Scientists and their social responsibility: Indian view


By: Dr. R. R. Kishore, MD, LLB

(Chief Medical Officer, Ministry of Health & Family Welfare, Government of India, President, Indian Society for Health Laws & Ethics, New Delhi. Telefax: +91-11-6876621 e.mail: rrkishore@vsnl.com

– This paper was presented by the author at Workshop organized by the Hastings Centre at New York, USA, 27 June-3 July, 2003)

Introduction

On September 11, 1990, following the disintegration of Soviet Union, President Bush, , sounded very optimistic while announcing emergence of an order “free from the threat of terror, stronger in the quest for peace, an era in which the nations of the world can prosper and live in harmony”. (1) For hundreds of years, economists and politicians have been experimenting with different philosophies and systems of state policy, ranging from monarchy to democracy but they have not been able to provide a secure and peaceful social order. By means of continuous and sustained efforts, in the hope of achieving a uni-polar world, easier to govern and administer, they demolished a communist system which stood erect for nearly seven decades. But, the outcome belied their assessment and expectation. Even more than a decade after the iron curtain was torn, world is as insecure as ever, perhaps more, and the perceptions remain drastically heterogeneous. People, in the same society and culture, continue to perceive aggression and liberation differently. There is no unanimity even on fundamental issues of human quests and values? The global village, shrinking day by day through faster communication and cultural assimilation, presents a painfully disintegrated picture in terms of human quests and goals. Science by its very nature is unanimous and integrative. It does not vary according to political systems and boundaries. Scientists worldwide share common principles and theories for their operations. As such, they are part of an independent and transparent civilization, offering a ray of hope in this multipolar world divided by race, religion, history and politics. This paper seeks to examine the socio-economic obligations of the scientists in the face of fast advancing science and technology and the strategies adopted in this regard by a developing country like India.

Existing Scenario

During the last decade there has been spectacular progress in science and technology. Capabilities in information, communication and transport have increased manifold and several areas of space have been successfully explored. Fast advancing biotechnology has turned fiction into reality. Human genome has already been mapped. Thousands of diseases are already known to result from defects in single genes and the screening of defective genes has become a practical possibility. Transplantation technology holds the promise of improving millions of lives by replacing diseased organs. Reproductive technology has transformed the life of many sterile couples into hope and joy. However, there are many areas in biotechnology where enhanced capabilities have added to human dilemmas. Genetics, in its attempt to understand life in molecular terms has led to objectification of human subjects, affecting person’s identity, autonomy, and equality. Individual’s body and its characteristics have become the object of commercialization leading to prolonged legal battles , with no definite results. (2) Non-existing are taking precedence over the existing (3) and the embryos are being subjected to inheritance rights (4). Claims for the “custody” of fertilised ova, “wrongful birth” and “wrongful life” are challenging judicial capability. (5) Human relationships and institutions like ancestry, parentage, marriage, and family are being redefined — and even collapsing. The rights of the mother and the embryo/foetus continue to interfere with each other increasingly and the search for ‘normal’ children by selection of embryos remains surrounded by ethical obscurity. End of life decisions, stem cells, genetic patentability, research involving human subjects, organ donation and allocation, and many more issues display lack of conceptual clarity. On top of all this has come the “Utility” with its vast potential of making the life worthless and misconceived, compelling one to search new meaning in the objects and phenomena.

Of the world’s 6 billion people, 2.8 billion – almost half – live on less than $2 a day, and 1.2 billion – a fifth – live on less than $1 a day, with 44 percent living in South Asia ” (6) Poverty is a complex phenomenon. It breeds many negative forces such as illiteracy, superstition, ill health, social bias, injustice, dependency, genderization, outsized families and migration, enhancing poor’s vulnerability. Media is full of disquieting reports indicating exploitation of the poor for organ removal, womb hiring (surrogacy), sale of dead bodies, sale of children, sale of foeti, DNA sampling, clinical research and experimentation. Malnutrition and communicable diseases are still the major killers in developing countries and the poverty-health nexus continues as ever before. World has slipped into 21st century with loud thinking, utopian goals, and health-starved people, and many questions remain unanswered.

It is very clear that the international pronouncements affirming human dignity and individual autonomy as essential components of contemporary ethics have failed to protect the poor. Despite enormous scientific and technological advancement today’s world displays following disappointing features –

1. The life of common man has not improved. The inventions and innovations have brought comfort and luxury to those who belong to higher income group.

2. A large portion of the world’s population continues to live in poverty.

3. Genderization is prevalent in many parts, with blatant discrimination against women

4. Many vulnerable groups have emerged, with huge possibilities of coercion and exploitation

5. Social sectors such as healthcare, food, water, sanitation, housing, education, and justice have been ignored.

6. There has been extensive degradation of earth’s environment and natural resources are rapidly depleting.

7. Future generations are getting increasingly insecure

8. Political tensions and religious rivalries are mounting and the people are exposed to newer forms of threats

9. Individual is becoming more and more institutionalized, with loss of privacy, freedom and choice.

10. Growing commercialization is eroding the wealth of cultural and traditional knowledge

A scientist is not expected to watch the above trends as a mute spectator. As a member of civilized society he has to play a proactive role in its formation and betterment.

 Science, humanities and values

For centuries science and humanities have been treated as two different extremes for the understanding of universe, resulting in to inadequate utilization of both. While the former discovers the power of Nature, the latter determines its application. Technology therefore contemplates a matching human content in order to unfold itself for a purposeful role. Since technology is rooted in urge for productivity, resource optimization, automation, and innovation, there is a general belief that it improves the quality of life by imparting higher functionality, comfort and security. But, technology, in fact, acts in a strange paradox. On one hand it enhances human capability by increasing access to knowledge and resources, on the other hand it encourages concentration of scientific and economic power, leading to inequality and vulnerability.

In the recent years the common man who was earlier concerned with the problems of his daily life has become increasingly conscious and inquisitive of the scientific progress around him. He has become a part of interactive and proactive world, asking many questions concerning moral, economic and social implications of scientific pursuits. Three vital questions in this context are-

1. What is the human face of scientific research and development ?

2. Are the scientists a mere tool in the hands of economists and politicians or are they bestowed with a vision and commitment to use their knowledge and skill for evolving a secure and peaceful world order?

3. What is the interplay between human resources and scientific pursuits? Is it worthwhile to spend billions of dollars of people’s precious money on the development of spacecrafts while millions are hungry and devoid of basic necessities of life?

These questions point towards the basic human values associated with scientific and technological development. These values are truth, common good, transparency, independence and responsibility. In a civilized society, therefore, scientific advancement and moral evolution should proceed simultaneously and technological pursuits ought to be founded in deeper perspectives of human needs and aspirations than merely the desire for quantitative gains. Primacy of the human being is a uniformly recognized principle and the “ interests and welfare of the human being shall prevail over the sole interest of society or science” (7) No research or research applications “should prevail over respect for human rights, fundamental freedoms and human dignity of individuals or, where applicable, of groups of people” (8) Based on these perspectives one can identify following goals of scientific and technological advancement-

1. To preserve and sustain nature

2. To bring peace and security to the people.

3. To impart equity and justice to social dispensation

4. To enhance unity and integrity of the world.

 Science and social responsibility

Public responses reflect fairly widespread moral concern about advancing technology and its applications. Instances such as Bhopal, Chernobyl, depleting ozone layer, green house effect, genetic interventions and nuclear arsenal have shaken people’s faith in science and technology. Many feel that since it is not possible to regulate and control such outcomes it is safer not to have such capabilities. This mistrust about science and technology is partly because of lack of people’s participation in the decision making process. “Exaggerated reports of success are likely to hurt the very people who we were trying to help.” (9) The situation calls for a continuous dialogue between the scientists and the general public in order to discuss the ethical, social and economic aspects of scientific and technological developments. Such a dialogue would lead to wider public acceptance of scientific promises. It is therefore necessary that scientists come out of their laboratories and research establishments and share a common platform with the general public.

