Teaching and Learning > DISCOURSE

Commodification of Body Parts,Tissues and Fluids

Author: Sue Roff

Journal Title: Discourse

ISSN: 2040-3674

ISSN-L: 1741-4164

Volume: 7

Number: 2

Start page: 187

End page: 206

Return to vol. 7 no. 2 index page

The following briefing paper is a resource generated by a project funded by the Subject Centre for Philosophical and Religious Studies: 'Development of Case Based Teaching Materials for Inter-disciplinary Ethics Teaching about Organ Donation under the new Human Tissue Acts'. The aim of the project was to create materials that could be used to explore the new religious, philosophical and applied ethics issues that arise out of the Human Tissue Acts in the UK. Course materials have been developed for inter-disciplinary education for organ transplant coordination teams, which commonly consist of religious and social work counsellors as well as health professionals. The materials have been piloted in ethics classes at the University of Dundee and there will be a report on this side of the project in a future issue of Discourse.

Abstract

The recent insistence by a senior adviser to the WHO on issues relating to global trafficking of organs that transfer of body parts for transplantation through either illegal market mechanisms or even regulated organ donor systems is a form of 'sacrificial violence' comes at a moment when the volume and reality of the trade in organs and other body parts and tissues is itself a major argument for its legalisation through regulation. Nancy Scheper-Hughes, who made this statement1, is an anthropologist who has studied the illegal organ trade for decades. But it is important to put the growing 'commodification' of body materials that have increasing utility and therefore value in modern medicine into perspective by looking at it from several aspects, as the following briefing does.

Introduction

Twenty years ago a prominent American legal theorist wrote a seminal article in the Harvard Law Review2 on 'market-inalienability' of body parts, tissues and fluids. Professor Radin maintained that 'We feel discomfort or even insult, and we fear degradation or even loss of the value involved, when bodily integrity is conceived of as a fungible object.' (p.1881) But in fact we allow the sale of many body parts and services. The fact that 'bodily integrity' is being 'violated' on a daily basis in all our societies suggest that hers was an ivory tower view. In other words we have to 'get real' and put the ethical issues surrounding the fungibility of commodified body elements—the sale of human tissues, fluids and organs—into the current social context of rapid changes in medical technology that makes transplantation as likely to be as an option for many of us at some stages of our lives as open heart surgery and valve repair or replacement is today. We refuse to countenance the possibility of a regulated, ethical, live kidney market, for instance, at a time when a black market is flourishing and the demand for kidney transplantation is increasing as it is recommended 'pre-emptively', even prior to dialysis, for many patients. Why are we being so precious about kidneys when we permit so much else of the body to be 'commodified'?

Stolen parts

Nearly two hundred years ago a new word entered the English language—'burking', meaning murder for dissection. The two most notorious practitioners were Burke and Hare who murdered 15 people in Edinburgh for the express purpose of selling their corpses to anatomists teaching medical students. The Aberdeen anatomy lecture theatre was called 'the burking shop' when it was burned down by angry crowds in 1831. Burking became profitable because the teaching of medicine became more scientific and anatomy became more important, to the extent that some medical students paid their fees to the private teachers with bodies that they had procured in the poorer quarters of the cities and countryside. Cadavers were in short supply because until the Anatomy Acts of 1829 and 1832 they were supposed to be those of hanged murderers, for whom dissection after death was decreed as an additional punishment. (Holland also allowed anatomists such as those at Leiden to publicly dissect the corpses of executed criminals as a further punishment as well as a resource for medical teaching; reconstructions of the tiered anatomy theatre can be seen in the Boerhave Museum.)

The Anatomy Acts now authorised the use of 'unclaimed' corpses, usually from the indigent, for anatomy teaching. The poor usually regarded that as a punishment for being poor, and I can remember in my own childhood in the 1950s in Australia that keeping up the funeral fund contributions when the collector came round fortnightly was a very real concern. Because body snatching had become such a real danger in Britain, many funeral practices involved guarding the corpse until it could be buried. Funeral processions were often accompanied by guards bearing truncheons to fight off snatchers. The wealthy encased their coffins in metal grids and stored them in stone mausoleums. Some graveyards still have stone 'death houses' where bodies were laid to decompose before being buried so that they would be of less interest to the body snatchers.

