Winning Entry – 10th Annual Bioethics Essay Contest

As a medical student at the University of Wisconsin School of Medicine and Public Health (SMPH), Nicholas VanDerwerker  received the 2024 Dr. Norman Fost Award for the Best Medical Student Bioethics Essay. The tenth-annual contest—sponsored by the SMPH and its Department of Medical History and Bioethics—asked students to choose their own topic.

The Kidney Conundrum – the Case for Compensated Kidney Donation
By Nicholas VanDerwerker

More than 89,000 people in the U.S. are on the kidney transplant list as of March 2024, but only about 28,500 patients received kidney transplants in 2023.¹ Progress has been made in transplanting kidneys from non-human species into humans to help fill this gap.² But this use of non-human organs is currently experimental and not widely used. Incentivizing kidney donation would be an alternative method to increase supply of this vital organ. I argue that it would it be ethical to legalize paying individuals to donate one of their kidneys, provided there are appropriate safeguards in place.

First, any system allowing payment for kidney donation must be highly regulated to prevent abuse. Current medical standards for donation and medical care must be closely followed and all aspects of informed consent must be adhered to throughout the donation process. The failure to uphold these tenets is why this proposal is often poorly received, with examples of abuse and inadequate medical care in kidney donation black markets.³ As an additional safeguard, these transactions should not occur in a completely free-market setting. A governing body should ensure adequate donor compensation and that organs are distributed according to need rather than to the highest bidder.

There are several arguments for why paid kidney donation should be legal. First, such an exchange would almost certainly increase the supply of this needed organ and save many lives. Healthy individuals can survive with only one kidney with no to minimal impacts on their health, so millions of potentially transplantable kidneys are available in the U.S.⁴ Second, it is contradictory to permit the donation of some body parts (such as plasma and hair) in exchange for payment while prohibiting the same for one of an individual’s kidneys.⁵ Most people can survive after donating these three tissues, so they all ought to have similar moral status. However, it is true that kidney donation, unlike plasma or hair donation, requires surgery, but the surgical risk of donation is low: Based on nearly 20-year-old data, the risk of death is rare, and the risk of major complications is less than 5%.⁶ It is fair to assume that advances in surgery have since further reduced complication rates. Furthermore, selection for younger and healthier donors under a payment-for-donation system would likely decrease complication rates even more. Third, permitting paid kidney donation would demonstrate respect for an individual’s bodily autonomy. If one wishes to give away one of their kidneys to save another’s life, all the while receiving a financial benefit and not causing harm to anyone else, they ought to have the right to do so.

The objections to paid kidney donation are varied, and I will address a two of them here. The first is that it would disproportionately burden the poor, as the wealthy would have no need to donate one of their kidneys. But this argument struggles on at least two fronts. First, the risks of surgery are low, and as stated above, data suggests that people can function well in the long-term with only one kidney. Second, we must distinguish undesirability from exploitation. Higher rates of kidney donation among the poor would not constitute exploitation, provided that informed consent and the highest standards of medical care are applied. As an analogy, many (often lower income) individuals are employed in dangerous or “dirty” fields such as construction and sanitation – jobs that the wealthy avoid. Thus, if being paid to donate your kidney is exploitative of the poor, would not the same be true for these lines of work? Should we thus ban people from building homes or collecting garbage? Donating your kidney for payment may be undesirable but would not be exploitative in a well-regulated system. A second objection to paid kidney donation is a more metaphysical argument, the so-called Kantian objection.⁷ This critique states that being paid for organ donation demeans bodily integrity and treats the human body solely as a means to an end. However, this argument would also prohibit donating plasma for payment. It is also questionable if being paid to donate one’s kidney would truly demean one’s bodily integrity. The risks of kidney donation are small, and it does not impair one’s autonomy and ability to engage in rational thought (unlike other self-inflicted behaviors such as suicide and drug abuse). Thus, being paid to donate a kidney would not damage these critical components of what it means to be human and subsequently would not violate one’s bodily integrity.

Citations

• Organ Procurement and Transplantation “National Data.” OPTN, accessed 28 March 2024, optn.transplant.hrsa.gov/data/view-data-reports/national-data/
• Mallapaty, Smriti, and Max Kozlov. “First pig kidney transplant in a person: what it means for the ” Nature, 10.1038/d41586-024-00879-y. 22 Mar. 2024, doi:10.1038/d41586- 024-00879-y
• Warsi, “In Nepal’s ‘Kidney Valley,’ poverty drives an illegal market for human organs.” PBS News Hour, accessed 22 March 2024, www.pbs.org/newshour/world/in-nepals- kidney-valley-poverty-drives-an-illegal-market-for-human-organs
• Matas, Arthur J, and Andrew D “Long-term Medical Outcomes of Living Kidney Donors.” Mayo Clinic proceedings vol. 97,11 (2022): 2107-2122. doi:10.1016/j.mayocp.2022.06.013
• Gill, Michael B, and Robert M “Paying for kidneys: the case against prohibition.” Kennedy Institute of Ethics journal vol. 12,1 (2002): 17-45. doi:10.1353/ken.2002.0004

• Lentine, Krista L, and Anita Patel. “Risks and outcomes of living donation.” Advances in chronic kidney disease 19,4 (2012): 220-8. doi:10.1053/j.ackd.2011.09.005
• Morelli, M. “Commerce in organs: a Kantian critique.” Journal of social philosophy 30,2 (1999): 315-24. doi:10.1111/0047-2786.00020

Winning Entry — Eighth Annual Bioethics Essay Contest

As a second-year medical student at the University of Wisconsin School of Medicine and Public Health, Bethany M. Erb received the 2022 Dr. Norman Fost Award for the Best Medical Student Bioethics Essay. This year, the contest invited students to critically examine the ethical values and principles relevant to health disparities.