Failure of political and religious leaders to take clear position on the issues emerging out of advancing technology has added to scientist’s responsibility to educate the public about the nature and consequences of their pursuits. In today’s democratic societies it is not possible for the politicians and the policy makers to ignore the public opinion even if such opinion is not scientifically well-founded. This may lead to discouraging impact on the scientists due to fear of getting their grants stopped and also on the industrialists due to fear of not getting adequate markets. In the process, many valuable opportunities may be lost. “… what can be done to change the present situation? The scientist must enter the public arena and must explain what he is doing and why it is important to the public. He must speak of it with same passion as the activist, and without condescension. He must abandon the jargon of his guild and speak in ways the public can understand” (10)

Science is becoming increasingly inter- and multi-disciplinary, and calls for multi-institutional and, in several cases, multicountry participation” (11) Rapid advancements in science and technology have thrown profound and formidable ethical, social and economic challenges. Knowledge which was considered to be a universal asset has become a commodity, with severe restrictions on dissemination and sharing. Scientific knowledge for its adoption, transfer and diffusion requires participation of scientists in social tasks. Those engaged in research and development in the field of basic sciences ought to be conscious of the needs and aspirations of the community in which they live. The scientists must regularly interact with those who are involved in social sectors and humanities. This is necessary in order to impart social perspective to scientific pursuits. Many problems in today’s world can be attributed to rigid compartmentalization of disciplines. Human existence in its essence is holistic. No scientific pursuit is complete unless the resulting knowledge is integrated with social, economic and emotional aspects of human personhood. There are several other intelligible reasons justifying close interaction between scientists and society. Some of them are as follows-

1. Mundane breeds subtle: Practical circumstances and challenges provide the best impetus to scientific discoveries and inventions. Most of the scientists feel that the only places for them to pursue their knowledge and expertise are research and development laboratories. But, it ought to be realized that laboratories are not the only places to practice the art of science. Had Newton not been sitting in a garden he would not have discovered the laws of gravitation. Real life situations provide perspectives and insight which are not available in a study room or a laboratory. Working with lab rats and guinea pigs is one thing, working with human beings in flesh and blood is another. Interaction with surroundings is the best source of imagination and creativity. As such it is in the interest of science and technology that their initiators remain close to nature and community.

2. Scientists are a part of common intellectual stock of the society. Substantial natural and social resources are spent in making each one of them. They owe an obligation to return the debt by means of effective service to humanity i.e., the common man. The best service a scientist can render to the society is to use his scientific knowledge and expertise in a manner that improves accessibility of fruits of research and development to the common man.

However, the above social obligations notwithstanding, the choice of pursuit adopted by a scientist depends on a variety of factors such as –

  • Pesronal likes and dislikes

  • Individual circumstances

  • Nature and quantum of incentives by the state

  • Political atmosphere

  • Civil rights consciousness of the society

  • Economic status of the community

  • Cultural milieu

  • Historical background

As such, the scientist will behave differently in different societies. In an economically developed society most of them may like to pursue a purely research and development career. Scientists in a developing country, confronted with many a social problems may prefer to devote his knowledge and acumen in order to find solution to the problems in various social sectors.

Indian Scenario

Science and technology have been an integral part of Indian civilization and culture over the past several millennia. India was the fountainhead of important scientific discoveries which cover many great areas in the field of mathematics, astronomy, architecture, chemistry, physics, metallurgy, medicine, and several others. India too learnt a great deal of science from other jurisdictions. Many Indian scientists such as Chanakya, Aryabhatta and Sushruta who gifted the world rare ideas and discoveries were not only involved in scientific research and development but were also social reformists actively associated with community’s daily life and spirit. For this reason, the scientific discoveries and inventions in ancient India were never contrary to the interest of common man. Such scientific advancement was a part of overall social development, intermingled with economic, moral and religious processes.

Indian culture displays a unique universalism, perceiving the whole world as one big family-

“That person is my own, and the other one is not

my own is a thinking of small-heartedness. For the

generous ones the entire humanity is one family”

The above cultural thought provides a valuable direction to scientific pursuits.

India is committed to play her role in the global as well as national fields of science and technology. The emphasis has been on sustainable and equitable development of technology. The country has been successful in building a sound infrastructural base of scientific institutions and a highly skilled human resource. Indian capabilities in science and technology span through a wide range of disciplines. Agriculture, healthcare, education, information, communication, chemicals, fertilizers, nuclear energy, civil aviation, defense production, astronomy an astrophysics are some of the areas in which country has made remarkable success. A scientist cannot remain unaffected by the social milieu to which he is continuously exposed. In a country like India there are many specific challenges contemplating involvement of young scientists. These areas reflect a unique blend of scientific talent and social commitment. Areas like safe drinking water, nutrition, control of pests, flies, rodents, low cost housing, irrigation, power generation, indigenous system of medicine, and a host of others contemplate active involvement of scientists. Some of the common goals to be pursued by the Indian scientists may be identifies as follows-

1. To raise the quality of life of the people, particularly of the disadvantaged sections of the society

2. To generate wealth for all

3. To make the country globally competitive

4. To utilize natural resources in a sustainable manner

5. To protect the environment

6. To ensure national security

Scientists enjoy a unique social credibility which was never as compelling as it is today in view of increasing commercialization and politicization of resources in the name of globalization. The basic goal of all human development is to enhance access to justice. Scientists can be part of important policy initiatives in this direction.

Scientific and technical manpower (S & T) constitutes one of the major input resources for scientific and technological development. It provides measurement of country’s development potential. India has 7.27 scientists, engineers and technicians (SET) per thousand of population as compared to 180.66 in Canada, 139.16 in Russian Federation, 113.63 in Sweden and 112.77 in Japan. India’s per capita research and development expenditure was Rs. 130.26 (US $ 3.1) during 1998-99. There were 220 universities, 11 institutions of national importance and 11397 colleges in 1998-99 imparting higher education in the country. In 1999 the total strength of S & T personnel was 7.24 million. Many of these scientists and technicians are not gainfully employed. As per the data on the S & T personnel worn on the Registrar of Employment Exchange the number of unemployed S & T personnel was 1.72 million in 1998. (12)

India’s Science & Technology Policy for 2003

In the words of M. M. Joshi, India’s Minister for Science and Technology, “Our new policy is anchored in our abiding belief that for science and technology to grow, it must be green, it must be ethical, it must have a human face, it must be gender sensitive, it must be region and contest specific, reflect our enormous diversity and plurality, and it must empower the community as a whole and not merely a section of it.”(13)

In order to ensure integrated and fruitful development of science and technology and assimilation of country’s scientists in the socio-economic and cultural mainstream of nation’s life the Government of India announced a comprehensive policy for the year 2003. The policy takes in to account the emerging global and national challenges in the field of science, technology, economics and politics and the part to be played by the Indian scientists in this regard. The evolving world order founded on liberal economic policies, changing political equations and expanding people’s aspirations contemplates a proactive and multisectoral role by the scientific community. The Indian policy identifies several distinct objectives and envisages a multi-pronged approach in order to address the emerging imperatives. Some of the policy objectives are-

1. To inculcate scientific temper amongst the Indian people so that they emerge as a “progressive and enlightened society” and are able to participate in the development of science and technology and its application for “human welfare”

2. “To ensure food, agricultural, nutritional, environmental, water, health and energy security of the people on a sustainable basis.”

