Tales from the organ trade

Imagine that you live in poverty. A chance arises for you to earn a year's salary in one day. All being well, no one will get hurt. In fact, what you're going to do will save someone's life. Sounds like quite a deal. Or at least it does until until you realize that what we're talking about here is selling one of your kidneys. And that it's illegal almost everywhere.

The decision to sell an organ is a stark choice. It speaks so much of all that is wrong with our global inequities. It shouldn't be happening. But, like it or not, it does happen. For many people looking to get out of poverty, the sale of one of their organs is clearly a desperate choice ... but it is also a choice that they are sometimes willing to make.

The illegal organ trade is not for the faint hearted. Sure, it saves lives, but it's an ugly business. Ric Esther Bienstock, the documentary-maker behind the award winning "Sex Slaves" documentary about global sex trafficking has taken on the subject head first and eyes open with her new film, Tales from the Organ Trade. It's getting it's North American premiere tonight here in Toronto at the Hot Docs festival. We sat down with her recently to find out exactly what lay behind her decision to focus on such a moral minefield and to ask what she's trying to achieve.

"I'm not advocating for incentivised donation. That door is shut. But I'd love the film to spark debate" says Bienstock. Unlike Sex Slaves, Tales from the Organ Trade doesn't take any sides. As Bienstock says, "sex trafficking is a very black and white issue". But making Tales from the Organ Trade took Bienstock into a lot of grey areas. "It shook me up," she admits. "When I started making the film I had a very different view from when I finished making the film. I started off thinking, its purely exploitative, period. And that's 90% of how it's characterised in media reports, films, and anything I've seen.... but there are thinkers out there, surgeons and ethicists who think that a regulated, incentivised system is the way to go. And there are people who think it is repulsive and exploitative. So I really have a sense of what they all believe, and why they believe that."

The turnaround for Bienstock was going to countries like the Philippines, Ukraine and Moldova and meeting donors. The fact is, she says, so many of the people she met were not coerced. They actively sought out the brokers who would find them a buyer. "You don't need to coerce people in the Philippines," she argues. If they are coerced, she says, they are, as she puts it, "effectively coerced by their own poverty." And what is more, they are forced into the black market, where there are virtually no protections. "If you think about it," she says, "it's a situation where you have extremely desperate people on both sides, crashing together in a black market." It's a situation ripe for exploitation.

Bienstock took more than 3 years to make the film, crisscrossing the world to talk to the different people involved in the organ trade, from donors and recipients, to the brokers and surgeons that make it all happen. Although these characters are operating outside the law, and are often portrayed as evil, exploitative crooks, Bienstock had little trouble finding them - and again, saw them as much more complicated than the typical black-and-white narratives. But getting them to give their side of the story to camera was much more difficult.

One doctor wanted by Interpol only agreed to be filmed after his mother had approved of Bienstock following a lunch date in Istanbul. Another only agreed after Bienstock had flown to Israel to meet him for coffee. "The first thing he said to me", recounts Bienstock, "is I'm not going to be in your film." He eventually agreed after Bienstock convinced him that she wasn't out to vilify him; she simply wanted his side of the story.

Tales from the Organ Trade ends up being powerful for resolutely avoiding taking sides. Rare among documentaries tackling such sensationalist subjects, it doesn't look to reinforce prejudices but invites us to make up our minds. This may make for uncomfortable viewing, but it's a necessary approach to a subject that often defies conventional ethical logic. As the film's publicity materials put it: "This is a world where the villains often save lives and the medical establishment, helpless, too often watches people die. Where the victims often walk away content and the buyers of organs - the recipients - return home with a new lease on life "

Is selling human organs really so unethical?

Earlier this week, the World Health Organization (WHO) reported on the rise in the illegal trade in human organs. The WHO estimates that more than 10,000 black market operations involving purchased human organs are now carried out every year. There are serious ethical and medical concerns associated with the practice. Sellers risk being exploited, buyers may be victims of scams, and both parties face far higher risks of medical complications due to the lack of proper medical care.

The problem is though, although the commercial trade in organs is in many respects morally repugnant, many of the problems associated with the illegal trade in organs are actually directly a result of its illegality. Backstreet operations, black market trading - these are the critical risk factors here, not its dubious moral status. Plus, for all the important concerns about the problem of poor people being exploited to sell their organs to the rich, it is important not to mix up what are two different ethical issues here - one about exploitation of organ sellers and one about whether the commercial trade in organs is something that is acceptable in society at all. Both of these are worth examining in a little more detail.

