sid

The Ethics of Organ Selling: A Libertarian Perspective

by Harold Kyriazi, Ph.D.
Department of Neurobiology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania, 15261

First Principles

As a libertarian, I believe that people own themselves. Any alternative would involve some form of slavery. And as owners of themselves, individuals have the right to sell their organs, give them away, and even to allow themselves to be "harvested" of their organs in a productive form of suicide, for whatever reason they choose. (Of course, surgeons and hospitals would be free to denounce, and to refuse to perform, such macabre procedures, and medical societies would be free to expel members who assist in such suicides.) Having said that, I also wish to emphasize that I share the concerns expressed by bioethicist Stephen G. Post, of the Case Western Reserve University School of Medicine=s Center for Biomedical Ethics:

...in India, where a huge black market in nonvital body parts provide kidneys for the wealthy, it is the poor who sell. Is this truly freedom, as the libertarian proclaims? Or is it a forced choice made in destitution and contrary to the seller=s true human nature? I see such a market as the most demeaning form of human oppression, as unworthy of any valid human freedom...(1)

But one could make the same argument for coal miners and others with dangerous jobs, who risk life and limb to support their families. Certainly such people are better off having these additional choices. But while it is a pernicious paternalism that would seek to deny the poor these choices, it is also a sterile libertarianism that would stop the inquiry here, hailing the enlarged freedom of the destitute, and looking no further.

Margaret Radin, professor at the University of Stanford Law School, reached a similar conclusion:

If people are so desperate for money that they are trying to sell things we think cannot be separated from them without significant injury to personhood, we do not cure the desperation by banning sales. ... Perhaps the desperation is the social problem we should be looking at, rather than the market ban. Perhaps worse injury to personhood is suffered from the desperation that caused the attempt to sell a kidney or cornea than would be suffered from actually selling it. The would-be sellers apparently think so. Then justice is not served by a ban on "desperate exchanges." ... We must rethink the larger social context in which this dilemma is embedded. We must think about wealth and power distribution. (2) [p.125]

And so we are led to consider the larger societal question of basic economic justice.

But before discussing the world as it should be, I wish to make a few comments about the ethics of the world of organ transplantation as it is.

Comparing the Indian and U.S. situations

Both India (three of the key states in 1994, and others subsequently) and the U.S. (nationally in 1984) have banned monetary compensation for human organs. The ban has been effective in the U.S., while it is routinely circumvented in India. But which system is the more ethical? In India, at least, those upper class Indians and wealthy foreigners who need organs are getting them, while some of the poor are afforded more financial opportunity than they would otherwise have. In the U.S., however, over 5,800 peopleCrich and poor alikeCdie every year while waiting for donor organs that never arrive. And with most such deaths are associated years of waiting, years of debilitating sickness, and years of mental anguish not only for the ill, but for their families and friends. Against this horrendous backdrop, is a ban on market activity ethically sound? Another professor of lawCLloyd R. Cohen, of the George Mason University School of LawCthought not:

People are dying while the organs that could restore them to life, and that a market (3) would provide, are being fed to worms. Were more to suffer and die for want of organs that a market would provide, the high minded pieties that support the prohibition would be revealed for the vacuous moral posturings that they are. (4)

Finally, on this issue, Professor Radin insightfully notes that the U.S. positionCthat altruism shall be the only permitted motivation for organ donationCmay simply be a convenient way of shutting its eyes to the desperation of its own poor. "To preserve organ donation as an opportunity for altruism is also one way of keeping from our view the desperation of poor people." [Radin, p.126]

Let us now proceed to the heart of the matterCpoverty and economic justice.