Inequality or Inequity
The Ethics of Health Outcomes in the United States

by Bethany M. Erb

Just as nucleotides link polarized deoxyribonucleic acid strands, many health inequalities are a nexus between race and socioeconomic status in the United States. The COVID-19 pandemic exposed these inequalities in stark fashion. It is well known that non-white populations experience higher rates of COVID-19-related hospitalization and death compared with non-Hispanic white populations, despite accounting for demographic variables.[i] Health inequalities like those from the pandemic, whose effects are unequally distributed between socially constructed groups, are intrinsic moral problems. Unaddressed, these inequalities will sink deeper into the status quo—new mutations of their causal injustices and biases will arise and maintain their original cause: a national tradition of codified racism.

Before we continue, it is important to clarify what health inequalities are inequities—immoral differences in health outcomes. Not all health inequalities necessitate a call-to-arms. For instance, age-related health differences are not considered unjust. While a thirty-year-old has a relatively lower risk of osteoporosis compared to a seventy-year-old, this health difference is rooted in biology; bone resorption is an unavoidable part of the aging process.[ii] The seventy-year-old has had younger bones and the thirty-year-old will soon have older bones; neither individual is denied access to the other’s health state based on their position in shared social hierarchies.

Health inequities are not rooted in biology but rather the unfair distribution of resources and opportunities in the past or present. As such, health inequalities become inequities when it can be shown they are not biologically determined, or simply products of cultural differences, but arise in part due to identity-based discrimination. These inequalities are remnants of institutional oppression, perpetuating unjust economic and social policies born by innocent individuals.

We know that race and socioeconomic status often have a synergistic effect on patterns of disease distribution.[iii] It is increasingly obvious that minority groups face implicit bias within the American healthcare system that affects method and means of treatment and prognosis.[iv]^,[v] It is well documented that these same groups have historically been denied access to economic and social resources and opportunities that predict positive health outcomes and social stratum.[vi] Since bias towards persons of color is a driving cause of these phenomena, and one of our nation’s moral tenets is that racism is an injustice, a violation of the categorial imperative and norms of equal opportunity and respect, we arrive at a logical finish-line: health inequalities between racial and socioeconomic groups are intrinsic moral problems.

A familiar objection is that health inequalities reflect individual autonomy more than circumstance. If less healthy people are responsible for their health, capable of freely choosing between outcomes, then they are not victims of conditions; rather, they create their fate despite these conditions. If people can make choices in relative isolation from a broader social environment, the individual is the only meaningful level of moral analysis. Health inequalities cannot be injustices if the individual is the sole moral agent responsible for their existence.

I would argue this objection overlooks the neuroscience of free will and the reality of health determinants that lie outside of choice. Current research suggests the unconscious initiates activity, implying a reservoir of feelings, thoughts, urges, and memories spurs action.[vii]^,[viii] This suggests the social and environmental habitat that helps creates this reservoir is responsible in part for population outcomes. Health inequalities are then moral issues to the degree they reflect injustice grown within this habitat.

It is not necessary to accept this degree of determinism to acknowledge many health predictors defy choice. Poverty, with its physical and psychological stressors and lack of ways to handle these stressors, is one such variable. Simply being born into a low-income family or neighborhood predicts premature mortality and morbidity.[ix] Given historic housing segregation practices and environmental injustices define many low-income areas, it is highly problematic to claim the individual alone can be held responsible for health outcomes shaped by poverty. This example helps us imagine how policy and social determinants of health can be just as, if not more than, responsible as the individual for multifactorial health conditions.[x]

Many health inequalities today are remnants of legislated economic and racial oppression in the United States. These inequalities count as inequities because they maintain codified discrimination between social groups that violates norms of dignity and respect. Thus, we can say these inequalities are intrinsic moral problems. Acknowledging the moral weight of such health inequalities is necessary. We only begin to lift the load of this injustice from our shoulders when we accept it is real and unfit to bear.

References

[i] Lopez L, Hart LH, Katz MH. Racial and Ethnic Health Disparities Related to COVID-19.

JAMA.2021;325(8):719–720.

[ii] Clarke, Bart (2008-11-01). “Normal Bone Anatomy and Physiology”. Clinical Journal of the American Society of

Nephrology. 3(Suppl 3): S131.

[iii] Williams, David R., et. al. “Understanding associations among race, socioeconomic status, and health: Patterns and

prospects.” Health Psychology. American Psychological Association. vol. 35,4 (2016): 407-11.

[iv] FitzGerald, Chloë, and Samia Hurst. “Implicit bias in healthcare professionals: a systematic review.” BMC medical

ethics vol. 18,1 19. 1 Mar. 2017.

[v] Matthew, D. B. (2015). Just medicine: A cure for racial inequality in American health care. NYU Press.

[vi] Hanks, Angela, et. al. (2022, January 19). Systematic Inequality. Center for American Progress. April 24, 2022.

[vii] Smith, K. Neuroscience vs philosophy: Taking aim at free will. Nature 477, 23–25 (2011).

[viii] Bargh, John A, and Ezequiel Morsella. “The Unconscious Mind.” Perspectives on Psychological Science: A Journal

of the Association for Psychological Science vol. 3,1 (2008): 73-9.

[ix] Minkler M. “Personal responsibility for health? A review of the arguments and the evidence at century’s end.”

Health Educ. Behav. 1999 Feb;26(1):121-40.

[x] Braveman, Paula, and Laura Gottlieb. “The social determinants of health: it’s time to consider the causes of the

causes.” Public Health Reports (Washington, D.C.). vol. 129 Suppl. 2, Suppl. 2 (2014): 19-31.