3. “To mount a sustained attack on alleviation of poverty, enhancing livelihood security, removal of hunger and malnutrition, reduction of drudgery and regional imbalances, both rural and urban, and generation of employment, by using scientific and technological capabilities along with our traditional knowledge pool.”

4. To ensure that science and technology enterprise in the country is “fully committed to its social responsibilities and commitments’

5. “To integrate scientific knowledge with insights from other disciplines, and ensure fullest involvement of scientists and technologists in national governance so that the spirit and methods of scientific enquiry permeate deeply into all areas of public policy making.”

Thus, it can be seen that the nation’s science and technology policy perceives the scientists not only as initiators of research and development but as persons capable of playing a much wider role in the country’s overall development. The policy seeks to realize this goal by adopting a dynamic and flexible approach, necessary to accommodate the evolving world order. The policy reiterates India’s “commitment to participate as an equal and vigorous global player in generating and harnessing advances in science and technology for the benefit of all humankind”

While spelling out the strategy and implementation plan the policy recognizes the need for the development of technologies which address the “basic needs of the population” and lays special emphasis on “equity in development” so that the benefits reach the “disadvantaged section”

 Conclusion

Unregulated technological advancement generates serious socio-economic challenges. It causes diversification of resources for the comfort and luxuries of few, imparts higher power to certain sections of society, neglects social sectors, exacerbates people’s vulnerability and aggravates overall inequity. Owing to past bitter experiences and lack of conceptual clarity the promises of technology seem to have turned into suspicions and many technological feats have been shelved for fear of moral miscarriage. In a civilized society the economists, politicians and religious leaders are not the only characters cast with responsibility to ensure people’s development. As enlightened members of society scientists have a complementary role to play in the people’s development. No technological development is complete unless it is integrated with social sectors. Scientists can utilize their scientific knowledge and skill in order to address many socio-economic challenges. They are bestowed with unique human attributes namely the truth and transparency and, as such, they are the founders of bright future. Scientists must understand that they are not robots operating at the command of their economic and political masters. They have an obligation towards disadvantaged sections of population which means that their scientific knowledge and skill should unfold itself in order to discover methodologies capable of liberating such sections from deprivation and neglect. Scientists also carry an obligation to ensure that their discoveries and inventions are not misused by business entrepreneurs and the industry to mislead the people by false claims and publicity. They should therefore engage themselves in dialogue with general public. With this perspective in mind, India’s Science and Technology Policy for the year 2003 seeks to integrate development of science and technology with social sectors, by encouraging scientists to play a complementary role, along with other players, in the overall development of the people.

References

(1) U. S. Department of State, Current Policy Document No. 1298

(2) Moore v Regents of the University of California, 793 P.2d 479, 271 Cal, Rptr, 146 (1990), Cert. Denied, 111 S.Ct. 1388 (1991), as reported in the Journal of Legal Medicine, Vol. 14. No.3, September, 1993

(3) C Byk “A Map of a New Treasure Island”, Journal of Medicine and Philosophy, 1998, Vol 23, pp234-246 at p 236

(4) In the Matter of Estate of Late K and In the Matter of the Administration and Probate Act 1935 ex parte The Public Trustee , as commented upon by Derek Morgan, in “Rights and legal status of embryos”, Australian Health Law Bulletin, Vol, No7, April/May, 1996).

(5) Michael S. Yesley. “Bioethics in the United States of America: Who Decides?” Human Genome Research and Society. Proceedings of the Second International Bioethics Seminar in Fukui, 20-21 March, 1992. P34-45

(6) World Development Report 2000/2001 Attacking Poverty, published by the World Bank, p3

(7) Convention for the Protection of Human Rights and Dignity of the Human Being with regard

to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine,

Oviedo, 4 April 1997, (Article 2)

(8) Universal Declaration on the Human Genome and Human Rights, UNESCO, 11 November,

1997, Article 10

(9) Heiner Westphal, M. D. Animal models of human diseases. Genethics. Published by Ciba-Geigy Limited, Ciba Communications, Basel, Switzerland, 1995, p28

(10) Gerald E. Gaull, M. D. The new biotechnology: communication with the public. Genethics. Published by Ciba-Geigy Limited, Ciba Communications, Basel, Switzerland, 1995, p68

(11) Science and Technology Policy 2003, Ministry of Science & Technology, Government of India

(12) Research and Development Statistics 2000-2001, Govt. of India, Ministry of Science and Technology, Deptt. Of Science and Technology, New Delhi, May 2002

(13) Dr. M. M. Joshi, Minister for Human Resource Development, Science and Technology, India. Science and Technology Policy 2003, Ministry of Science & Technology, Government of India

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Model Election Manifesto of Political Parties in India


(This Model Menifesto is posted by: Dr. R. R. Kishore, Advocate, Supreme Court)

This is a model election menifesto that must be compulsorily adopted by all poilitical parties in India, with the needed variations that a political party may wish to make on the following items of life’s basic needs of Indian citizens:

(The name of the party) …………..  will, inter-alia, ensure the following,

  1. Free supply of 200Litres of safe water per day to each individual.
  2. Electricity @ Rs. 2 per Unit up to 400 Units per month to every consumer
  3. Supply of 2500 Calories of balanced food to each adult individual, at affordable price.
  4. Daily disposal of garbage and other household waste, free of charge.
  5. Free medical facilities to every individual
  6. Free education to every individual up to class XII.
  7. Suitable residential accommodation to be calculated @ 150 Sq. Ft. per individual, for a rent @ 10% of the income the family,  in case of those who do not have resources to purchase a house.
  8. Containment of prices of food, medicines and other essential commodities. If the prices of any item are to be enhanced owing to unavoidable circumstances, it will done after due notice to the public.
  9. Compulsory disclosure of ownership by the media i.e. television channels and the print media.
  10. Maximum time limit for commercials to be fixed during telecast by the TV channels as also the maximum space to be used for advertisements in the print media.
  11. Telecast/publication of false news by the media houses to be made a criminal offence attracting stringent penalties.
  12. Harnessing of national resources such as water, petroleum, minerals, spectrum etc. will be allowed in private sector with full transparency i.e., the contract will be finalized after making the terms and conditions public and it will be subject to close and strict regulatory control by the Govt. and breach of contract will be made a criminal offence, in addition to attracting civil liabilities.
  13. The existing public sector enterprise such as railways, roadways, airlines, hospitals will not be privatized without the people’s approval as determined through referendum
  14. 30% of the seats in the State legislature and the Parliament  will be reserved for women candidates
  15. Only a person who has been permanently living in an area for at least 10 years will be eligible to contest  election from that constituency.
  16. A person having a minimum qualification of a bachelor’s degree will be eligible for contesting the election
  17. The upper age limit for contesting the election will be fixed at 70 years
  18. A person will be eligible to contest the election subject to being declared physically and mentally fit  by a duly constituted Board of medical experts.
  19. No person will be eligible to contest from more than one constituency in an election
  20. It will be compulsory for the elected representative to remain available in his/her constituency for at least 60 days in a year
  21. The details of funds received by the political parties will be made public and full particulars of the person/agency extending the funds will be available on the party’s website.
  22. When our party is presenting this Menifesto to the public, we understand that it is a promise in the legal sense, which can be enforced by an electer in a court of law against us. We, our party and the central officials of our party HEREBY agree that the moment our candidate is elected on the promise of this Manifesto, this Menifesto become an enforceable AGREEMENT, which AGREEMENT can be enforced for a civil and/or criminal liability in a court of law against US, JOINTLY AND SEVERALLY for the breach of the same.