Burke and Hare's first sale was of a lodger who died owing Burke rent. They found a market ready to pay £7.10 shillings to help recoup the outstanding monies. Much of the parliamentary rhetoric in the debates leading to the new Acts was about recouping the costs of keeping paupers in workhouses by selling their corpses to the medical teachers. As Ruth Richardson writes in her definitive account, Death, Dissection and the Destitute3 'What had for generations been a feared and hated punishment for murder became one for poverty.'

The fact that Burke's body was publicly dissected as a muchpublicised 'fitting' additional punishment to his execution (and his skin rumoured to have been made in to a wallet still on view at the Edinburgh Surgeon's Hall Museum), and that several hundred bodies a year were supplied by parish workhouses, prison hulks and hospitals because they were 'unclaimed' by family or friends who could not afford their burial in the 1830s and 1840s, did not endear the prospect of dissection to the British public. The philosopher Jeremy Bentham donated his body for dissection in 1832, but the scientific and medical classes did not rush to similarly serve the public good of enhanced medical teaching. The practice of public authorities selling unclaimed bodies to medical schools continues today in the US, as evidenced by recent reports4from Portland, Oregon of a corpse of an unclaimed man being sold for $37.50 to the local medical school whose students did not realise that the bodies they were dissecting were procured in this way. It is alleged that very little or no effort was made to contact the man's relatives because he had been homeless in the city in earlier years and was thought to be without family or friends. In 2006 an exhibition of the anatomists' art using bodies from Dalian Medical School in China opened in London, shortly after Gunther von Hagen's similar Bodyworlds exhibition of 'plastinated' bodies, also from Dalian. Uneasiness over the origins of the bodies and the level of consent to their posthumous use was countered by the promoters by appeals to the educational and artistic value of the exhibitions. However the UK Department of Health reported5 a drop in donations of bodies for anatomy teaching and medical research. The Chief Medical Officer wrote to all doctors in England in early 2006 to urge them to leave their bodies to institutions such as medical schools and the Royal Colleges of Surgeons. The English Department of Health maintains6 that in the 1990s very few medical schools accepted bodies without the personal request of the donor, and none since 2000.

George Washington is said to have had a tooth implant from a dead soldier, and the poor commonly sold their teeth in the eighteenth century. Sir William Osler reputedly said to a drunken beggar 'There is only one thing of value about you, and that is your hobnailed liver'— which he received a fortnight later when the man died.

In recent years, the public's willingness to donate their cadavers for medical teaching and research has been further dented by the misappropriation of body parts and tissues on both sides of the Atlantic.

As the twentieth century ended, two major programmes of unconsented 'organ and tissue retention' came to public attention almost simultaneously. In the early 1950s the US Atomic Energy Commission had instituted a secret collection of bones and other material from stillborn and other deceased children as well as adults from several countries including Australia and the UK. Called Operation Sunshine, the objective was to test the 'uptake' of Strontium 90 (named after the Strontian region in Scotland where it was first found) from the 'atmospheric' atomic and nuclear weapons tests that were being carried out at the height of the Cold War. It was beginning to be realised that the 'fall out' from these tests was more substantial, more injurious and occurring more quickly than had been anticipated. Thousands of samples were collected—more than 21,000 samples in Australia alone. The bones, particularly femurs, were taken from the corpses before burial—and without consent of the newly-bereaved parents or other next of kin. The bones were reduced to ash, which was sent to the US for radioactive analysis. The collectors were recruited through professional contacts around the world, and were working in what has been termed by US reviewers as a 'twilight between openness and secrecy.' Pathologists and their assistants were paid to collect these samples without consent. In the correspondence subsequently reviewed by the Independent Review Group convened under Professor Sheila McLean in Scotland (which had also supplied thousands of samples) there is a statement from Dr Willard Libby of the AEC—'If anybody knows how to do a good job body snatching, they will really be serving his country.'7 In fact, the study was significant in bringing about the ban on atmospheric nuclear tests in 1963 but when the practice came to light in the late 1990s there was strong condemnation of the lack of consent even under conditions of national security. Papers were published in the medical journals about the studies, which tended to undermine the 'official secrecy' prerogatives claimed by the collectors at the time and in retrospect.

