Kidney Blogging Cont'd
In response to a challenge from Dan and me on Bloggingheads, Kieran Healy weighs in on my dispute with Amitai Etzioni about organ donation. It's a long, thoughtful post and deserves reading in its entirety. The conclusion is what I would have expected from reading Kieran's book and is, I believe, correct.
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.
Amitai Etzioni may want to ostracize me as a "zealot" and imply that I have no business writing in respectable places like The New York Times Book Review, but both Healy and I have a much deeper knowledge of the empirical realities of organ donation than Mr. Communitarian. I am not the ideologue in this debate.
Another empirical reality is that many people are deeply suspicious that doctors will rush the deaths of prospective (deceased) organ donors. Stories like this only feed that suspicion. Legitimate or not, those fears--and those agency problems--have to be respected. That's one reason I believe incentives for donation, including but not limited to full-blown markets, should focus on living donors. It's also a very good reason for opposing "presumed consent," the policy which would require people to explicitly state that they do not want to be organ donors on death. Without such statements, the organs would be harvested from brain-dead patients, regardless of the family's wishes. (Some European countries have adopted this policy; rumor has it that Kieran Healy has done research on the outcomes, but I haven't seen it.)
Today marks the first anniversary of Sally Satel's kidney transplant, for which I provided a kidney. I'm happy to say that she's doing great. Aside from having to take immunosupressant drugs, she's completely cured.