Economic Justice

The essence of economic injustice, as it is currently institutedCessentially worldwideCis no longer chattel slavery, as it was in the 19th century and before, but wage slavery. And wage slavery is made possible by land policies that allow a small portion of mankind to monopolize the land on which and from which all must live. Said 19th century American economic and social philosopher Henry George, "…the ‘iron law of wages,’…which determines wages to the minimum on which laborers will consent to live and reproduce…is manifestly an inevitable result of making the land from which all must live the exclusive property of some. The lord of the soil is necessarily lord of the men who live upon it. They are as truly and as fully his slaves as though his ownership in their flesh were acknowledged." (5)

I cannot here go into detail about economic justice, but I refer those interested to my recently published book on the subject (6). The short answer, however, is that those who "own" land and natural resources should pay to the community a yearly rental fee, based on the market value of their holdings (irrespective of buildings or other improvements). Such a fund will guarantee landless citizens at least a minimal income, and also pay for the valid expenses of government. More importantly, the community=s act of charging market prices for land and natural resources will help ensure that the latter are put to their highest and best use, generating more jobs and wealth for all. Additionally, no taxation should exist on productive human activity (such as working, via wage and income taxes; buying, via sales or value added taxes; saving and investing, via income and capital gains taxes; giving, via gift and inheritance taxes; etc.), as that punishesCand hence lessensCgood behavior, while robbing people of the fruits of their labor.

From what I understand of recent Indian history, efforts at land reform in the various states have been economically counterproductive, aimed at forcibly subdividing the land itself (7) rather than merely its economic rent. My impression of the Indian economy in general is that central planning and control have effectively stymied individual initiative. But all that is necessary for people to thrive economically is for them to have free and equal access to the earth (or its equivalent in rent) and the rights to free action and free association (i.e., to engage in entrepreneurial and free market activity), with the only proviso being that they do not violate the equal rights of others.

The U.S. has, of course, long championed the latter freedoms, but has ignored the injustice inherent in its monopolistic system of land tenure. It was able to escape the harmful consequences of the latter for much of its history by virtue of its frontier, which provided a safety valve for oppressed laborers, who could escape wage slavery by homesteading frontier land, thus becoming their own masters. That avenue of escape was gradually eliminated, and the U.S. then took the indirect route of wealth redistribution (via income, estate, and other forms of taxation) to attempt to redress the situation, rather than eliminating the injustice at its root.

As Winston Churchill said, "land monopoly is not the only monopoly that exists, but it is by far the greatest of monopolies. It is a perpetual monopoly, and it is the mother of all other forms of monopoly." (8) Thus, while many forms of monopoly now exist, and many people make money in partly unfair ways in many fields other than real estate and natural resource utilization, these other forms would not be possible without the primary monopoly of land and natural resources.

The U.S. and most other countries have thus allowed the privileged to retain their immoral means of subjugating their fellow men. (Not that I believe the privileged are, in general, aware of the partly immoral nature of their means of attaining wealth. If they could perceive the basis of the injustice, so also would most others.) But perhaps the day is coming when the masses will understand the true nature of their plight, and will take proper remedial action.

A proper ethical focus

A primary ethical focus throughout the world must be the establishment of true economic justice, along the lines discussed above. Only in that way will the question of the exploitation of the poor be properly addressed and satisfactorily answeredCby the elimination of poverty.

Additionally, most of the world needs to adopt something like the de facto (but not de jure) system now in place in India, by permitting monetary compensation for organs. Said Henry Hansmann, of Yale Law School: "...this prohibition may be overly broad... It appears possible to design suitably regulated market-type approaches to the acquisition and allocation of cadaveric organs (and perhaps of organs from living donors as well) that will be neither unduly offensive to ethical sensibilities nor easily abused…" (9)