 

Who is more and who is less developed?


(This article is based on the interaction of ideas between Shreepal Singh and Dr. R. R. Kishore)

Freedom allowed to one to pursue the goal of happiness is his or her liberty. Happiness is the natural goal of life. The quantum of happiness that one possesses is the measure of his or her development and/or progress. Happiness is a state of mind, which today – in the present state of scientific development – cannot be measured.

But the effect of happiness expressed by one in the outer physical / objective world through his or her conduct can very well be measured. The conduct of one in his or her private and public life is the reflection of his or her state of mind.

The unmistable imprint of happiness is the sense of contentment that one happy person possesses in his or her life. Conversely speaking, the unhappy person is a discontented human being. He or she is a person who has not got what he or she wanted or attempted to get. On the other hand, a happy person is one who is contented with what he or she got or attempted to get.

Discontentment is a negative trait that gets reflected in the violence and agitation in one’s conduct and the properties of violence and agitation in one’s conduct are objective things, measurable quantities and amenable to be put on a scale.

On the scale made-up of violence and agitation, the higher is one, the less happy and developed he or she is.

The wholesome concept of happiness is that it is a sense of fulfilment of a person produced by his or her creative industry. Its elements are: industry, which involves physical labour; creativity, which involves the use of natural human tendency of inquisitiveness; a sense of fulfilment, which involves a mental state.

Happiness is a mental product of biological activities. It lies more not in reaching the goal but in the hard physical work or industry proceeding towards achieving the desired goal.

Bhutan – as a country – has rightly put the happiness as a constitutional goal of making its people happy and, therefore, developed. It is unlike India where the constitution chases the chimera of artificial Western concepts of progress. The Western ideas of making Gross Domestic Product, Per Capita Income, Individual Intakes of Water, Calories etc. a measure of development are false concepts in this respect.

Advancing Biotechnology and the crisis Of Purpose


 

(3-8 Nov, 1997 in Kobe/Fukui, Japan; Asian Bioethics Conference (ABC97) and WHO-assisted Satellite Symposium on Medical Genetics Services: Advancing Biotechnology and the Crisis of Purpose: by Dr. R. R. Kishore, MD, LLBChief  Medical Officer, Ministry of Health & Family Welfare, Government of India, President, Indian Society for Health Laws and Ethics (ISHLE), New Delhi – 110023, INDIA)

Introduction

In a world where every religion and culture contemplates continuance of life after death despite total absence of its proof the human endeavours can not be evaluated in the context of material perspectives alone. They are intimately linked with emotions, beliefs, faith, and traditions and require to be handled accordingly. Science, no doubt, has significant impact on human behaviour and relationships but it is not sufficient to sever the religious anchorage which acts as a great force to determine the moral content of human acts. On the biological plane, inspite of having a distinct genetic make-up, we are similar to other forms of life. All of us are born, live and die. But we are different from them inasmuch as we are persons. The human personhood is an emotional and value-based entity. All of us experience pain, misery, love, and joy. Human emotions are same everywhere and they have been same in all ages. This is a sign of human universalism and forms the basis of all human acts. This brings babies, discoveries, wars, and peace. This creates families, societies, and nations. But despite this intrinsic similarity the individuals can not be confined to a world of generalized standards, as the expressions differ. They reflect an individual’s response to the situation in which he is placed. Different people react differently to the same environment and expect different responses from others. These varied attitudes and expectations notwithstanding there has not been much dispute over the concepts of ‘right’ and ‘wrong’. What is right and what is wrong? How do we learn it? From where did it come, why and when? It is difficult to answer these questions but one thing is certain: It is present in all human beings and has been with them since very long. It is deeply embedded in our thoughts. It is this concept, coupled with human emotions, which has assigned purpose to our actions. Biotechnological advancement has shaken this inherent edifice and the existing realities are no longer compatible with the emerging developments. Contemporary milieu therefore calls for answers at a much deeper level as the problem is not only medical, legal, technological or economical but involves questions of values, convictions, and human emotions.

Fundamental Questions

In a world where the requirement of health range from safe drinking water to breast prosthesis, promises of biotechnology range from humanising  animals to creating new life forms, and the concerns of human rights range from the rights of dead to the rights of unborn, there are many diverse and overlapping areas. Let us consider the following questions:

  1.         What is the harm if genetic structure of Homo sapiens is modified and a

different phenotype is created? After all, there was a time when we were grossly different from our present shape. Are we the sufferers because we failed to maintain our original form? We take pride in our present form rather than grieving over our lost identity. We call ourselves most evolved living beings. Those who failed to keep pace with the change died like Dodo and Dinosaurs. To resist change means to force extinction on our future generations. We have no right to compel the future generations to live in racial prejudice, impoverishment, disease, debility, and premature death. Our ancestors have never done it. What is the harm if a human being is created who consumes less resources, is more resistant, and more compatible with nature? Rather, this will provide more security and endurance to our future generations. Wisdom lies in vision and imagination and not in sticking to the present and the status-quo. Human race is already under pressure of dwindling resources, moral deficiency, and ecological disharmony. If the genetic intervention leads to creation of human species which requires less resources, lives under diverse whether conditions and is more compatible with other forms of life it should be treated as welcome change.

2.         What is wrong in having parentless children? Our social and family concepts developed when biological processes were beyond human intervention. Today, when we have learnt the art of framing our biology the human relationships need redefinition. We have so far been synonymizing parentage with origin without realizing that parentage is only a social and emotional expression. Advancing biotechnology mandates separation of this component from the biological element which is only confined to genetic linkage but our failure to reconcile with the emerging reality has led to the ethical miscarriage of concealment of genetic identity of the babies born out of donated gametes. Furthermore, an individual may not like to be created out of borrowed or donated gametes. Rather he/she would like to have been produced in the natural manner. But we have been making babies by artificial means. How are we competent to take decision in this regard? Why should an individual be a victim of hidden origin in order to satisfy the urge of others to own him as their child? And since the individual has already paid the price by being born why should his interests not prevail over the parents and why should his roots be concealed from him? Morality is intimately linked to science. Secrecy breeds mistrust and the moral structure raised on such false foundations cannot be stable. Transparency is the manifestation of truth and purity and affords the surest guarantee for rational and orderly human conduct.

3.         Why should we not grow foeti to harvest organs and tissues? We can liberate millions from disease and agony, improve their quality of life, enhance their contribution to the society and divert resources to other meaningful areas. What is wrong in it? How does it affect us? Does it imperil our survival, disturb our social order or cause economic insecurity? Or does it impart moral impoverishment or transgress our religious domains? Or is it the expression of our emotional vulnerability, without any scientific or metaphysical basis? Millions of people are dying due to organ scarcity. Sizable resources are being spent for curbing organ trade, enforcing prohibitions, maintaining organ banks and waiting lists, and on palliative measures to prolong life of terminally ill patients. Death has been redefined in an attempt to tide over the organ scarcity. Those who did not feel convinced with the new doctrine and perceived it as a premature termination of life had to ultimately concede. Quest to alleviate human misery took over moral mores. But the mere thought of producing foetal crops for harvesting tissues generates abhorrence and self-hatred. This reflects human sensitivities totally independent of scientific and material considerations. One may argue that rights accrue to a ‘being’, not to those who are yet to be born. Whatever I do i.e., my food, indulgences, priorities, likes-dislikes, job and everything else affects my progeny and in the process they may suffer avoidable harm. Does it mean that I should stop living in order to promote the interest of those who do not exist?

