Abstract
One of the central considerations to be taken into account in evaluating the ethics of compensation for donated plasma is respect for donor autonomy. And one of the main arguments against compensated donation systems is that many donors do or would come from circumstances of poverty that restrict their alternatives in a way that compromises those donors’ autonomy. In this paper, I develop and defend a novel version of this “compromised autonomy argument” which improves upon extant versions by employing a more nuanced account of the relationship between alternatives and autonomy. According to the version of that argument I offer, donors lack autonomy with respect to the sale of their plasma if their economic circumstances leave them with no choice but to sell their plasma (i.e., “plass”) on the basis of a desire they have had no choice but to hold. After explicating the key terms of this argument, I examine its policy implications. I argue that, given several reasonable empirical assumptions, my argument implies that a majority of individuals whose income falls below a specified threshold would indeed lack autonomy with respect to the sale of their plasma. Most individuals whose income falls above that threshold, on the other hand, would be able to autonomously sell their plasma. I argue that respect for donor autonomy therefore speaks in favor of an income-restricted system of compensated donation which permits collection centers to purchase plasma from those whose income falls above the relevant threshold, but not those below it.
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Notes
Although Wilkinson here mentions only “consent” rather than “sufficiently autonomous consent,” it is clearly the latter that he must have had in mind. Control over one’s body of the sort relevant to autonomy requires not merely that one is not interfered with in ways one has not consented to, but that one is not interfered with in ways one has not consented to in a sufficiently autonomous manner. After all, young children and adults under the influence of mind-altering drugs may consent to having their bodies damaged, touched, etc. by others. But while such agents are not wholly nonautonomous, they nevertheless lack the degree of autonomy needed to give valid consent of the sort that would waive their right to bodily integrity. Our concern here lies not with “minimal” or “complete” autonomy, but with this important degree of autonomy, and references to “autonomy,” “autonomous consent,” “autonomous action,” and the like should be understood accordingly. The claim that an individual “lacks autonomy” or that her autonomy is “compromised” for example, should be understood to mean, not that she totally lacks autonomy, but that she lacks the degree of autonomy needed to give valid consent. And the claim that an agent “autonomously consents” or “is autonomous with respect to the sale of her plasma” should not be taken to mean that she is fully autonomous, whatever that might involve, but that she is sufficiently autonomous to give valid consent.
It would of course also be necessary to take into account further considerations that might bolster the autonomy-based case against such a system, such as any negative consequences it could be expected to produce.
Raz (1986, p. 376) states simply that “a choice between survival and death is no choice.” On the account I shall go on to develop, this will depend upon the details of a given case. According to that account, an individual who can seriously consider taking a path she foresees will lead to her death does have a meaningful, autonomy-enabling choice to make. We can, though, assume that this is not true of Raz’s hounded woman.
Specifically, James and Mustard (2004, p. 1227) found that although “extreme poverty areas” (i.e., those in which the household poverty rate was greater than 40 %) represented only 4.4 % of all 1980 census tracts and 5.6 % of all 1990 census tracts, 22.6 % of all commercial plasma clinics were located in such neighborhoods in 1980; by 1995, the proportion of commercial plasma clinics located in extreme poverty areas had increased to 37.1 %.
Buyx (2009, p. 330) goes on to say that while “most agree” that this version of the CAA implies that “in poor countries … the poorest of donors” do or would lack autonomy with respect to the sale of their plasma, whether this holds also for donors from the bottom of the socio-economic ladder in developed countries “remains a matter of open debate.” I will argue below that there is good reason to think that the autonomy of many such donors is indeed compromised. Although they do not elaborate this claim in as much detail, Folléa et al. (2014, p. s387) similarly contend that “As it may be more attractive to those from lower socio-economic groups who have a greater need to use this option to gain income, remuneration for blood could be viewed as coercion against donors, compromising their autonomous decision-making.”
Hughes (2009, pp. 608–609) makes his argument from a lack of alternatives to compromised autonomy by way of an appeal to “successful necessity defenses” in “modern criminal justice contexts,” which, as Taylor (2009a, p. 637) argues, merely distracts from the philosophical issue concerning autonomous consent and is best ignored.
Frankfurt goes on to develop a specific theoretical understanding of “unthinkability.” Here, I use the term in its ordinary sense—roughly, as describing an act one cannot consider as a serious possibility. A more precise account of the alternatives autonomy requires will be offered below.
This claim comes in the context of a response to Hughes, whom Taylor follows in addressing kidneys specifically. His argument, though, would clearly apply also to plasma and other body parts.
