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Kidney Sales and the Analogy with Dangerous Employment

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Abstract

Proponents of permitting living kidney sales often argue as follows. Many jobs involve significant risks; people are and should be free to take these risks in exchange for money; the risks involved in giving up a kidney are no greater than the risks involved in acceptable hazardous jobs; so people should be free to give up a kidney for money, too. This paper examines this frequently invoked but rarely analysed analogy. Two objections are raised. First, it is far from clear that kidney sales and dangerous jobs involve comparable risks on an appropriately broad comparison. Second, and more importantly, even if they do involve comparable risks it does not follow that kidney sales must be permitted because dangerous jobs are. The analogy assumes that kidney sales are banned for paternalistic reasons. But there may be other, non-paternalistic reasons for the ban. And paternalists, too, can consistently defend the ban even if kidney sales are no riskier than occupations that they find acceptable. Soft paternalists may want to protect would-be vendors from harms that they have not voluntarily chosen. Egalitarian hard paternalists may want to protect already badly off vendors from further worsening their situation. For neither species of paternalist is the size of the risk prevented decisive. I conclude that the analogy with dangerous jobs, while rhetorically powerful, pulls little real argumentative weight. Future debates on living kidney sales should therefore proceed without it.

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Notes

  1. In addition to the authors already quoted, see Andrews [1, p. 32], Dworkin [11, p. 157], Harris [18, p. 161], Radcliffe-Richards et al. [31, p. 1951], Savulescu [35, pp. 138–139], Wilkinson [40, p. 108], Taylor [38, ch. 6], Matas [23, p. 2010] and Matas [24, p. 1131].

  2. The main exception is Taylor [38], who dedicates a whole chapter of his book Stakes and kidneys: why markets in human body parts are morally imperative to the analogy. For shorter but nonetheless useful discussions, see Audi [5, pp. 143–146], Zutlevics [43, pp. 298–299] and Nuffield Council on Bioethics [29, pp. 142–143].

  3. For more on incommensurability, see Chang [9]. My very rough characterisation of the problem differs from some of the characterisations in that volume, but should be suitable for the purposes of this paper.

  4. I bring up seatbelt, drunk driving and public drunkenness laws to illustrate the point that liberty-limiting policies have different rationales. Whether actual such laws are or should be based on the rationales I attribute to them is not my present concern.

  5. Authors who explicitly make the connection to paternalism include Dworkin [11], Audi [5] and Taylor [38].

  6. For contemporary expressions of this old worry, see Radin [32] and Satz [34].

  7. A different, but structurally similar, challenge worth mentioning relies on an analogy with unpaid living donation rather than hazardous employment. If the paternalist thinks that people should be permitted to give up a kidney for free, how can she consistently deny that they should be permitted to do so for pay? After all, payment would not make the exchange any more dangerous [30, 40]. A thorough discussion of this challenge would require another paper. Let me just note that paternalists could respond by employing the same strategies that I shall employ against the analogy with dangerous jobs. In brief, soft paternalists could argue that selling is more likely than donation to be non-voluntary, and egalitarian hard paternalists could argue that the risks of selling are likelier than the risks of donation to be borne by the worst off.

  8. This rough characterisation is compatible with major more elaborate accounts of paternalism [6, 10, 13].

  9. I say “primarily” for two reasons. First, as pointed out above, soft paternalists hold that the dangerousness of a choice is indirectly relevant to whether it should be permitted in the sense that riskier choices require higher standards for ascertaining voluntariness. Second, group soft paternalist policies must justify interfering with both competent and incompetent agents. The restricted freedom suffered by competent agents is not justifiable by appealing to potential harms to them. However, it is justifiable by appealing to harms to other, incompetent agents—and more so the greater these latter harms are. (For discussion, see [22]). Nevertheless, voluntariness, not harm, remains of first importance.

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Acknowledgments

I thank Kalle Grill, Jurgen de Wispelaere and two anonymous reviewers for this journal for helpful comments.

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  1. Division of Health and Society, Department of Medical and Health Sciences (IMH), Linköping University, 581 83, Linköping, Sweden

    Erik Malmqvist

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Malmqvist, E. Kidney Sales and the Analogy with Dangerous Employment. Health Care Anal 23, 107–121 (2015). https://doi.org/10.1007/s10728-013-0270-3

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