For most of the world, cadaver tissues and organs should be adequate to meet demand. This seems a reasonable assumption, given that BelgiumCwhich has a policy of "presumed consent," in which people are presumed to be willing organ donors unless they have indicated otherwiseChas such a surplus that it is able to supply many foreigners with needed organs (10). And data from the U.S. on accidental deaths, where the death itself occurs in a hospital setting, suggests a potential surfeit of transplantable organs (11). The laws against monetary compensation thus need to be repealed, allowing Organ Procurement Organizations the freedom to use whatever financial incentives are required to bring the supply up to meet demand. (From an ethical standpoint, it would be wrong to use live donors when cadaver organs are available, assuming that cadaver organs are equally as effective and safe as those from the living. If this is not the case, i.e., if cadaver organs stand a greater chance of failing or infecting their recipients than those from living donors, it=d require careful consideration and balancing of the risks to donor and recipient to decide the proper course of action. Nevertheless, it is the individuals involved, and not legislators and bureaucrats, who should make such decisions.)

For most of the world, then, the question of the ethics of living donation will be a peripheral concern, arising only in cases of extreme time urgency, when one simply cannot wait for a cadaver with the proper tissue match to become available. In those cases, live donation, in which the pool of potential donors is much larger, will continue to be the only viable option. For India, however, for a variety of reasons, any large-scale use of cadaver organs is not currently feasible. Thus, for India, live donation will continue into the foreseeable future.

Summary

Given the above considerations, were I a transplant surgeon in India, I would have five relevant ethical concerns:

1. Economic justiceCsupport the establishment of genuine economic justice.
2. Cadaveric vs. living donorsCsupport a transition from a system emphasizing living donors to one relying mostly on cadaver organs from those who have suffered brain death.
3. Fair compensationCtry to ensure that donors are paid as much as possible (since the current market contains some degree of exploitation, due to the entrenched economic injustice). In practice, this would entail dealing only with organ brokers who treat donors fairly.
4. Do no harmCover and above the usual concerns expressed in the Hippocratic Oath, take all reasonable steps to ensure that patients have adequate follow-up care and legal options for redress of grievances.
5. Legalize organ sellingCbecause the above-mentioned legal options are unlikely to be feasible under a black market system (lawbreakers rarely wish to attract legal attention to their own "criminal" behavior), one must seek to remove the laws banning organ selling. Their existence, in an atmosphere in which black market activity nevertheless thrives, not only places those involved outside the protection of the law, but engenders disrespect for law and law enforcement in general, to the detriment of society. More importantly from an immediate standpoint, removing the ban will free the operations from the clutches of organized crime, and make transplants less expensive for recipients, less exploitive of poor donors, and less dangerous for all involved. (12)



Nationally, almost 92,000 people are awaiting an organ transplant. Approximately 17 will die each day without receiving one. Bad legislation is killing them. Help us make it better.

The only thing that could save them, the thing that made America great - freedom - has been flatly rejected by our federal government...

Welcome to Organ Selling, the website dedicated to reestablishing our ownership of our own bodies (including our internal organs!), repealing the 1984 U.S. Congressional ban on compensation for cadaveric human organs, and ending the needless suffering and death each year of thousands of prospective transplant patients.

Each year, thousands of potential organ donors take their organs to the grave, unutilized. Shamefully, the families of 40% aren't even asked to donate, while half of those that are asked respond affirmatively. Thus, only 30% of the life-saving potential is being utilized. Monetary incentives have been banned by our lawmakers, effectively condemning over 6,000 people to agonizing death each year. We maintain that if this ban were lifted for cadaveric organs, the supply would increase 200% or more, to near its maximum possible level. And when that happens, no one need suffer or die for lack of a suitable replacement organ.

Even if you're one who's offended by the prospect of people getting something tangible in return for their loved ones organs, there are many things on this site you may find of interest - expert testimony, patient and donor stories, ethical analysis, morality, history, economics, poetry and more. Enjoy!

The only thing that could save them, the thing that made America great - freedom - has been flatly rejected by our federal government...

Nationally, almost 92,000 people are awaiting an organ transplant. Approximately 17 will die each day without receiving one. Bad legislation is killing them. Help us make it better.