Revelations about Operation Sunshine coincided with the realisation that several UK hospitals—particularly in Alder Hey and Bristol—had been 'stockpiling' more than 100,000 organ, bone and tissue samples without informed consent from patients or their next of kin. Although intended for medical research, there was often little evidence of plans to use the material. At much the same time, there was evidence of the selling of some material such as pituitary glands to commercial drug companies without informed consent.

The fact that the doctor at the centre of the Alder Hey scandal, Professor van Velzen, could not be prosecuted under the existing law (although he was later struck off the Medical Register by the General Medical Council) highlighted the need for a review of the legislation covering the retention of human material at post mortem and the level of informed consent required from patients and their families. Major consultations were initiated throughout the UK leading to the Human Tissues Acts in Scotland and south of the border in 2006. Some— particularly medical researchers—consider the Acts' provisions an over-reaction to the practices of the previous fifty years but in fact, as we will see, they widen the opportunities for the giving of kidneys from living donors in particular. It was estimated that of the approximately 37,000 people affected by the 'organ retention' scandals, about 2,000 claimed compensation which cost the NHS nearly ten million pounds. There was a sharp drop in the number of autopsies being agreed to, such that pathologists warn of problems in securing material for medical research—and problems in the public perception of their profession.

In the USA, the public have become aware that body parts— bones, tendons, ligaments, heart valves, teeth—are being appropriated from corpses for sale to dentists and surgeons for implantation in patients. When the family of the broadcaster Alastair Cooke scattered his ashes in Central Park from Starbucks cups as he requested, they did not realise that several bones had been removed and sold for $7000. The Guardian reported8 that 'Funeral directors were reportedly paid $500 for a corpse, which would then be dissected. The relevant body parts were then taken away and PVC pipes used to fill out the clothed bodies that would go into open caskets. The body parts would later be separated, frozen and shipped by express mail to legitimate companies which would undertake further processing before final sale and transplant. Meanwhile medical records, including the age of the deceased and cause of death, would be altered to make the body parts more attractive to potential buyers.' It has been estimated that the final market value of one corpse can be up to $200,000 in a market, both legitimate and illegal, estimated at $1 billion a year. Some state Medical Examiners' offices have standing arrangements with commercial companies to alert them to potential donors—but the donors' families are not always told that commercial transactions including annual fees to the officials are involved. Even major universities such as the University of California, Los Angeles reportedly9 have been involved in the trade. Patients—including for instance British footballers who go to the US for cruciate ligament replacements—cannot be sure their transplanted and implanted 'parts' have not come from such sources, or that they have been properly checked for HIV, Hepatitis C or other pathogens. American body parts have been exported to Australia and Europe. These latest 'body snatching' scandals will hopefully lead to mandatory regulation by the American Association of Tissue Banks rather than the current voluntary process, but observers warn that the industry has powerful reasons to oppose such legislation.

Medicine is moving so swiftly now that the genome has been mapped and many more procedures and research opportunities are opening up that will need both deceased and living materials from patients to benefit us all in the near future. 'Tissue banking' and its licensure are critical priorities for our Departments of Health. The new Human Tissues Acts are a first effort to develop 'fit for purpose' legislation for the twenty first century, and they already include compromises. The Secretary of State for Health told the House of Commons10 on the publication of the report of the inquiry into the Alder Hey retentions that Professor van Velzen 'systematically ordered the unethical and illegal stripping of every organ from every child who had a postmortem. He ignored parents' wishes even when they told him explicitly that they did not want a full post-mortem, let alone the retention of their child's organs…van Velzen lied to parents. He lied to other doctors. He lied to hospital managers. He stole medical records. He falsified statistics and report and encouraged other staff to do the same.' Yet he could not be prosecuted under English law as it stood at that time. Five years later the vice president of the Royal College of Pathologists reminded us in an editorial on The Human Tissue Act in the British Medical Journal11 that the previous year the Nobel Prize for Medicine had been awarded for the discovery of Helicobacter pylori as the main cause of peptic ulcers. 'This work started by staining sections from 100 archival gastric biopsies—highly speculative research, without consent, external funding, or peer review.' As we move inexorably in to the new era of 'spare parts medicine' we need to balance these two imperatives.