4.         What is misery? What is pain? It is an individual’s response to the situation in which he is placed and as such it may vary according to his personhood. We want organs to save the ill and dying. The family members do not allow them to be removed from a brain-dead person for fear of mutilation of the body leading to loss of peace to their dear-one in the heaven. Should we dismiss it as absurd, a mere superstition? Similarly, one may feel withdrawing support from a terminally ill patient is inhuman while another may feel it is perfectly in order. Medical decision is not based only on scientific imperatives but is also a matter of personal emotions, feelings and relationships. The decision in clinical and family settings contemplate flexibility. Paradigmatic rigidity in certain situations may lead to ethical miscarriage. Bioethics is a blend of biotechnology and culture and the discipline is further complicated because, in the same value system, different people feel differently.

5.       What are the foetal and maternal rights? Termination of pregnancy or abortion is an issue that displays different approaches in different parts of the world. It is striking that in the countries like USA and Canada, situated adjacent to each other, with strong socio-economic, religious and cultural similarities, the approach has been diagonally opposite. While USA has adopted a cautious approach linking the termination to the duration of pregnancy by adopting a trimester system Canada has adopted a much liberal approach recognising abortion as the woman’s fundamental right as is evident by the land-mark pronouncement of the Canadian Supreme Court in 1988 declaring that prohibition of abortion constitutes breach of “liberty” and “security of the person”, as protected by the Canadian Charter of Rights and Freedoms.

6.         Let us consider the following examples

i.          ‘A’ in the terminal stage of renal failure, is fighting for his life and needs immediate kidney transplantation but nobody is prepared to donate his kidney to him. ‘B’, totally depleted and impoverished requires money to buy food for himself and medical aid for his child, dying of serious sickness but nobody is prepared to provide financial support to him. ‘B’ gives his kidney to ‘A’ who in turn extends consideration to ‘B’ in order to safeguard his and his family’s survival.

ii.      ‘A’ is blind and requires corneal transplantation to restore his vision. ‘B’, under renal failure, needs immediate kidney. ‘A’ gives kidney to ‘B’ who donates one of his corneas to ‘A’. ‘B’ survives. ‘A’ sees the world.

How should the above interaction be viewed? Immorality? Trading? Crime? Exploitation? Human Commodification? Perhaps none. Truly speaking, it is the expression of mutuality and reciprocity based on pragmatic considerations. So long the society is not capable of catering to the genuine and compelling needs of ‘A’ and ‘B’ they have the right to look after themselves with the help of each other. The instinct to survive is a biological reality and it is their inherent duty to preserve their life. However, one may argue that there are things worse than death and greater than life and in order to uphold human dignity sacrifices have to be made.

(7) We have to ensure that the advancing biotechnology remains a purpose oriented pursuit and the cart is not put before the horse as we have done in the past. We discovered atomic energy without attaining maturity to put it to the right use. We have been exploring space without knowing its impact on the humanity. And now we are involved with human genome. Knowledge in the absence of right attitudes may be dangerous. Time has come when we have to see beyond our scientific achievements. Why are we so deeply involved with biotechnology? What is the purpose behind our tryst with the genes? Why do we want to decode human genome? Who is going to be benefited ? What is meant by benefit? Before searching answers to these questions we have to answer two basic questions-

I.          What is a human being?

ii.          Why should there be a human being?

Let us answer the first question. Had the human being meant only the human genome and its expression the answer would have been simpler. But the human being means human creature plus human personhood. I leave this question here as I would be discussing it further in the next section of this paper, namely, the ‘Indian Cultural Thought’. The second seems more difficult. It can be replied by counter-questions. Why should there be a universe? Why should there be anything at all? What will happen if the human being becomes devoid of human entity? What is the harm if I live like a plant? Why blue is blue, and red is red ? Why 2+2 = 4 ? Quest to find an answer to every question leads to nullity. Universe exists on intrinsicality. Analysis and dissection beyond a certain point results into loss of an object. There seems to be no other answer to these questions except that existence is a purpose in itself. To be a human being is a purpose in itself. Without the human genome there can not be a human identity and in order to continue as human species we are bound to preserve human genome.

The Indian Cultural Thought

  1.         In Indian thought the facts are perceived at a level much deeper than the molecular plane. The theme of Indian perception is universality, holism and spontaneity which means that the things exist in a state of mutual interdependence, interlinked with each other and the cosmic forces. The objects owe their integrity to a stable centrality and an interplaying peripherality. This is common to all phenomena, i.e., the solar system, the atom, and the life. In case of living beings the centrality is constituted by the instincts which are basically two: the instinct to survive and the instinct to multiply. In case of Homo sapiens this centrality is impregnated with certain essential traits which distinguish them from other forms of life. These essential human traits are known as dharma (in ancient Indian language Sanskrit), the nearest synonym to which in English is virtue. These virtues are; righteousness, truthfulness, love, trust, compassion, beneficence, tolerance, forgiveness, sacrifice, and rationality. The moral values — justice, equality, autonomy, benignancy, altruism, human solidarity, respect for the dead, respect for other forms of life, and protection of the weak  — emerge out of these virtues. These values guide the individual and the societal conduct and the material concepts like, ‘utility’, ‘quality’, and ‘economics’ reflect an attempt to uphold these values. No other being is embellished with these properties and this is the reason why human beings are the most advanced mortals in the Nature.

2.         The objects in the Nature are identified more by their functional attributes than their physical formation. Sun, a mass of hot gases is perceived as a source of light and heat; Water, a compound of Hydrogen and Oxygen, with coolness and quenching of thirst; Iron, an element of specific atomic structure, with strength and resilience; Rock, a compound of many elements, with firmness and stability; Lion, an animal, with valour and courage; Flower, a bunch of petals, with beauty and fragrance. Similarly, the Homo sapiens, a biological entity comprising of twenty amino acids is perceived as “Human” because of the above virtues. In other words the expression ‘Human’ synonimises human virtues or dharma. With the loss of this human content he looses the ‘Human’ personhood and is reduced to human creature.

3.         The Indian thought seeks integration by continuance and spontaneity which means that germination, growth and decay are the phenomenon occurring successively as well as simultaneously, i.e., the one not only preceding or succeeding the other but concurring with the other. Events in the nature are the roots and fruits of each other and this complimentarity is the source of unending sustenance. The termination of life by human intervention (which includes non-intervention) amounts to an adversarial action opposed to Nature’s complimentarity. For this reason Indian philosophy discovers the preservation of life as a natural imperative not merely a metaphysical concept and perceives it as an absolute value, not related to abundance or scarcity. The individual autonomy does not include the right to kill or to be killed and that is why killing is always unethical and the will to be killed is always invalid. As such Indian thought provides a clear and distinct message, i. e., the individual’s life is to be preserved — regardless of resources constraints and his desire.

4.         In the Indian cultural thought the concept of common heritage of humanity is well-rooted since long and the entire humankind has been perceived as one big family and those who choose to divide the humanity on the basis of race, religion, consanguinity, personal proximities or any other ground are seen as narrow-minded. The said thought is contained in the following Sanskrit verse-

“That person is my own, and the other one is not my own is a thinking of small-heartedness. For the generous ones the entire humanity is one family”

The Purpose

Humanity is the manifestation of human content of Homo sapiens. It is an accumulation of human endeavours, pursuits and attainments. It reflects a collective wisdom, i.e., the wisdom of all people of all ages — including the future generations, through a composite phenomenon known as culture which is the process of transformation of the raw, primitive and the hidden into finished, advanced and revealed through the development of intellectual and moral faculties resulting into enlightenment and excellence in the form of religion, art and science. The process involves interaction between human virtues and instincts on one hand, and the environment on the other. It is an ongoing process during which the outputs merge with the source leading to further enrichment. All discoveries and inventions are a part of this human process and at the essential level there is no difference between the two. Both constitute the process of knowing the unknown through the known and are basically the search and the revelation involving the faculties of imagination and investigation. But there is one big difference. Inventions have applicability. Applicability involves purpose. Purpose makes all the difference: As wide as between a power-house and Hiroshima or as wide as between a cancer cure and Nazi eugenics.

