Hastings Center Report

To the Editor: We read with interest the article by Farhat Moazam, Riffat Moazam Zaman, and Aamir M. Jafarey ("Conversations with Kidney Vendors in Pakistan: An Ethnographic Study," May-Jun 2009). Given that the authors have generically characterized our views as "parochial and cavalier" and "cynical and out of touch with reality," we feel compelled to respond.

Moazam and colleagues decline to mention that nearly every contemporary defender of a regulated market in organs scrupulously distinguishes the features of illegal, underground organ trafficking (which they describe) from the function of a regulated market, governed by moral principle. They characterize our arguments as either ignorant of or indifferent to the vast literature cataloging exploitation that has occurred in unregulated markets.

We are neither ignorant nor indifferent. Indeed, we have made substantive efforts to outline the causal connection between the organ shortage in wealthy countries and the flourishing of the underground organ trade in developing countries. By merely deploring the employment of the language of supply and demand, rather than the brute fact of this causal connection, Moazam et al. miss the point: exploitation of the vulnerable occurs in large part because of organ demand. A regulated system in the developed world may reduce (or eliminate) this demand from recipients of means, which in turn will reduce their economic support of organ trafficking in developing countries. While this will not eliminate organ trafficking, reducing the demand from the developed world will substantially raise the opportunity costs for indigenous middlemen, who as a group have not been moved by moral exhortation nor by the empty threat of inconsistently enforced (or deliberately unenforced) laws. Merely outlawing organ trafficking has not substantively attenuated its practice—a point reinforced both by this article and by a front-page story in Pakistan's Dawn from June 17, 2009. In the latter article, S. Adibul Hasan Rizvi, director of the Singh Institute of Urology and Transplantation in Karachi, is quoted as blaming "the government and law-enforcers who, [Rizvi] says, are conniving in making Pakistan a 'bazaar for cheap organs.'" Invoking the manifest failures of an unregulated system in Pakistan as an argument against a regulated system in Western Europe, the United States, and Canada is simply a non sequitur.

Moazam and colleagues reiterate the objection that a market in organs would come at the expense of altruistic donation, citing evidence of this in Iran, Israel, and Hong Kong. However, the regulated system of exchange in Iran came about because altruistic donation there failed to meet the demand for kidneys. Since the inception of this system of exchange twenty years ago, rates of uncompensated altruistic kidney donation from living related donors in Iran has remained at 11 to 13 percent of all organs donated. No attrition was observed. Furthermore, far from attenuating the growth of deceased donation—which was hampered in Iran by a lack of legislative recognition of brain death until 2000—the market in organs appears to have done the opposite: uncompensated deceased donation in Iran has increased tenfold since 2000 and now represents 15 percent of all procured organs. For reasons beyond the scope of this letter, the cases of Hong Kong and Israel are not nearly as straightforward as Moazam et al. represent. Regardless, an incomplete understanding of the social forces at work in these countries and cultures is not improved upon when methodologically sound ethnography is enveloped by the cant of ideologically predetermined conclusions.

The disparity between the supply of and demand for organs for transplantation will continue to buttress illegal organ trafficking in developing countries. We suggest, as a falsifiable hypothesis, that a regulated market in organs, undertaken in countries where safeguards and oversight are possible, is a plausible and morally defensible solution to the growing shortage of available organs.