* Nationally, more than 73,000 people are awaiting an organ transplant; approximately 16 will die each day without receiving one, including two within the CORE service area.
* At the six CORE-affiliated organ transplant hospitals, approximately 1,600 people are awaiting organ transplantation, while thousands more await tissue or corneal transplants.
* Between 10,000 and 12,000 people die annually who are considered medically-suitable for organ donation, yet only an estimated 5,200 donate.
* One organ, tissue and eye donor may help between 200 and 400 people.
* Major organized religions support donation, considering it a kind act.
* More than 46,000 people await a kidney transplant. Following kidneys, livers, hearts, and lungs are the organs in greatest demand for transplantation.



Facts and Statistics of Organ Transplantation

[Taken from the CORE (Center for Organ Recovery and Education) website, 3/3/01]

* Nationally, more than 73,000 people are awaiting an organ transplant; approximately 16 will die each day without receiving one, including two within the CORE service area.
* At the six CORE-affiliated organ transplant hospitals, approximately 1,600 people are awaiting organ transplantation, while thousands more await tissue or corneal transplants.
* Between 10,000 and 12,000 people die annually who are considered medically-suitable for organ donation, yet only an estimated 5,200 donate.
* One organ, tissue and eye donor may help between 200 and 400 people.
* Major organized religions support donation, considering it a kind act.
* More than 46,000 people await a kidney transplant. Following kidneys, livers, hearts, and lungs are the organs in greatest demand for transplantation.

Here are some general facts, as well as some statistics from California, taken from a January 23, 2000 article in the San Diego Union-Tribune, by Caitlin Rother, entitled "Of Death and Life."

* The first kidney transplant was performed in 1954.
* Organs may be donated only if a person is declared brain dead, which means that all brain function has stopped and the heart continues to beat, though mechanical support must be used to keep blood flowing to the organs. Organs such as the heart, lungs, liver, kidneys, small bowel and pancreas may then be donated.
* Brain death may be caused by a severe head injury, a fall, a blow to the brain, or a gunshot wound to the head. It also can be caused by a stroke or aneurysm, which results in massive bleeding or swelling in the brain. Other causes include brain tumors, which cut off blood flow, or other injuries that cut off oxygen to the brain such as drowning, heart attack or carbon monoxide poisoning.
* Patients whose hearts stop beating can donate only tissues, which include eyes, corneas, joints, tendons, ligaments, heart valves, skin and bone. The number of potential tissue donors outweighs the number of potential organ donors by 10 to 1.
* 1,500 people die of brain death each year in California, but only 500 become organ donors. About 7,000 Californians are waiting for an organ transplant, and one-third of these people will die for lack of a donor. Experts characterize this as a statewide health crisis.
* Nationwide, more than 60,000 men, women and children are waiting for organs. That waiting list is growing three times faster than the rate of organ donation. Of those 60,000 patients, 1,200 are listed in San Diego.
* Kidneys are in the highest demand, comprising nearly two-thirds of the waiting list.

Statement of Principles

WHEREAS each individual is the proper owner of himself or herself, including all of his or her internal organs,

WHEREAS the free market is the most moral and practical way to provide for human needs,

WHEREAS the current "altruism only"-based system results in the needless suffering and death of thousands of people each year as they wait for donor organs, not to mention the trauma inflicted upon their families and other loved ones,

AND WHEREAS efforts to increase the rate of donation through educational campaigns have failed miserably,

WE PROPOSE that Congress rescind its 1984 ban on the sale or purchase of human organs (National Organ Transplant Act), so as to allow monetary compensation for cadaveric organs.



Our proposal and how it will save lives

We propose that Congress pass the following bit of legislation: "The National Organ Transplant Act of 1984 is hereby amended to permit monetary compensation for cadaveric organs." Click here for our May 2003 letter to Congress.