Defective parts

The collection of the 'renewable' body fluid, blood, provides an important case study in the issues surrounding the provision of 'spare parts' for medical purposes. Nearly forty years ago, Richard M. Titmuss, Professor of Social Administration at the University of London, wrote what is widely considered to be the classic study of The Gift Relationship: from Human Blood to Social Policy.12 However, even in 1970, Titmuss noted that only Britain, Eire and two or three other countries were relying on totally voluntary, unpaid donation of blood. Most countries were paying 'donors' for their blood even then. Titmuss issued a stinging critique of paid blood provision, raising several issues that we need to address today not only in relation to blood but to all the other tissues, organs, fluids and 'services' such as surrogacy that 21st century medicine will need. He wrote in 1970: (p.277)

'From our study of the private market in blood in the United States we have concluded that the commercialization of blood and donor relationships represses the expression of altruism, erodes the sense of community, lowers scientific standards, limits both personal and professional freedoms, sanctions the making of profits in hospitals and clinical laboratories, legalizes hostility between doctor and patient, subjects critical areas of medicine to the laws of the marketplace, places immense social costs on those least able to bear them—the poor, the sick and the inept—increases the danger of unethical behaviour in various sectors of medical science and practice, and results in situations in which proportionately more and more blood is supplied by the poor, the unskilled, the unemployed, Negroes and other low income groups and categories of exploited human populations of high blood yielders. Redistribution in terms of blood and blood products from the poor to the rich appears to be one of the dominant effects of the American blood banking systems.'

But Professor Titmuss's views about the superiority and sustainability of the 'gift relationship' as the basis of sourcing of human blood supplies were based on shaky data even in 1970. Blood provision has been 'incentivised' by various strategies in the United States, ranging from out right cash payments to trading stamps, and tickets to movies or baseball games. In South Carolina and Mississippi 'discounts on prison sentences' were offered if prisoners donated blood; in the Commonwealth of Massachusetts five days for each point of blood remission on sentences over 30 days. Members of the armed forces are given additional leave if they provide blood.

By 1970, according to Titmuss, in Japan approximately 98% of all blood was bought and sold. The quality control was poor—65-95% of patients developed serum hepatitis from bought blood at one Tokyo hospital. The transmission of syphilis was as big a danger as that of hepatitis.

Apart from being a 'renewable resource' in the donor or provider, blood proved to be storable, and separable into various valuable constituents such as plasma and albumin. Not every medical use required whole blood. Nearly a hundred years ago, in 1912 the French doctor Alexis Carrel was awarded the Nobel Prize in Physiology and Medicine for his work on the storage of tissues for transplantation, especially blood. The market potential was immediately recognised in the United States, and various forms of commercial and non-commercial 'blood banking' were set up. They relied predominantly on bought blood, although there is an active donation programme around churches and hospitals in the US. The production of blood products was intensified, as were many other procedures such as the bulk production of penicillin during the Second World War as the government worked with the private sector to increase supplies and distribute them in freeze-dried form to war zones on several continents.

The first clotting products for haemophiliacs were developed in the 1960s, and in the 1970s the UK imported large quantities of Factor VIII from the US because its voluntary donation system could not keep up with the demand for blood products—despite Titmuss' assumptions in his 1970 book. But these imported products were made from blood collected from high risk groups—and the British authorities were aware of this by the early 1980s—perhaps even by 1976. A meeting held on July 3, 1983 on the Committee on Safety of Medicines was told that patients who repeatedly receive blood clotting-factor concentrates were at risk of contracting AIDS. The Committee was advised that 'It is to be hoped that there is no 'ticking time bomb' for haemophiliacs.' However, because of the shortage of the products for haemophiliacs and others, the UK authorities continued to import from the USA. The UK government acknowledges that 4,760 patients with haemophilia were exposed to hepatitis C through contaminated NHS blood and products and 1,243 of these people were also exposed to HIV. By mid- 2007 1,757 had died, and many are terminally ill.

