Arguments for the defense – are they valid?

Not many in the medical fraternity have been surprised by the exposure of the sale of kidneys in Bangalore. A more worrying aspect is that several are not shocked. They argue that taking kidneys from a donor unrelated to the recipient is not, per se, unethical. It is only the commercialism that is unacceptable. We should eliminate ‘not the trade but its abuses (1).

Do they have a point?

1. All parties benefit the seller, the buyer, the doctor. This is patently false. The argument that the sum received helps the donor rise above his poverty is fundamentally flawed. Surely it is the duty of every society to see that none of its citizens are so desperate that they have to sell themselves piecemeal to survive.

The buyer often gets poor and exploitative medical care. Disregard for social ethics seems to go hand in hand with disregard for medical ethics and several patients have had HIV, hepatitis B and other infections transmitted to them during the transplant operation (2).

The only person who unequivocally benefits is the doctor.

2. The choice for doctors treating patients with end stage renal disease is ‘buy or let die (3).

Only l-2% of such patients receive transp’lants, an important limiting factor being the cost. Less than half of these do not have a suitable related donor. The cadaver transplant program is expected to help these and some of the remaining 98% who, at present, have no hope at all since they cannot afford the costs of transplant from an unrelated donor.

The question really is, ‘Should we ration medical technology by need or by the ability to pay? Shall we permit those with money to exploit a poor man’s body while condemning those without it to go home and die? ‘

The argument about eliminating the abuses whilst retaining the trade is nothing but a subterfuge to continue this lucrative business.

Other ethical abuses

Many other ethical abuses occur in the trade:

1. The potential recipients of organs are often not told that they will require approximately Rs. 5000 per year, lifelong, for immuno-suppression.
2. The long term fate of these grafts is shrouded i n secrecy since these ‘transplant centres’ rarely publish their results.
3. Although it is claimed that the seller suffers no permanent harm (1) there is no long term followup study of their fate. It is unlikely that individuals so poor as to sell their vital organs will be in good general health or that when recipients suffer so many complications from major surgery on their kidneys, donors suffer neither morbidity nor mortality.

Chicanery

Those involved in the trade attempt to confuse the international community by pleading that ‘special circumstances in India’ make such transplants from unrelated donors necessary. They cite lack of facilities for dialysis, absence of a program using kidneys from cadavers and poor facilities in public hospitals in support of their argument. Each of these lacunae can be filled by concerted effort by the very persons whom this trade benefits the rich and influential and the medical professionals. The existence of the easy option of buying kidneys has, in fact, retarded effective action to establish a cadaver transplant program.

The only real special circumstances in India are the presence of people poor enough to sell vital parts of themselves, people rich enough to buy these and a medical community unscrupulous enough to facilitate the exchange.

The argument that it is unethical to interfere with a patient’s autonomy over his own body definitely sets one on the slippery slope to disaster. Should one, then, permit sale of one eye, lung or joint?

The recent Act

The Transplantation of Human Organs Act, notified this February, is a progressive piece of legislation. The Act must now be notified in each State individually to become the law in that State. The government of Tamil Nadu passed the Human Organ Transplants Bill on 5 May 1995.

We fear that if sufficient public pressure is not brought to bear on the governments of other states to enact this law, the unethical trade in human organs will merely shift to them.