The essential facts:

* only a third to a half of those capable of being organ donors actually donate
* if monetary compensation for cadaveric organs were allowed, the donation rate would increase dramatically
* an increase of any amount would save lives and eliminate much human misery

The proposal is to allow monetary compensation for cadaveric organs, i.e., organs that are removed after death - specifically, after brain death. We are not proposing to allow monetary compensation to living donors, although we discuss it as an option below, and have excerpted an article in which this was proposed and defended. Thus, there'd be no need to fear that poor people would sell one of their kidneys just to put food on the table. (This is not the place to get into a discussion of poverty and economic justice, but here are some of our favorite links regarding fundamental questions about economic justice and the only true remedy for poverty.) Neither is there any need to fear that some people might be killed for their organs. Organs for transplantation, unlike bodies to be used for anatomical dissection, must be removed in a hospital while the person's heart is still beating. One would have to have almost an entire hospital staff complicit in murder - people who have nothing to gain and everything to lose from such behavior. Thus, fears about a new breed of "body-snatchers," at least in this country, are totally unreasonable.

How the cadaveric market will work, in detail

A cadaveric organ market could work in several ways. One would be a future's market, where individuals would sell the future rights to their organs for money now, to be enjoyed while they're still alive. (This could take the form of reduced health insurance premiums.) Because only a small percentage of people would actually yield usable organs, the amount might be fairly small - several hundred dollars, and a few thousand at most. This may not be the most efficient sort of market. The other is an after-death market, whereby the families of brain-dead potential donors could receive some form of payment after the death, either as cash given to the deceased's estate, or in the form of reimbursement of funeral and/or hospital expenses.

Organ brokers would pay Who'd pay for the organs, or for the future rights to them? Organ brokerage firms, which would act as intermediaries between buyers and sellers, i.e., between those who need organs and those who provide them. Many similar organizations exist today (about 110 existed in 1983), called Organ Procurement Organizations, but they are prevented by law from offering monetary incentives to potential donors.

Living donor option If, contrary to our view, a free market in cadaveric organs proves insufficient to meet the demand, we see nothing wrong with allowing living donors to be compensated for donating renewable organs, such as a portion of their liver, bone marrow, or even a kidney, given that survival rates for people in this country with one kidney are the same as for those with two. (Supposedly, one only needs the output of half of one kidney to survive.) From the standpoint of the doctors involved, such an alternative would be morally justifiable only if the cadaveric market was already being completely utilized, and still found to be unable to provide a sufficient number of replacement organs. This is so because a doctor's first duty is to do no harm, and there is always risk associated with being a living donor.

Furthermore, we note that our current system allows friends and/or relatives to donate a kidney to a loved one. Why is it an acceptable risk, or a moral act, when the motive is love for the recipient, and not an acceptable risk or a moral act when the motive is love for those whom the money would benefit?

Future's market As mentioned above, this would have healthy people selling the (hopefully!) far-distant future rights to their organs. Organ brokers could make one payment of a few hundred or thousand dollars, buying the rights for a lifetime, or yearly payments of lesser amount, in effect leasing the rights for a year. Such yearly payments would have the advantage that people would have to remain in touch with the organization, and the amount of payment might even be made contingent upon the physical condition of the seller. After death, the deceased's relatives might object to the organs being removed, and could be provided with an option of making repayment, with interest, to the brokerage firm, subject to the firm's consent. Or, the organ brokerage firm might insist that the contract be honored.

This future's market, or "pre-payment" approach, can be thought of as "reverse insurance" - the brokerage firm pays lots of people a relatively small amount of money, in the knowledge that a few of them will pay off bigtime (in usable organs). With health insurance, the reverse happens - lots of people pay the insurance company a relatively small amount of money, in the knowledge that, for a few unlucky ones, there will be big-time medical expenses which the insurance will cover. (This interesting reverse relationship is part of what makes reduced health insurance premiums for those who agree to donate organs (upon death) what some experts consider the ideal mode of transaction.)