First off, lets bracket for a moment the problem of exploitation and just consider the ethics of commercial organ trading. Sure, we know the practice has been made illegal in almost every country - but is selling human organs really so bad? One major issue that we have to consider here is that, like it or not, the sale of human organs saves lives. Donations of organs from the deceased are simply too limited to meet demand almost everywhere. In the US, more than 100,000 people are currently waiting for organ donations.  In China ,it is estimated that a million people are currently in need of a kidney ... yet last year only something like 5000 actually received one. Most countries are facing a severe supply problem. So from a simple societal cost-benefit perspective, then,  providing the seller stays in relatively good health, and the buyer is able to live longer or better than they would have otherwise, the benefits would appear to exceed the costs. Without sufficient supply from other sources, commercial organ trade can make society as a whole better off.

That is not to deny that there are indeed very significant costs that have to be borne by the seller here in terms of potential health risks. Even if society can be shown to benefit in aggregate, not everyone benefits equally. After all, the seller is potentially putting their own life at risk here. But if we can  imagine a situation where the seller is provided with suitable safeguards to minimise these risks - through a guaranteed level of decent medical care for example - then the cost-benefit argument could certainly prevail. In fact, that is precisely why we do often permit some forms of voluntary non-paid donation: under the right conditions,  live organ donation can make a net positive benefit to society. In principle, that cost-benefit equation should not be materially changed by introducing a commercial transaction ... except of course we have thrown some actual financial costs and benefits into the mix.

To be sure, few of us are comfortable with the idea of selling organs for money. For critics, it only makes sense from a cost-benefit point of view if we ignore the more ambiguous costs involved, such as the loss of basic humanity involved in such an act. Simply put, it is not something we want to accept in a civilized society. A similar argument is also raised in relation to other "unacceptable" practices, such as euthanasia, prostitution and drug use. Legalization might well create benefits, minimize harms, or simply enable greater personal freedoms, but the law also has to codify the principles of  human society that we want to establish and live up to. And commercial trade in live organs, so the argument goes,  is against those basic principles.

Let's be clear though: those principles come at a cost - the cost of human lives. People are literally dying waiting for suitable organ donors. At a time when the illegal trade is actually growing, shouldn't we be revisiting the question of whether the commercial organ trade is really so unacceptable that it's worth letting people die for our principles? Isn't it time we asked whether the legal prohibition route is actually working?

The exploitation question is a different but no less important question. The prospect of the most disadvantaged in society selling their own body parts just to get by assaults our most basic principles of human dignity. Obviously we need to tackle poverty itself in a more concerted fashion to get to the heart of this problem. But in the meantime, the big question we have to ask is whether the decision to make the commercial trade in organs illegal is actually benefiting or further exacerbating the exploitation of the poor?

Regardless of its legal status, people will continue to do whatever they can to escape poverty, and for the truly desperate, their organs may be their most valuable asset. Pushing such people into the hands of criminals and unlicensed medical practitioners, however, is a recipe for adding yet more exploitation onto an already unfair situation.

Legalization by itself would not solve the problem.  But if we were to accept that, in principle at least, the trade in human organs might be socially acceptable, the real question then becomes: how could we do it in a responsible way so that people do not get exploited?

There's no easy answer to this, but it is possible to conceive of a tightly regulated system that could eliminate most if not all of the worst forms of exploitation. Price controls for organ donations, strict rules for participation as donors and recipients, mandatory counseling for prospective donors, enforcement of medical follow-up, quality control checks, a transparent system to ensure clear organ provenance - these are the kind of arrangements that a serious regulator might want to put in place.

Many governments probably won't have the will or the capability to do this effectively, and it's hardly a very encouraging sign that the only country currently operating a legalized system is that great bastion of freedom and security, Iran. But a few years ago the Singaporean Government was apparently also considering the issue, although nothing seems to have come of it. Who's to say that China wont be the next, especially given that they are currently operating a widely condemned practice of harvesting organs from executed prisoners. A voluntary system could hardly be more controversial. But who these days would really be brave enough to advocate legalization given the international consensus against the trade? Maybe it's time for those on the intermiable organ waiting lists to start getting organized.

 Photo by Lasse-san. Reproduced under Creative Commons Licence