From my vantage point as a master’s student paying to live in Stockholm in part to study ethics, this is an interesting dilemma to consider. Of course, I only have to consider it: that’s the privilege of looking down from the Ivory Tower built not by my own virtues, but by the money into which I happened to be born. Others are not so lucky. For over twenty years, it has been reported that people across the world sell a kidney, as their ticket out of poverty (BBC, 2013; Chatterjee, 2017; Maher, 2016; Shimazono, 2007).
Like any other business, the kidney trade is based on the market principle of ‘supply and demand’; the present disease burden of kidney failure has reached a point where demand outstrips supply (Astier, 2020; Chatterjee, 2017; McCormick et al., 2018). The economic logic – and I dare to add, the ethics – holds: some people need kidneys and others need money, so why not play the world’s most morbid game of ‘blind date’, where one meets their match and both players get to live? “Because it’s wrong!” comes the reply. But, is it? People have two kidneys, and the autonomy to choose to sell one for the chance of a better life. I suspect that few would contend that it is ethically justifiable to deprive some of the world’s poorest people of such a chance.
However logical or even ethical the conclusion is, it leaves a bitter taste. Something doesn’t feel right about it. There lurks a deeper question here. One that asks not ‘is it ethical to do this?’, but ‘what kind of society puts people into this dilemma in the first place?’ If we spar only with the ethics, we miss the point: the ethics adapt to whatever society is willing to tolerate (Epstein, 2014, 2016). Across much of the world, societies tolerate an economic system where it is each person for themselves, and individual profit is the prize. Capitalism is the name of that game. And the issue is that there are very few winners, and they tend to win all the time; the rich get richer and the poor ever poorer (Sell, 2019). When we accept this, we accept that the answer to our titular question will be yes.
Medicine is not immune: it is driven by the same economic incentives that run the rest of society. Access to healthcare is for many limited by their ability to pay (Krohmal & Emanuel, 2007; Sell, 2019; Thomson et al., 2019), and medical care is often prioritised for those who show a greater potential for economic contribution down the line(Archard & Caplan, 2020; Jessop, 2020; Shaw, 1994). In 2010, healthcare spending caused financial catastrophe for about 10% of the world’s population (Wagstaff et al., 2018). Calls to ensure that all people have access to the quality healthcare services they need without suffering financial hardship – known as ‘universal health coverage’ – are growing (WHO, 2021), but is this possible within capitalism as we currently do it? Are the same societies that allow their people to ethically sell a kidney in order to survive likely to start providing them with affordable healthcare? The chances seem slim.
Acknowledgments: this work is written solely by me, but my worldview has been influenced by the philosopher Miran Epstein.
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