One advantage of the future's market is that it moves the time of decision-making to long before the actual time of death, when the deceased's relatives are grieving and least able to make a rational decision. [Note: organs are generally taken only from people who have undergone brain death, but whose bodies are still functioning. In order to maintain the organs in a usable condition, the body must be kept on life support until the organs are removed. Asking a family to make a decision at a time like this, when they've just been told their loved one has suffered brain death, is a very touchy proposition.]

[For a more detailed, expert discussion of such futures markets, click here.]

After-death market Post-death payment contracts could be entered into in several ways. One way is that the person dying could make the arrangement, with the money to be paid to their estate after death. Or, the dying person's family and/or legal heirs could make the arrangement if the dying person is comatose or otherwise unable to make a decision, with payment also going to the estate.

Already, here in Pennsylvania, a pilot program has been proposed that will permit payment of hospital and funeral expenses (only $300 according to the official press release, but said to be up to $3,000 by a state legislator), with the money going directly to the hospital and/or funeral home. Since there is already some legislative movement in this direction, reimbursement for hospital and/or funeral expenses may one day become the major financial incentive, and one which greatly increases the supply of life-giving organs. This would not be a true market, with competing buyers and market-driven prices, but it would be better than what we have now. (Two problems I see with the proposed Pennsylvania plan are that, 1) the $300 reimbursement may be too small to make much difference - but maybe not - and 2) the money comes from state taxpayers, not from health insurance companies.)

A true market in cadaveric organs would result in payment of the organs' full market value, a combination of their usability and scarcity. For those with many usable organs, the payoff for their estate could be considerable. If the estate heirs so choose, the money could go to charity. Or, the donor could designate a charity of choice beforehand. (With freedom, all things are possible!)

The main advantage of this latter type of market is that the higher monetary rewards for those with known, usable organs would tend to induce a much greater degree of organ retrieval. But, in my view, even reimbursement of funeral expenses will be enough to nudge many reluctant families to "do the right thing." (I think most of the reluctance is due to a sense that doctors and hospitals are making lots of money, while the family and deceased are being taken advantage of.)

Regardless of which of the above arrangements becomes the most popular, with such a wide variety of monetary incentive structures available, the shortage of organs would quickly come to an end.


Lloyd R. Cohen, Ph.D., J.D. Professor, George Mason University School of Law

"The best way to increase the supply of transplant organs is by establishing a futures market in cadaveric organs in which a typical healthy person would be offered a contract that would provide that, at the time of his death, if organs were successfully transplanted from his body, a substantial sum (perhaps $5,000 per major organ) would be paid to his designee (which of course could be a charity). The hospital in whose care the decedent died would have the legal duty, enforced by tort liability to the designee for his financial loss, to take appropriate care of the decedent's body and to notify the purchasing agency of his condition so that it could harvest his organs. Do not blanche at the thought of a market in so precious and sacred a thing as a cadaver. People are dying while the organs that could restore them to life, and that a market would provide, are being fed to worms. Were more to suffer and die for want of organs that a market would provide, the high minded pieties that support the prohibition would be revealed for the vacuous moral posturings that they are."

"Organ donation can be increased in two ways. First, with living donation, such as occurs with kidney transplantation, financial disincentives to donating a kidney must be removed. This should be done by government underwriting of workman's compensation, travel expenses for the donor, and limited life insurance surrounding the circumstances of giving a kidney.

The second way organ donation can increase is by expansion of cadaver donation. In order to expand the number of live-saving organs from cadaveric donors, motives to give consent for organ recovery must change. Currently, the only motive to a family of a potential donor is to help unknown recipients. Since this has not been very effective at obtaining the organs which are known to be available, other motives such as financial incentives (survivor benefits such as in Social Security), bereavement counseling, donor family recognition, and support for burial expenses must be considered.