It must be understood that the humanity is not merely the expression of biological profile of the human species. It is the outcome of interaction of human beings with themselves and the environment. It reflects the content and the impact of human actions and interactions The destiny of the human race therefore does not depend on the genetic characteristics alone. Owing to many factors beyond their control the humankind has a common destiny. But this holds true only as long as there is no interference in the basic structure of human genome, alteration of which may result into loss of human characteristics leading to many distortions in the existing setup, imperiling the survival of human race.

The security and dignity of human race lies in its survival as a distinct entity. For this purpose an intimate and sustained inter-human relationship is the prime requirement. Human solidarity is necessary in order to maintain effective equation with other objects in the Nature The secret of human solidarity lies in similarity emerging out of genetic uniformity. It is therefore imperative to preserve this genetic oneness. It is with this perspective that the human genome has been conceived as a common heritage of humanity.

Continuance of human species as a distinct biological entity is a functional imperative not only in the interest of their own survival but also to ensure preservation of biosphere. The human being endowed with virtues as intrinsic human property constitutes a source of responsibility towards other forms of life and objects of Nature. The saga of human existence displays a continuous quest to win over vulnerability and ignorance by pooling of knowledge, experiences and resources. The orderly conduct, mutuality, reciprocity and optimization of resources has led to further security and enrichment. The human race, after long journey of evolution, has reached the present stage of scientific, religious and cultural attainment, with vast potential of material and intellectual creativity. The Nature can not afford to loose this prized possession.

We may also appreciate that we are always at a particular stage of development in the course of biological evolution. The genetic mutation is a natural and on-going process, and it is because of this process that we are in existence today as a human species. Inevitably, a time will come when we will be replaced by ‘higher forms’ as we have replaced the ‘lower forms’ (who knows we might have been the ‘lower forms’ as there are many missing links in our knowledge about the history of evolution). But we do not feel concerned as the change due to natural process occurs very gradually, spread over a long period of time and it not confined to human beings alone, it affects all that exists in the Nature.

Conclusion

The discovery of genes is the mankind’s biggest achievement and we have reached a stage where it is not possible to stop the march of advancing biotechnology because the genetic research is driven more by curiosity than application. Many questions are still open and a cautious, but pragmatic, approach is required while dealing with a force as strong as advancing biotechnology. Scientific advancement leads to cultural evolution which means change in human thinking, lifestyle and relationships. The existing norms and patterns of human behaviour are redefined. That which appears strange today becomes acceptable tomorrow. The crisis of purpose exists as long as we do not change our conceptual fixations. We must remember that the universe runs on Laws, not on man-made rules, priorities, concepts, likes or dislikes. Those who ignore this truth become incompatible and perish. The essential purpose of biotechnological advancement is to ensure continuance of a virtuous, peaceful, egalitarian, and eco-friendly human race.

Human Organs, Incentives and Sale: Moral Contexts and Emerging Imperatives


 

 

 (This article  is a modified version of the paper presented  on 22 September, 2003 at Kyoto, Japan in the International Conference on “Dialogue and Promotion of Bioethics in Asia” Human Organs, Incentives and Sale: Moral Contexts and Emerging Imperatives

By Dr. R. R. Kishore, MD, LLB Advocate Supreme Court of India, President, Indian Society for Health Laws and Ethics, New Delhi, India   e.mail:  rrkishore@vsnl.com)

Before I start, I would like to express my gratitude to  Japanese Ministry of Education, Culture, Sports, Science and Technology, and also to organizers of this conference, namely the “Dialogue and Promotion of Bioethics in Asia,” and in particular Prof. Ryuichi Ida.  I would also like to clarify that what I am going to speak reflects  my personal views and does not, in any manner, project  the policy of the government of India.

Introduction

“a.        ‘A’,  in the terminal stage of renal failure, is fighting for his life and needs immediate kidney transplantation but nobody is prepared to donate his kidney to him.  ‘B’, totally depleted and impoverished requires money to buy food for himself and medical aid  for his child  dying of serious illness but nobody is prepared to provide financial support to him.   ‘B’ gives his kidney to ‘A’  who in turn extends consideration to ‘B’ in order to safeguard his and his child’s survival.

b.        ‘A’ is blind and requires corneal  transplantation to restore his vision. ‘B’, under renal failure, needs immediate kidney.  ‘A’ gives kidney to ‘B’  who donates one of his corneas to ‘A’.  ‘B’ survives. ‘A’ sees the world.

How should the above interaction be viewed in the context of organ transplantation? Immorality? Commerce? Trade? Trafficking? Exploitation?  Perhaps none.  Truly speaking, it is an expression of mutuality  and reciprocity, based on pragmatic considerations, and is not in divergence from essential human traits. So long  the  society is not capable of catering to the genuine and compelling needs of ‘A’ and ‘B’,  they have the right to look after themselves  with the help of each other.  The instinct to survive is a biological reality and the human beings equipped with intellectual faculties will not allow their survival to be imperiled without exploring all reasonable possibilities”(1)

There has been much debate since the time I wrote the above article (1995) and during this period many persons have died of organ failure and many continue to be terminally ill, but there has been no breakthrough in ethical principles or legislative strategies. Recently,  “Walter Land, the internationally renowned transplant surgeon from Munich University Hospital, Grosshadern, was suspended”  because he, allegedly, carried out a kidney transplantation in Al-Mafraq Hospital, Abu Dhabi  for which “ethical and legal doubts were raised about a possible involvement in organ trade”(2) Investigations are also on in Germany for “alleged organ trading in four cases of kidney transplantation carried out by a prominent surgeon” Christoph Broelsch, who “has often and controversially said that he would like to have the transplantation law changed so that living donors or relatives of deceased donors would be able to receive payment”. Pending investigation, “Johannes Scheel has had to step down as director of his department because of his involvement in the organ trading case” and “the liver and pancreas transplantation programme has been put on hold.”(3)  In India there are periodic reports of organ trafficking involving clinicians, managers of  clinical centres, middle-men and even state officials and several cases are under active investigation and trial. The “worldwide shortage of kidneys from cadavers has resulted in illicit organ sales and even kidnapping and murder of children and adults to “harvest” their organs, which is morally much worse than allowing a person to voluntarily donate a kidney for compensation.” (4) Millions of people are suffering, not because the organs are not available, but because ‘morality’ does not allow them to have access to the organs.

The question is what is good and what is bad. How to measure the moral content of a particular act? Morality is always contextual. It depends on how and in what context we interpret values. “The famousRoman physician Galen, for example, did most of his anatomy researchon pigs and dogs as it was regarded as immoral to dissect humansat that time” (5) but, subsequently, dissection of human cadavers during medical education became a routine practice. The issue of biotechnological achievements  and their social assimilation contemplates a much deeper dialogue than what is being done in the contemporary ethical discussions. This paper is an attempt in that direction.

The problem

 “About 65 000 transplant operations are done each year worldwide, of which about 45 000 are kidney transplantations.”(6) As on 20 June 2012,  114730 people are on the organ transplant waiting list in the USA. (7) In India, specific studies are yet to be conducted but keeping in view the countries large population of nearly 1.2 billion and the rising incidence of ESRD, the requirement for kidney transplantation alone is expected to be around 100, 000 per year.