Taylor (2009b, pp. 7–8) goes on to argue that the degree to which a person is autonomous with respect to a decision and any action it prompts depends upon the degree to which the decision is the result of a decision-making procedure with which the agent is satisfied. The agent can thus be identified with her decision-making capacities because (and only if) she is satisfied them, which suggests that she is fundamentally identified with that satisfaction. It is her satisfaction with a decision-making procedure, we might say, that incorporates that procedure into her self-determining self, thereby bestowing upon it the power to confer autonomy on the actions in which it results. This complicates the position Taylor takes on the metaphysical issue of what constitutes an agent’s self-determining self, but as explained below the key point here is simply that he has a position on that issue.
More specifically yet, and as explained in the preceding note, it is only those of his actions that are determined by capacities that constitute a decision-making procedure with which Othello is satisfied that can be so regarded.
This understanding therefore distinguishes the question of whether an agent’s autonomy is compromised from the question of whether anyone has acted wrongly with respect to her. This is helpful, in my view, because it enables us to address the issue of whether the autonomy of impoverished individuals is constrained by their economic circumstances and, if so, what could be done to remedy that, without tackling the contentious issue of who, if anyone, is to blame for that fact.
Both approaches can be elaborated in a variety of ways, depending on how the relevant capacities/motivations are specified. Our concern here lies not with any particular versions of those approaches, but the general ways of conceiving of autonomy that they embody. I mention these two theories only for purposes of illustration.
This understanding of adequate options can be understood as a more precise elaboration of the understandings suggested by Buyx and Hughes. There is a sense in which an alternative that an agent can realistically imagine pursuing is for that reason “meaningful” or “practical.” But there are other senses of these terms as well and it is therefore necessary to specify the usage of the term relevant in this context, as I have attempted to do here.
If Beth’s Mansonian values are seen as internal to her (new) identity, then she, too, would be autonomous with respect to actions prompted by those values, regardless of whether they leave her with any meaningful choice to make.
While the cause of Müller’s transformation is thus in the case the actions of another agent, I would argue that, just as in the Beth examples, he would be equally nonautonomous if it had instead been impersonal forces that turned Müller into Luther’s psychological twin.
Nor, we should add, does she creatively develop any such alternatives on her own—e.g., she does not conceive of a new religion or construct a novel normative philosophy.
As we have seen, however, what matters to the autonomy of a pro-attitude is simply whether the agent employed her deliberative capacities in exercising a meaningful form of control over the pro-attitude. If an agent is prevented from exercising such control, the pro-attitude is nonautonomous, regardless of whether this is due to the actions of another agent or impersonal forces/circumstances. Hence, if we imagine that the sheltered daughter has been unable to apply her reflective capacities to her Lutheran values, not because her father has deliberately sheltered her, but rather because a rare brain disorder renders her incapable of consciously recognizing any alternatives to those values, she would likewise lack autonomy with respect to them.
For a more thorough explication and defense of this condition, see Weimer (2009). I emphasize that my claim is only that the availability of such alternatives is necessary for the autonomy of a pro-attitude; it is not only its own sufficient. At the very least, an agent must during the relevant time period also possess adequate deliberative capacities and not be prevented from exercising those capacities by external forces. In a complete theory of autonomous pro-attitudes, an “alternatives-availability” condition of the sort proposed here would therefore need to be supplemented with, at the very least, “competence” and “independence” conditions. In this paper, I set these further conditions to the side in order to focus on the notion that autonomy requires alternatives which lies at the heart of the CAA.
On this condition, what matters is whether an agent has had a choice in the sense that she has had multiple alternatives to consider. She need not have made a conscious choice as to which pro-attitude to hold, for there are other ways in which one’s deliberative capacities might play a meaningful role in determining one’s pro-attitudes. It is doubtful, for instance, that Luther at any point explicitly chose to adopt his reformist values. It is more likely that during his process of study and reflection he simply found himself developing those values. Those values are nevertheless self-determined because the process by which they developed clearly exercised the capacities with which he can be identified. Although they were not called upon to make a conscious choice, those capacities were nevertheless “at work” adjudicating between viable alternatives: in reflectively evaluating the reformist values he eventually adopted and the more traditional values with which he presumably began and which he presumably could realistically imagine maintaining during at least some period of time during his studies.
It may be, for instance, that she realizes she could possibly acquire that money by robbing a store. But let us suppose that she is a morally decent person who cannot realistically imagine taking such an immoral path.