Because altruism is the only permissible motive, the shortage of organs is so chronic that international organized crime has become involved. But while altruism is a noble motive, it seldom is compelling. Economic theory clearly recognizes that when demand is high for a good or service, its price will increase until the supply and demand reach an equilibrium. If the price is prohibited from rising, a shortage will occur. To restore the balance so supply meets demand, price controls must be removed.

But, it is argued, wouldn't commercializing or "commodifying" human organs undermine the idealism of the system, enticing potential donors to think only of the monetary value and not of the moral value of their act? Perhaps, if one thinks that good can be achieved only if no compensation changes hands. For example, it would be kind of educators to donate their time to our children and beneficent for grocers to give away their food. Yet no one accuses teachers or grocers of undermining morals by accepting payment for their work and goods.

The fact that people usually receive compensation for their goods and services does not preclude them from being generous on occasion. When a major tragedy occurs, vendors often donate products -- food, clothing, tools, etc. -- and people often volunteer their time to help the victims. But these acts of generosity are the exceptions, not the rule -- and it is precisely because they are exceptional that we find them praiseworthy.

In Christianity, for example, the imperative to benevolence is an individual imperative, and Christians thus are individually praiseworthy or blameworthy for their acts. The New Testament never implies that those who are compelled to do benevolent acts are worthy of praise. Thus, in accordance with Judeo-Christian teachings, the proper attitude with respect to organs and other bodily tissue is that while it would be considered a great humanitarian act for a person to donate an organ, there should be no ethical stigma attached to someone who desires compensation.

Those who want to donate their organs free of charge should keep that right, and they should continue to be honored for their generous acts. The decision would be up to the donor. People who could afford to do so would respond out of generosity by giving organs for those who could not afford to pay. But those who are unwilling or unable to donate their organs should have an alternative.

Instead of promoting altruism in society, however, opponents of the commercialization of organ donation are promoting something that has been widely rejected by ethicists and philosophers: paternalism.

Two of the most basic ethical principles among medical ethicists are "patient autonomy" and "informed consent." Patient autonomy is the notion that each patient has a fundamental right to control what happens to his or her own body. Most medical ethicists agree that a competent, dying patient who wants to be removed from life-sustaining treatment has that right, even if others -- including the patient's physician -- disagree. Informed consent says that each patient has a right to be fully informed about the costs, benefits, risks and expected results of a therapy before consenting to treatment.

...Many of those who otherwise support patient autonomy and informed consent oppose permitting people to receive compensation for their organs, even though they recognize the principle of "self-ownership" in the body. In an effort to prohibit what they believe to be unethical -- namely, the sale of body parts -- opponents are willing to use the force of law to restrict donors' freedom.

But would the act of exchanging an organ for some type of compensation be so hideous? Are there other ways besides money to compensate donors for their time, pain and loss, or to compensate heirs for a donor's organs? The answer is yes.

A market for organs could develop in a number of ways. Some would be more open and direct; others might be indirect and incorporate the concerns of some of those who oppose compensation. The important point is that there are solutions.

First, allow people to sell whatever they want, when they want. The most open and market-oriented approach would be to permit anyone who wanted to sell one or more organs to do so. Thus, if someone wanted a kidney and was willing to pay for one, a compatible donor could provide the recipient with a kidney at the market-set price. While opponents of organs sales are horrified by this thought, it could serve a beneficial and humanitarian end.

...The proposal mentioned above is, for some people, the most ethically troubling and thus is the least likely to be adopted. But a second alternative is to develop a futures market for organs. To discourage people from selling all or part of an organ they might need later, people could be compensated today for the possible future use of their organs. Financially, this approach might not be very rewarding, but it might slightly increase the supply of organs. If, for example, I want to put my heart up for sale, the possible purchaser -- an organ broker -- would have to look at the current value of a heart (let's say $5,000) and discount the time value of money and the possibility that my heart might not be physically sound at my death (though even the elderly whose organs are too old for transplant could participate, since physicians need organs for clinical trials and training). As a result, selling an "option" on my heart might not be very lucrative.