Shortage of available organs is a global feature of organ transplantation and has been a challenge almost since its inception. Strategies such as liberalization of brain-death concept, introduction of presumed consent, routine harvesting, required request, mandated choice, enhancement of donor’s upper age limit, relaxation of consanguineous riders and allowing altruistic donations from strangers have not resolved the problem. Organ scarcity continues to prevail leading to inequitable therapeutic dispensation, escalating costs, trade and crime. The extra human sources of organ supply have not so far borne fruits. Xenotransplantation is confronted with serious scientific and ethical challenges and production of artificial organs is still in the conceptual stage. Cloned organs are not morally acceptable since  “the notion of human cloning to produce individuals for use merely as organ donors is repugnant, gruesome and unimaginable” (8) While the ethicists are busy debating moral content of biotechnological promises millions continue to die of avoidable causes. In the context of organ sale, the most commonly advanced arguments are human dignity, preservation of life, safeguarding of future generations, protection of vulnerable sections, distributive justice and slippery-slope. The forgotten ones are continued human suffering, exorbitant costs, substandard procedures,

circumvention and non-compliance of law, underutilization of biotechnological feats, preference to non-existing over the existing and harassment to transplant surgeons and clinical centres. It seems moral introversion has overtaken pragmatism thereby closing several candid options such as growing organs from stem cells, legitimizing mutual donations and allowing consideration in lieu of organs, and an immensely promising intervention like organ transplantation is not able to effectively unfold itself.

Changing concepts

A discussion about  “possible payments to living donors for time off work, lost income, pain, and suffering and a move by prisoners to become donors in a bid to reduce their sentences” has already begun (9) In view of chronic shortage of organs, the Bellagio Task Force examined different aspects of organ sale and recommended “some incentive should be in place for families of deceased organ donors’ (10) and, in USA,  the Pennsylvania Department of Health proposed granting US$ 300 financial incentive as a “funeral grant” to “help defray the expenses for organ donors” (11) It does not stand to reason to “prevent adults from entering into contacts from which both sides expect to benefit, and with no obvious harm to any one else” and the “potential harm of losing a kidney must be weighed against the potential benefits of whatever payment is received”. (12) According to Professor Peter Bell, vice president of the Royal College of Surgeons, “family members who donate kidneys to ailing relatives” ought to be  remunerated “for the inconvenience caused in terms of the convalescence period, time off work, and so on.” (13) One of Britain’s leading transplant surgeons, Dr. Nadey Hakim, has called for the legalisation of payment for kidney donations since he feels that the ” trade is going on anyway, why not have a controlled trade where if someone wants to donate a kidney for a particular price, that would be acceptable?. If it’s done safely the donor will not suffer.” (14)  “The Department of Health is considering softening the rules against payments to donors, in a bid to clear the backlog of patients awaiting transplants.” (15) Then there are people who find organ sales to be beneficial to the poor owing to “a net flow of cash from the richer” but feel that such sales may adversely affect the ‘cadaveric donation of organs other than kidneys” (16) “The severe shortage of kidneys for transplantation has induced Israel’s health ministry to make a 180 degree turn in its policy and prepare a bill allowing compensation to be paid to people who donate a kidney for transplantation.” (17)

Liberal thinking is a not a  new phenomenon. More than  a decade ago, people realized that prohibition on payment for organs was “overly broad” (18) and “a market for organs is morally and ethically superior to the current altruistic procurement system” (19) The Council on Ethical and Judicial Affairs, American Medical Association  in their report, accepted for publication  on September 16, 1994, concluded that “No incentives should be allowed for organs procured from living donors” but strongly argued in favour of financial incentive to “prospective donors” for “future contracts” of cadaveric organs. (20) Even those who are not in favour of financial incentives feel it is worthwhile  to subject the idea  to “market test” through “carefully evaluated pilot programs” (21) While some feel that “paid donation is more transparent than other situations where altruism and voluntariness cannot be established” (22) Others  believe that in the event of reversal of existing moral positions “the profession will suffer a serious setback” (23) Even those who oppose monetary consideration in lieu of organs feel that donor’s recognition by means of  “awards, plaques and ceremonies” (24) would be a step in right direction. There is also a view  that “Human behavior can be shaped and manipulated by incentives, financial and otherwise” (25) However, people who feel procuring organs for a consideration is not unethical are cautious while making their views open because of the fear of strong public reaction.

At times one feels persuaded to conclude that organ sale is more ethical than presumed consent. On one hand the ethicists  talk of informed consent while on the other they practice presumed consent. This is a striking example of double standards.  Those who are dead do not lose personhood. A “person is living one moment and a cadaver the next” (26) Sale is a conscious decision  taken  by a  person after considering all aspects of the matter and is fully consistent with individual autonomy unlike organ removal based on presumed consent, which is devoid of any participation by the person concerned.

Essential questions and values

Denunciation of organ sale reflects a kind of emotionalism rather the principlism. The basic ethical principle involved in organ transplantation is whether a person has a right to enjoy life on the basis of organs belonging to others. Once we choose to answer it in affirmative we concede that we are prepared to inflict harm on others in order to improve our health or to prolong our life. Thus we sacrifice the long cherished principle of non-maleficence in medicine. Whether the organs come through donation, gift or sale is a matter of individual choice and circumstances. Even if a persons gives his organ without any consideration he suffers harm to his body. In this context it may be worthwhile to refer to the Guiding Principles adopted by the Forty-Fourth World Health Assembly in May 1991 which have been the touchstone of legislative strategies in many jurisdictions, including India. (27) Guiding  Principle No. 3 states “Organ for transplantation should be removed preferably from the bodies of deceased persons. However, adult living persons may donate organs, but in general such donors should be genetically related to the recipients. Exceptions may be made in the case of transplantation of bone-marrow and other acceptable regenerative tissues.” These guiding principles are an express example of  dominating attitude of the few by laying rules of conduct for the rest of the world. It is a fact that in every gift or donation some kind of expectation is involved though it may be different from a material consideration. In case of live organ donors the organ is donated to a particular person who, in fact, may not be the neediest or the most deserving keeping in view the depth of illness, period of waiting, age, family circumstances, capability to afford post-transplantation therapy  and other criteria. This means that the act of donation  is tainted with considerations of personal relationship, choice and preference which in other words means that the donation is not a candid act of altruism or human solidarity, rather it is  motivated by desire to save life of a near and dear one which may, at times, be in order to secure one’s own comfort and future. Such urges and motives  also constitute consideration since they are aimed at pleasure and fulfillment. Even a donation made to a stranger is not without consideration which in such cases may be in the nature of discharging a religious duty, correction of wrong done in the past, mental or moral satisfaction or the lure to become a good Samaritan. As such, in order to determine the moral content of organ donation/sale and before embarking on any moral shift, following questions need to be addressed

1.   Who owns the organs?

2.   Does an individual have a right to organ transplantation?

3.   Why should the human organ and tissues not be exchanged for a consideration?

4.   Is organ sale contrary to the established values in medicine?

5.   What constitutes consideration, only the material gain or other kinds of gratifications also?

6.   Is the urge to survive against a terminal illness by buying organ and the urge to survive against poverty by selling organ inhuman or immoral?

7.   Which is the greater evil? To compel a person to die of a curable illness or to allow a person to sell his/her organ in order to save the life of a fellow-being ?

