no indication of how to weigh these competing values. Perhaps we may look forward to Taylor producing such an account in a future work. Taylor's Case for Market RegulationIn addition to arguing that markets ought to be permitted, Taylor’s other major premise is that, in order to uphold autonomy, such markets ought to be subject to some minimal regulation. He presents two arguments in favor of market regulation, the first of which comes out of his discussion of “constraining options.” Some opponents of markets in human organs argue that although the option to sell one’s kidney may be chosen voluntarily, it may be a constraining option, that is to say, this choice may diminish one’s future autonomy. To illustrate the concept of a constraining option, Taylor relays J.S. Mill’s example of selling oneself into slavery. Although someone might choose this option voluntarily, it is clear that making such a choice severely diminishes his ability to be autonomous in the future. Taylor analyzes two specific arguments that make the case that the option to sell one’s kidney would be a constraining option. He concludes that neither of these arguments succeeds in showing that selling one’s kidney is necessarily a constraining option. Taylor agrees, however, due to the empirical evidence that exists about the current state of black markets in kidneys, that under certain conditions the option to sell one’s organs could be a constraining option. In his first pro-regulation argument Taylor suggest that autonomy simply requires that the purchasers of organs provide the vendors with sufficient post-operative medical care in order to keep the selling of one’s kidney from adversely affecting the vendor’s health and subsequently his economic status. Taylor argues, however, that this level of regulation is still too weak to uphold the value of autonomy. He claims that even in cases where offers do not diminish autonomy and may even increase the well-being of everyone involved, It is possible for a person to make offers to others that, from the point of view of one who prizes autonomy, are morally impermissible because they evince a less than morally appropriate evaluation of the autonomy of the person to whom they are made (p. 98). To illustrate an offer that evinces a less than appropriate evaluation of someone’s autonomy, Taylor gives the example of someone calling out to a drowning man and offering to save him if, and only if, he then becomes the rescuer’s personal slave. It is clear that the drowning man’s well-being is increased by accepting the offer but that the terms offered are morally impermissible. Taylor claims that this offer is not morally acceptable because it indicates an inadequate respect for the value of his autonomy. Taylor goes on to suggest in his second pro-regulation argument that (1) when regulation does not have an adverse effect on the options made available to potential kidney vendors and (2) when it is clear that an offer evinces too low a concern for the autonomy of the vendor in a kidney market, regulation should be used to require that the purchaser provide the vendor with conditions that will not compromise their autonomy (p. 99). In order to give a clearer sense of the meaning and application of his second pro-regulation argument, Taylor focuses on how the argument applies to poor sweatshop labor conditions. He claims that autonomy requires that such sweatshops should be regulated to give more morally appropriate options to the sweatshop laborers. Then, arguing by extension, he applies his argument to kidney markets more specifically and suggests some specific regulations that he deems appropriate to remedy potential inequities. This argument for regulation assumes, however, that there exist no adverse effects on employment from such regulation. Taylor plainly acknowledges that his argument for regulation is weakened to the extent that this assumption is false, that is, to the extent that attempting to ensure better working conditions for someone through regulation causes them to lose the opportunity to work altogether. It is an absolute law of human behavior that when the cost of doing something rises, people do less of it. It is implicit in the concept of cost. As it becomes more costly to employ people, fewer people become employed. Taylor writes, however, that his argument for regulation rests on certain “empirical claims being true, such as the claim that the regulation of wages will not adversely affect employment” (p. 94). Taylor shows skepticism about the fundamental economic truths that oppose this claim. He provides evidence to support his skepticism from David Card and Alan Krueger’s work on the effects of labor regulation and minimum wage on employment. They argue that their studies provide evidence against the standard economic view. Taylor quotes Card and Krueger as saying that in their studies, “the estimated effect of minimum wage was zero or positive” (p. 105). Taylor is correct in highlighting the controversial nature of these claims. On one hand, Taylor’s argument for regulation places a responsibility on those who are committed to liberty and free-markets to continue to address seriously the claims upon which this argument for regulation is based. On the other hand, Taylor’s discussion of regulation may make the pill of legalizing organ markets easier to swallow for the mainstream of bioethics and policy makers, making Taylor’s proposal more politically feasible. One hopes that Stakes and Kidneys will have a beneficial impact on the issue and that both medical ethicists and healthcare professionals will accept and endorse it and that policy makers will take notice. |
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