Kidney Sales and Disrespectful Demands: A Reply to Rippon.

Simon Rippon, revising an earlier argument against kidney sales, now claims that offers involving the performance of invasive acts, when extended to people under pressure, constitute a kind of rights violation, Impermissibly Disrespectful Demands. Since offers involving kidney sales so qualify, Rippon finds prima facie reason to prohibit them. The present article levels four independent objections to Rippon's argument: the account of Impermissibly Disrespectful Demands implausibly condemns kidney donation as much as kidney sales; the normative importance of having autonomous veto control over bodily incursions does not plausibly underwrite a right to not be extended invasive offers under pressure; Impermissibly Disrespectful Demands can easily be transformed into innocuous offers; and the prohibition has greater welfare costs than Rippon acknowledges.

The best option argument and kidney sales: a reply to Albertsen.

In a recent article, Albertsen both elaborates the best option argument for regulated markets and levels a justice-based objection to kidney sales. In the present article, I show that Albertsen has crucially misunderstood the best option argument. It is not a defence of kidney sales, as Albertsen claims. It is a reply to an objection. The objection, perennial in the debate, opposes kidney sales on the grounds that sellers would be harmed. The best option argument-proving that prohibitions tend to set back the interests of those denied their preferred option-shows this thinking to be confused. If sound, the best option argument dramatically undercuts any attempt to oppose a market citing would-be sellers' interests.

The Altruism Requirement as Moral Fiction.

It is widely agreed that living kidney donation is permitted but living kidney sales are not. Call this the Received View. One way to support the Received View is to appeal to a particular understanding of the conditions under which living kidney transplantation is permissible. It is often claimed that donors must act altruistically, without the expectation of payment and for the sake of another. Call this the Altruism Requirement. On the conventional interpretation, the Altruism Requirement is a moral fact. It states a legitimate constraint on permissible transplantation and is accepted on the basis of cogent argument. The present paper offers an alternative interpretation. I suggest the Altruism Requirement is a moral fiction-a kind of motivated falsehood. It is false that transplantation requires altruism. But the Requirement serves a purpose. Accepting it allows kidney donation but not kidney sale. It, in short, rationalizes the Received View.

Kidney donors' interests and the prohibition on sales.

I shall argue, first, that potential kidney donors may be subject to harmful pressure to donate. This pressure may take almost any form; people have diverse interests, and anything that could set them back may qualify as pressure. Given features of the context-the high stakes, the involvement of family, and the social meaning of donation-such pressure may be especially harmful. This problem is less tractable than the more familiar worry that pressure may compromise consent. Screening may ensure donors validly consent, but it provides no protection against harmful pressure. I shall argue, second, that the use of such pressure is the predictable consequence of the prohibition on kidney sales. Potential donors have something-a transplantable kidney-that is both valuable and scarce. Many of them, informed about donation, decide against it. Those in need of a transplant may seek to persuade the unwilling. Given the prohibition, the donation cannot be made more attractive in absolute terms by, say, the addition of money. However, it can be made more attractive in relative terms. If declining the option is made worse, then, by comparison, accepting it is made better. The application of harmful pressure has the desired effect. With so much at stake, and no good alternatives, its use is predictable. I conclude that potential donors' interests should figure more prominently in the discussion of transplant policy. Those who defend the prohibition have made virtually no attempt to account for its impact on that group.

A regulated system of incentives for living kidney donation: Clearing the way for an informed assessment.

The kidney shortage continues to be a crisis for our patients. Despite numerous attempts to increase living and deceased donation, annually in the United States, thousands of candidates are removed from the kidney transplant waiting list because of either death or becoming too sick to transplant. To increase living donation, trials of a regulated system of incentives for living donation have been proposed. Such trials may show: (1) a significant increase in donation, and (2) that informed, incentivized donors, making an autonomous decision to donate, have the same medical and psychosocial outcomes as our conventional donors. Given the stakes, the proposal warrants careful consideration. However, to date, much discussion of the proposal has been unproductive. Objections commonly leveled against it: fail to engage with it; conflate it with underground, unregulated markets; speculate without evidence; and reason fallaciously, favoring rhetorical impact over logic. The present paper is a corrective. It identifies these common errors so they are not repeated, thus allowing space for an assessment of the proposal on its merits.

Understanding choice, pressure and markets in kidneys.

Here, I briefly respond to a recent paper by Julian Koplin, in which he criticises my earlier work in this journal. I show that Koplin has misunderstood the distinction I have made between pressure to vend and pressure with the option to vend. I also show that his pessimism about the market regulations I favour is unwarranted.

Reassessing the Likely Harms to Kidney Vendors in Regulated Organ Markets.

Julian Koplin, drawing extensively on empirical data, has argued that vendors, even in well-regulated kidney markets, are likely to be significantly harmed. I contend that his reasoning to this conclusion is dangerously mistaken. I highlight two failures. First, Koplin is insufficiently attentive to the differences between existing markets and the regulated markets proposed by advocates. On the basis of this error, he wrongly concludes that many harms will persist even in a well-regulated system. Second, Koplin misunderstands the utilitarian assessment of the market. He focuses on the costs and benefits of the transaction for the vendor. But, the relevant comparison is between an individual's welfare across different courses of action, namely, vending and the nonvending alternative. Although Koplin's empirically informed contribution is a welcome addition to this literature, the mistakes that pervade his interpretation of the data demand correction.

Misplaced Paternalism and other Mistakes in the Debate over Kidney Sales.

Erik Malmqvist defends the prohibition on kidney sales as a justifiable measure to protect individuals from harms they have not autonomously chosen. This appeal to 'group soft paternalism' requires that three conditions be met. It must be shown that some vendors will be harmed, that some will be subject to undue pressure to vend, and that we cannot feasibly distinguish between the autonomous and the non-autonomous. I argue that Malmqvist fails to demonstrate that any of these conditions are likely to obtain. His argument involves two common errors. First, he, like many, proceeds on a mistaken understanding of how to assess harm. What matters is not the balance of costs and benefits of vending, but a comparison of potential vendors' welfare across two possible courses of action. Second, Malmqvist's concerns about third-party pressure are predicated on an empirically unrealistic understanding of the operation of a regulated market. A widely underappreciated fact is that kidney sales will be relatively rare, and most who try to vend will be unable to. Because pressure on another to vend will not result in the desired outcome, few will exert it.

The best argument against kidney sales fails.

Simon Rippon has recently argued against kidney markets on the grounds that introducing the option to vend will result in many people, especially the poor, being subject to harmful pressure to vend. Though compelling, Rippon's argument fails. What he takes to be a single phenomenon-social and legal pressure to vend-is actually two. Only one of these forms of pressure is, by Rippon's own account, harmful. Further, an empirically informed view of the regulated market suggests that this harmful pressure is easily avoided. Thus, the harm that is the lynchpin of Rippon's opposition is neither a necessary feature of the market nor is it likely to play a significant role in its operation.