An independent enquiry into what Lord Winston calls 'the worst treatment disaster in the history of the NHS'13 in mid-2007 was told that haemophiliacs were not informed of their HIV status when it manifested, and were kept for years in ignorance of the danger to themselves, their partners and their families. One such person, Robert Mackie, told the enquiry: 'I believe non-consensual research was conducted by doctors of haemophilia in this country. We were all used as lab rats. There is no other way I can put it—we were all just guinea pigs.'14 Other victims and their families likened the situation to the Tuskagee syphilis trials which ran from 1932 to 1972 in Alabama. Nearly 400 poor Afro-American sharecroppers diagnosed with syphilis were not treated with penicillin when it became available and shown to be effective in the 1940s. They and their partners and families were not even informed of their diagnosis but were told they had 'bad blood' and could receive free medical treatment, rides to the clinic, meals and burial insurance in case of death in return for participating in the study. President Clinton apologised for the Tuskagee trials during his presidency; the UK government has established a compensation scheme of up to £45,000 for the victims of the contaminated blood products, but not their families. However, the Department of Health refused to send officials to the independent enquiry chaired by Lord Archer of Sandwell in 2007, although it was being held on the same street in London. The former Labour health minister Lord Owen told15 the enquiry in July 2007 that government documents relating to the contamination had been 'selectively' destroyed.

One problem was that the production techniques used in the last decades of the 20th century in the US for blood products pooled thousands of blood donations, so that large numbers of their products were infected by a few virus-carriers. In a bitter irony, British blood and blood products have shown to be contaminated with vCJD and are now banned in several countries where they had been sold. Individuals who have received blood transfusions in the UK since 1980 are banned from donating blood back in to the system. It is thought that the problem arose from just 23 donations made by 9 donors who went on to develop vCJD—an indication of the virulence of the disease. The Canadian Red Cross also distributed contaminated blood supplies which infected thousands of Canadians with HIV and hepatitis C. French administrators have been found guilty of lack of due diligence in similar problems. The new Scottish National Party government has announced an official enquiry into the continued provision of contaminated blood in Scotland after the warnings were sounded. The same month a major London hospital was planning to 'donate' blood samples from haemophiliacs to American researchers trying to develop a test for vCJD—without the patients' permission, and much to their chagrin. Similar chagrin is being expressed today by the Yanomani tribe of Venezuela and Brazil who agreed to give blood and other human tissue samples to medical anthropologists in the 1960s and 1970s for what they thought would be medical help for their increasing problems as they interacted with other societies in the modern world. Apart from the fact that it has been suggested that the research teams provoked a measles epidemic rather than containing it by their vaccination programmes at the time, the Yanomani have seen little return and now understand that their blood samples were used for DNA and other tests to establish the perils of radiation exposure at Hiroshima, Nagasaki and other atomic and nuclear testing sites. Remaining material has been handed over to the Human Genome Project without full consultation with the tribe, who are also offended by the long term storage of blood and other materials from deceased relatives, much against their beliefs and funerary practices which are based on cremation.

In its new market economy of the last decades of the 20th century, Chinese officials have not heeded the lessons from these countries. There are an estimated 55,000 commercial blood and plasma donors infected with HIV in China.16 Most providers are peasants selling their blood and plasma to officially condoned, and sometimes operated, buying stations. In some villages virtually the whole community participated, often in repeated donations over short periods of time, using soy bottles and plastic bags to store the blood. Yan Lianke has written a novel about the blood-selling scandal in his native province of Henan—the novel has been banned in China.

A study17 conducted ten years ago in the UK suggests that the two million current blood donors were a shrinking resource even then. Altruistic inclinations are apparently declining in young Britons in particular, and many reported a fear of needles, of making a fool of themselves by fainting or of discovering they had a serious disease. The European Parliament has recommended a shift to wholly voluntary unpaid donors. Studies in Sweden18, Spain19, the USA20 and the UK21 have explored the motivation of donors and conclude that many volunteers would be offended by payments beyond £10 or in-kind compensations such as cholesterol screening or PSA tests for prostate cancer. But the class basis of these findings is not clear and it may be that more affluent donors are not motivated by cash payments while indigent providers are highly motivated by them. It is estimated that the EEC still imports over $600 million worth of plasma and derived products from US manufacturers who pay the providers. Clearly there is a twotier 'economy' of blood donation and provision. Kieran Healy surveys the system of voluntary and paid blood collection in European countries in the early 1990s in his 2006 book Last Best Gifts22. The vCJD crisis in the UK shows that donors are not exempt from the need for as strict quality controls as sellers.