Desires flowing from addiction, for instance, might also be nonautonomous for lack of viable alternatives. If a donor is motivated to sell her plasma by such a desire which she can neither realistically imagine not acting on nor satisfy in any other way, she would lack autonomy with respect to that act. An autonomy-based case could thus be made for policies preventing alcoholics and individuals suffering from other forms of addiction from selling plasma.
It should go without saying that if the details of a policy of this general sort could be crafted in ways that would further minimize such violations, autonomy recommends doing so. For instance, perhaps an appeals process could be incorporated by which autonomous impoverished individuals could gain an exception (e.g., by demonstrating that despite their poverty they have met the absolute needs of themselves and their dependents). Or further conditions might be included to disqualify relatively well-off individuals who lack autonomy for other reasons (e.g., addiction, mental incompetence). I will not delve into such specifics here; my concern lies with identifying the general sort of policy that is recommended by respect for donor autonomy.
This assumes that violations of the right to bodily integrity and violations of the right to bodily disposal are equally, or almost equally, bad. This seems plausible, given that those rights flow from the same principle of respect for autonomy. However, my arguments are consistent with weighting the two rights differently, provided that one is not lexically superior to the other. Different weightings would simply imply that the income threshold should be located in a different place. Only lexical superiority would imply that respect for donor autonomy speaks for an alternative to the income-restricted approach I have outlined: for an unrestricted system if the right to bodily disposal is regarded as lexically superior to the right to bodily integrity, or for a total ban on compensated donation if bodily integrity is given lexical priority. It is, though, difficult to accept that either of these rights is lexically superior to the other and that protecting one person’s right to bodily disposal should take priority over protecting billions of people’s right to bodily integrity, or vice versa.
Objections to an income-restricted policy of the sort I have outlined which appeal to other normative considerations therefore lie beyond the scope of this paper. There is one objection of which I am aware that does not make such an appeal—namely, that an argument of the sort I have offered might prove too much. For instance, in his defense of a market in solid organs, Dworkin (1994, p. 157) argues that if the fact that impoverished donors lack alternative sources of income is taken to compromise the autonomy of their decision, this would have “a much wider implication than that [body parts] should not be sold. It suggests that poor people should not be allowed to enter the army, to engage in hazardous occupations such as high-steel construction, to become paid subjects for medical experimentation.” Cherry (2009, p. 665) makes a similar point. In response, it should first be noted that on the account I have developed, a lack of alternative sources of income does not necessarily imply a lack of autonomy. It is only if it is true of an individual (A) that there are no alternative means of acquiring the money a dangerous and/or invasive activity would provide that she can realistically imagine pursuing, (B) that she cannot realistically imagine pursuing the option of going without that money, and (C) that she is motivated by a pro-attitude to which she has had no viable alternatives that her action is non-autonomous on my account. In that case, there is indeed an autonomy-based reason to prevent her from performing that activity. On its own, though, this is not a difficult bullet to bite. I, for one, would not hesitate to agree that there is an autonomy-based reason to prevent a construction firm from hiring for dangerous work impoverished individuals who have no other realistic means of acting on their non-autonomous desires to feed themselves or clothe their children, say. Likewise for a pharmaceutical company that offers to pay such individuals to participate in harmful and/or invasive medical experiments. Regardless of how much they might benefit from the money received, it would of course be a violation of their subjects’ right to bodily integrity for such a company to experiment on people whose autonomy is compromised by a lack of mental competence, and as I have argued, autonomy can likewise be undermined by a lack of adequate alternatives to both the act one performs and the pro-attitude that motivates it. I am therefore comfortable accepting that to the extent that permitting people below a certain income level to participate in such activities could be expected to result in violations of their autonomy-based right to bodily integrity, there is reason to think that they should not be allowed to do so. This, though, would not be an all-things-considered “should.” Other normative considerations would have to be taken into account, including the social costs and benefits of permitting impoverished individuals to participate in a given activity as well as the costs and benefits of prohibiting them from doing so. If permitting such individuals to participate could not be expected to provide a significant net benefit in a given case, then the autonomy-based burden would likely not be met. If the reverse is true, then perhaps those benefits might outweigh the right to bodily integrity, such that the activity is justified, all-things-considered, despite the rights violations it would involve. As I have said, however, arguments to that effect lie beyond the scope of this paper.
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Weimer, S. “I Can’t Eat if I Don’t Plass”: Impoverished Plasma Donors, Alternatives, and Autonomy. HEC Forum 27, 361–385 (2015). https://doi.org/10.1007/s10730-014-9256-2
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DOI: https://doi.org/10.1007/s10730-014-9256-2