A cancer among the body social

Modern anthropology, the study of power in all its forms, is focusing on how elites and institutions affect individual lives and how the alienated can be empowered.

Those poor and desperate enough to sell their organs know nothing of 'choice' - only exploitation, argues Nancy Scheper-Hughes.

From the exclusively market-oriented perspective that is gaining ground in respectable medical circles, black markets in human organs, which operate in several countries around the globe, can best be handled by regulation rather than prohibition. Given the desperation of those stranded on national waiting lists or trapped in dialysis, the neo-liberal solution appears to be straightforward - those able to purchase a human organ should not be prevented from doing so. In fact, some surgeons and public health officials now argue that transplant patients should be officially aided to do so.

The problems with this "rational" solution to the chronic shortage of transplantable organs are many. To date, only kidneys, bone marrow and liver lobes can be taken from living donors and transplanted into ailing patients. Living donation is a risky procedure and obviously cannot supply the "demand" for hearts, lungs, pancreas and other irreducible or irreplaceable body parts. Meanwhile, removal of kidneys, let alone half the liver for transplant, even under the most favourable surgical and post-operative conditions, is hardly a risk-free procedure as recent deaths of donors in the US testify.

The problems multiply when the kidney donors and recipients are unrelated because the sellers are generally extremely poor and trapped in life-threatening environments where the everyday risks to their survival are legion. The few available longitudinal studies of the medical and social effects of kidney removal on kidney buyers and sellers in India and Iran are unambiguous. Even under-regulated systems in which "compensated gifting" is used to reimburse living donors, kidney sellers frequently suffer from chronic pain, debility, unemployment and social stigma accompanied by severe psychological problems.

Organs Watch has been working in nine countries, and we have found that kidney sellers often face daunting medical problems, including hypertension and, in some cases, kidney insufficiency without access to follow-up medical care, expensive medications, or dialysis, if needed. It goes without saying that kidney sellers are the least likely to have access to transplant organs themselves should that need arise.

On returning to their rural villages or urban shantytowns, itinerant kidney sellers find themselves unable to sustain the demands of heavy agricultural or construction work, the only labour available to men and women of their skills and backgrounds. Kidney sellers experience deep shame. In rural Turkey and eastern Europe, kidney sellers are stigmatised as "prostitutes", excommunicated from their churches, alienated from their families and co-workers and, if single, often excluded from marriage. Their children are ridiculed by other school children as "one-kidneys".

How can a government-regulated system set a "fair" price on a living person's healthy body part? The global market sets the value based on medical consumers' prejudices. In today's thriving kidney market, an Indian kidney fetches as little as $1,000 (£670), a Filipino kidney $1,300, a Moldovan or Romanian kidney yields $2,700, while a Turkish seller can command up to $10,000 and an urban, educated Peruvian as much as $30,000.

The new consumerist medical ethics that is gaining acceptability today creates the semblance of ethical choice (for example, talk of "the right" to buy a kidney) in an intrinsically unethical context. Bioethical arguments about the right to sell an organ or other body part are based on cherished notions of contract and individual "choice". But the social and economic contexts that make the "choice" to sell a kidney in a Calcutta slum, a Brazilian favela or a Philippine shantytown are anything but free or autonomous. The idea of consent is problematic when a seller has no other option left but to dismantle his or her own body. Putting a market price on body parts - even a "fair" one - exploits the desperation of the poor, turning their suffering into an opportunity for a more affluent person. And the surgical removal of non-renewable organs from healthy, unrelated donors is an act in which medical practitioners, given their ethical standards, should not be asked to participate.

The demand side of the organs scarcity problem also needs to be confronted. Part of the current scarcity derives from expansions of organs waiting lists to include very small infants, patients over 70 years old and those proven to be prone to transplant rejection, a practice that needs to be questioned. Liver and kidney failure are often due to a failure to promote preventive measures aggressively enough.

Ethical solutions to the chronic scarcity of human organs are not always palatable to the public, but they need to be considered. Foremost among these are systems of educated, informed "presumed consent" in which all citizens are assumed to be organ donors at brain death unless they have officially stipulated their refusal beforehand. This practice, successfully implemented in parts of Europe, preserves the value of organ transplant as a social good based on a social contract in which no one is included or excluded based on the ability to pay.

The division of the world into organ buyers and organ sellers is a medical, social and moral tragedy of immense and not yet fully recognised proportions.

Nancy Scheper-Hughes is professor of medical anthropology at the University of California, Berkeley, and co-founder and director of Organs Watch.