From prostitution to surrogacy via IVF

The selling of sexual services is as old as humankind. There are an estimated 1,400 female prostitutes working in Scotland. In Edinburgh and Aberdeen 'toleration zones' similar to those in Amsterdam exist. But they have been encroached upon by rapid urban development and 'anti-nuisance' laws could eradicate them. New laws coming in to effect in late 2007 establish fines of up to £1,000 for soliciting sex. In other words, the buyers are being targeted rather than the sellers of these 'body services'. Throughout the UK there is thought to be an 'expanding market' of sex workers coming in from countries in Eastern Europe or South America. Many of these women say they have been tricked and forced into working as sex slaves. One murdered prostitute's mother said23 she was proud of her daughter for choosing to pay for her heroin habit by prostitution rather than mugging. But she found that the Criminal Injuries Compensation Authority would pay only £5,000 for the loss of her daughter, half what would be paid for the murder of a 19 year old woman working in any less dangerous capacity.

Jane Austen's novels, like many of the last two centuries, treat marriage as the negotiation of financial agreements. This is one reason why marriage is declining in Western countries. Some women who value their financial independence over the perils of marital relationships even view the fathers of their children as mere sperm donors. The UK television 'hospital soap' Holby City has a story line involving a 40-something senior doctor using her 30-something male trainee as a sperm donor and fighting his access to the child. I have known children of broken marriages refer to their absent father as 'the sperm donor'.

The initial reaction to the loss of anonymity for sperm donors in the UK in 2005 was a dramatic reduction in the number of sellers and donors. We seem to have no ethical problems with the sale of lifecreating material from the male for relatively small amounts of money—usually £50 or $100 a phial. The quality control over this material is also uneven—Spanish fertility doctors have recently called24 for much more stringent procedures. In the US sperm banks commonly seek to match the buyers' preferences with the profile of the sperm seller—possession of a doctorate enhances the monetary value of the sperm—sometimes referred to as 'the Ivy League effect'. In the aftermath of Chernobyl there was a marked increase in sperm sales from US banks driven by people in Eastern Europe wanting to obviate the possible genetic effects of radiation exposure.

A study25 of 1101 men who contacted Newcastle Fertility Centre in the UK in the period 1994-2003 found that fewer than 4% were 'released' to become donors. Nearly 31% dropped out, and around 65% were rejected, mainly for poor semen quality. Nearly 90% of the applicants were aged 36 or under; more than half of them were students, and more than half without a partner. Around 85% were unmarried. The pregnancy rate from the sperm in this clinic over this period was about 24%, comparable with the national UK rates.

Our attitudes to the 'replenishable' provision of sperm seem very different to the harvesting of eggs from females. While women are born with a finite number of eggs, which become available in the menstrual cycle, most of us 'use' only two or three for conception in our lifetimes. At a time when fertility experts such as Lord Winston have stated26 that IVF services are becoming rapacious in the UK, with cycles costing £3-5000 and having barely 20% success rates, women who are undergoing stimulation therapy are being encouraged to donate extra eggs to less fortunate couples. In July, 2006 the Human Fertilisation and Embryology Authority (HFEA) permitted 'part-payment' of the IVF services with extra eggs. The HFEA extended that principle to the collection of extra eggs for research. Now women who are not involved in IVF treatments are permitted to 'donate' eggs for research, for up to £250 compensation for 'lost earnings'. The US has permitted the sale of eggs in a free market that often leads to payments of around $10,000. The Royal College of Obstetricians and Gynaecologists of the UK has urged stronger protocols to ensure the wellbeing of women who are undergoing ovarian hyper-stimulation which can lead to a life-threatening syndrome. There is evidence of cross-border selling of eggs, with women being brought in to Britain for the purpose and of British women travelling to other countries for the treatment because the waiting lists are long on the NHS and even in the private IVF clinics in the UK. A London woman aged 54 advertised for egg donors in a month-long poster campaign on buses and says her clinic received about 60 responses. One unpaid donor made it clear that she felt she was providing material for conception rather than becoming the mother of the resulting baby. She sees 'that this is an unfertilised cell. I would not think of myself as the child's mother. The recipient carries the child, gives birth to and makes milk for the baby and brings them up.'27

The number of women in the UK aged more than 40 seeking IVF treatment has increased more than 10-fold in the last 15 years.28 At the same time, restrictions are being placed on the number of fertilised embryos that are implanted because of the rising number of multiple births that put strain both on the mothers medically and on the NHS financially because the babies are likely to be premature and need extra post-natal support. It is not uncommon to see multiple sets of twins and triplets in UK primary school classes. There are 85 fertility clinics in the UK in an industry estimated to be worth up to half a billion pounds a year. As Lord Winston commented in May, 2007: 'One of the major problems facing us in healthcare is that IVF has become a massive commercial industry. It's very easy to exploit people by the fact that they're desperate and you've got the technology which they want, which may not work.'29 Debora Spar, a Harvard Business School professor who studied The Baby Business30 commented: 'When people learn they are infertile the diagnosis is received as harshly as a diagnosis of cancer. When people want children and can't produce they will do virtually anything in order to get these children. That means from a commercial point of view this is great. You will have customers that will do anything to get that product.'31 And the IVF techniques have extended women's childbearing capacity into their sixties if they are determined enough, as a 63 year old consultant child psychiatrist demonstrated using a donor egg obtained in Russia fertilised by her husband's sperm and carried in her womb—resulting in effect in a 'three biological parent' child born in 2006. At the other end of the age spectrum, eggs have been 'harvested' from a five year old Israeli girl suffering from cancer to enable her to conceive in adulthood. Ownership of frozen embryos has become a highly litigious issue for many couples whose relationship collapses, or in some cases where a partner dies without making explicit statements about the status of the reproductive material. The fertilisation and storage of embryos in Petri dishes also raises philosophical and religious issues not considered by our moral advisers in previous centuries. And the introduction of a 'surrogate' womb when a second woman is involved to carry the child— usually for 'living/loss of earning expenses' which commonly amount to $30,000 in the USA—further complicates the issues. There is increased reporting of mothers carrying their daughter's (i.e. their own grandchild) baby for them, and of siblings providing the same service.

Many of the same techniques that make up IVF can also be turned to 'foetal reduction' and 'foetal selection'. Some embryos are discarded in the laboratory; some are terminated in the womb to prevent multiple or defective births now that a wealth of genetic testing techniques are available. The most common 'selection' principle has been gender and this has been outlawed in India because it has resulted in a male-prevalent birth rate in recent decades. But 'pre-implantation genetic diagnosis' which became available in the 1990s can identify far more attributes and problems than gender; and 'post-implantation' diagnoses began with amniocentesis techniques thirty years ago and now are vastly wider and more sophisticated, leading to challenging decisions for some parents. Less invasive techniques than amniocentesis have been used in Denmark for all pregnant women, and resulted in a doubling of the number of foetuses diagnosed between 2004 and 2006 suffering from trisomy 21 but also a halving of the number of children born with Down's syndrome.32 And parents can also work with their doctors to achieve a 'designer baby' who will have genetic attributes required to save a sibling from a life-threatening disease such as Diamond-Blackfan anaemia or thalassaemia major. 21st century morality concerning abortion has to take account not only of the increased ability to help infants survive outside the womb at an earlier stage of gestation but also of the 'continuum' with foetal selection and reduction at the earliest stages of conception. Abortion rose 4% in the UK in 2006 over 200533 and it is thought that teenagers in particular are increasingly using it as a form of contraception. Even so the UK has the highest rate of teenage pregnancy in Western Europe. It is estimated that only 1% of UK abortions are performed for medical reasons. At the same time, wider familiarity with ultrasound pictures is making us realise that foetuses may have feelings earlier than assumed, and make it more emotionally difficult to terminate 'unwanted' or unexpected pregnancies. New techniques now make it possible to pursue stem cell research without destroying the embryos. The decidedly alarming prospect of human cloning and its attendant problems—including philosophical issues around the notion of 'personhood'—is virtually upon us. Umbilical cords have assumed ever increasing values in medical research and therapy and their futures market is likely to be strong. Child-raising is estimated at a quarter of a million pounds for the middle classes in the UK; the Financial Times columnist 'Mrs Moneypenny' refers to her children as 'costcentres.'And each new UK birth generates 160 times more climate-related environmental damage as a new birth in Ethiopia, or 35 times as much as a Bangladeshi newborn, according to a report by the Optimum Population Trust in July 2007. The same week it was reported34 that an Indian grandfather had buried his infant granddaughter alive because he did not want to bear the cost of raising another girl. Other Indian girls were having their hair 'harvested' for the wig trade in North America and Europe.

Renting bodies

There are already in operation several 'incentive models' for the involvement of human beings in medical activities which are not of direct benefit to themselves.35 In both the UK and the US living kidney donors currently have their expenses related to the operation and recovery reimbursed by NHS, Medicare and/or insurance companies or in the state of Wisconsin by tax rebates to the value of $10,000. Private sector employers and the US Federal government provide several weeks of leave for organ donation. This Reimbursement Model is closer to a 'service' model of compensation for income lost than a 'market' model of sale of a commodity. The service model is well established in the payment of research subjects who are paid for their time/loss of earnings (on a Wage-Payment Model that references the national minimum wage) and the risk factor and unpleasantness of the procedures they are subjecting themselves to. While a US study found a range of $5 to $2,000 for medical research participants, UK drug testing companies commonly offer £2,000-3,000 for unpleasant regimes requiring residence in a testing unit. Another American study found that while monetary payment had positive effects on respondents' willingness to participate in research regardless of the level of risk, higher payments did not appear to blind respondents to the risks of a study. This may not hold true in the UK where after the Northwick Park trials that resulted in life-threatening problems for several participants, there was a reported increase in enquiries from potential subjects to clinical trials managers. Many research organisations pay completion bonuses in order to motivate subjects to stick it out through unpleasant regimens.

As we have seen, we already permit the sale of body parts and fluids on the Market Model. Blood and gametes are distributed and redistributed for a monetary value. The UK is one of the minority of countries to still rely on predominantly volunteer donations of blood. Although the sperm and ova have the awesome power of creating new human life, we do not seem to worry too much about their 'fungibility'— the fact that in these transactions they are being traded and provided as 'things'. Which is to say that we have gone a long way towards 'commodifying' body parts, tissues and fluids and accepting their 'fungibility' in the process of enhancing their utility in both curative and preventative medicine. And indeed in elective procedures such as abortion, foetal reduction and selection.

We have also already determined 'tariffs' for the value of certain body parts in Compensation Models for workers' accidents or criminal injury or injury incurred during military service. The UK Criminal Injuries Compensation Authority pays £2,500 for a fractured coccyx, £3,800 for a hernia and £22,000 for loss of one kidney. The UK Veterans Agency has just issued a 15-level list of tariffs which is compatible with the Judicial Studies Board Guidelines for the Assessment of General Damages in Personal Injury Cases. More than a billion dollars has been paid out under the US Radiation Exposure Compensation Systems and the Marshall Islands Nuclear Claims Tribunal (which pays $75,000 for cancer of the kidney).

Conclusion

Is it so great a step to developing an ethical, regulated market for kidneys? An unethical, unregulated market in body parts flourishes and its volume is the single greatest argument that the time has come to engage in a public debate about a regulatory framework that would be ethical and efficient as the gap between 'donors', deceased or living, and the number of patients in need is set to widen even further with the acceptance of pre-emptive kidney transplantation as a better clinical response than dialysis. Several such frameworks have been proposed in recent years but there has been no attempt to examine public acceptance of the potential to extend existing notions of fungibility and commodification of other body parts to kidneys, or partial liver and lung transplants from living providers. At a time when the UK is likely to move to 'opt out' organ donation, we should look carefully at the alternatives.

Endnotes

Return to vol. 7 no. 2 index page

This page was originally on the website of The Subject Centre for Philosophical and Religious Studies. It was transfered here following the closure of the Subject Centre at the end of 2011.

-
The British Association for the Study of Religions
The Religious Studies Project