8.   Are there any other ways to ensure availability of organs to the needy except sale?

Once the practice of organ donation by the genetically related and also by strangers, based on altruism, has been accepted as ethically sound following components of organ removal stand morally vindicated-

(a)   A person’s expectation to enjoy life with the help of organs belonging to others is valid

(b)   Breach of donor’s bodily integrity and the consequent harms are permissible

The above moral vindication is rooted in fundamental human values namely beneficence, compassion, altruism, sacrifice, human solidarity, mutuality and reciprocity. All ethical concepts and strategies ought to be founded on these basic human values. These are the values which impart strength and endurance to human beings as a cohesive society. Judged on these values a person’s act of severing his/her organ in order to liberate a fellow  being from a terminal illness or to save his/her life cannot be dubbed as immoral simply because the act is accompanied by a reasonable material consideration. “when a person sells anorgan he or she acts both selfishly, in advantaging him- or herself,and altruistically, in contributing to a publicgood” (28) Presence of consideration is not a sufficient reason to transform an otherwise pious act in to a sin.  Otherwise, selling water to thirsty will be an equally big sin, rather bigger.

To equate an organ vendor with a criminal committing heinous crime like murder, robbery or theft, as is reflected in the legislative strategies of almost all jurisdictions,  is a monstrously misconceived act. A person who sells his organ does so because he knows that his organ is going to save the life of a fellow human being and as such he is convinced that he is not committing anything immoral or inhuman. Had he known that his act would lead to loss of life, property or inflict any other kind of injury on the buyer he would not have sold his organ. While a criminal does not have any such moral conviction or justification and commits the act solely for his personal gain, without caring for the loss or injury suffered by the victim. As such, it seems that the legislative strategies in the area of organ transplantation have not been realistic.

Donor and vendor compared

Donor                                                                                               Vendor

Injury and risk to the body                                                                    Do

Purpose of donation is to save life of a family     Purpose of donation is to save his/her  member or a fellow human being                         own life or the life of family member /

members and a fellow human being

Gain in terms of joy, satisfaction, goodwill                     Gain in terms of money and survival

Expectation of emotional or material support     No such expectation

and social security in case of donation to a near

relative such as wife, father, mother, sister,

brother, son or daughter

Free and informed consent is not possible                      Free and informed consent is not

owing to emotional stress and fear of losing                   possible owing to pressures of

a near relative and the consequent  loss of                     poverty and insecurity

security and support

Thus it may be seen that although the donation seems an innocuous and charitable act and the sale a commercial and profitable exercise there is not much difference between the two in terms of bodily consequences, purpose, intention and motive. It may be noted that sale, gift, donation and lease are rooted in recognition of property rights and which particular course is to be adopted for the transfer of property depends on the choice and circumstances of the parties.

Arguments against financial incentive and sale:

Moral arena has a vast scope of disagreement. One’s attempts to address the crisis of organ scarcity (29) may appear “satirical response’ to the other. (30) “In donation matters, emotion is a key factor” and “Live tissues and organs are not plain goods like drugs or pieces of equipment.”(31)  A  “loved one’s body is more than a piece of meat to be sold to the highest bidder and for this reason the “firefighters at the world trade center kept watch for months to discover and recover their deceased relatives and friends.” (32) The “integrity of the human body should never be subject of trade” and “it dangerously undermines human dignity by promoting the gloomy overlapping of human being and marketing” (33) There is a feeling that marketing of organs will lead to “redistribution of healthy organs from the poor to non-poor.” (34) as ““organ procurement will be increased only by contributions by the poor.” (35)

Policies on organ transplantation reflect unique social paternalism. Objections against sale of organs such as “(1) the dilution of altruism in society; (2) the risk that the quality of donated organs would decrease; (3) doubts about the voluntariness of those who accept financial incentives for donation; and (4) the treatment of human beings and their parts as commodities.” (36) do not  reflect an objective approach.  Recent critics of markets in organs give two main reasons to support their opposition (1)  “the integrity of human body should never be subject to trade” (2) a system is unethical “when it penalizes the weakest people and exacerbates discrimination based on census” and generates “the risk of exploitation of vulnerable donors” (37)  Some are more skeptical and feel that the “poor of the developing world could become a vast reservoir” of organs for the developed world  (38) and that the poor in a “starved country” can never be “fully informed and autonomous donors”. (39) Others feel that it amounts to  “exploitation of potential donors” (40)

Arguments against organ sale are thus grounded in two broad considerations: (1) sale is contrary to human dignity (2) sale violates equity. Let me examine them one by one.

Sale is contrary to human dignity?

In the contemporary ethical deliberations human dignity has become a very handy tool to  measure the ethical content of biotechnological applications, at times, without appreciating its true nature, ambit, and implications. It is not with in the scope of this paper to deal with human dignity in its entirety but it may however be worthwhile to know as to what it means in its essence. Essentially speaking, human dignity is an expression of human content of Homo sapiens. It is a reflection of properties or virtues due to which human creature is known as human being. These are the characteristic or attributes which are unique to human race and are not possessed  by any other living form.  What are these virtues? These virtues, known in the Vedic thought as Dharma, are ten in number namely love,  trust,  righteousness, compassion,  tolerance, fairness, forgiveness, beneficence, sacrifice, and concern for the weak. With these human virtues in mind, any act done to save the life of a human being or to liberate him from suffering cannot be construed as contrary to human dignity. The presence of a consideration does not alter the basic content of an act like organ sale which is grounded in the need to save at least two human lives, one from terminal illness, the other from hunger. Human dignity does not contemplate that the people should be forced to die a premature death owing to curable illness or hunger and their family members should be left to starve. Rather, it will be contrary to human dignity to promote such an act. Matter of payment is a logistical dimension, not the substantial aspect. Retrieval of organs from the dead by presuming consent on their behalf or the act of declaring a person dead in order to remove organs from his body are the devices discovered solely to augment organ supply but they are not treated as contrary to human dignity. Prohibition on sale makes the matters worse  by restricting transparency, fairness and choice and by generating arbitrariness, fear and bribes.  Vendor and buyer attain  vulnerability owing to unwarranted legal component which brings in many players such as police, lawyers, adjudicators and  social activists each with its own philosophy and interest thereby transforming a candid activity in to a highly complex exercise..

It is significant that the concept of human dignity is being selectively applied, in case of certain tissues only. Blood, bone marrow, sperms and eggs are being openly sold and  a woman  can “command $ 50,000 for her donated eggs” (41) but their sale, it seems, does not attract  notions of human dignity.

The argument that there cannot be genuine and free consent to the sale of organs is not sound. In fact such an argument is an antithesis of the concept of autonomy. The decision to sale organ taken by a person after considering all circumstances, consequences, options and possibilities cannot be disregarded by others on the ground that it has been taken under “undue influence or inducement” The individual is the best judge to decide as to what is best for him under a given situation and so long his decision does not affect others he cannot be stopped from acting upon his decisions. If the vendor is not able to give free and informed consent owing to pressures of poverty and the lure for money, the buyer is also not able to give such consent owing to pressures of illness and urgency of saving his life. The donor too is unable to give free and informed consent owing to fear of losing a near relative and the consequent insecurity and loss of support. Thus none of the parties involved is capable of giving free and informed consent owing to compelling circumstances. It means that the whole exercise of organ transplantation is not consistent with the principle of free and informed consent and therefore it is unethical. Why should then only the vendor be declared an offender?

Arguments linking  person’s autonomy to bodily “integrity’ or “fullness” and thereby declaring organ sale as “misuse” of  “our autonomy” (42) appear misconceived because if that is the case “integrity’ or “fullness” is breached in case of donation also, which is not considered to be unethical..

In order to reconcile with the failure to provide organs to the needy various considerations such as old age, associated diseases, bad prognosis and irresponsible behaviour etc. are brought in to exclude a number of potential organ recipients, knowing fully well that in such cases “the alternative to transplantation is death” (43) Organ scarcity has polluted the moral concepts and some feel “alcoholics should be given lower priority  for a liver because of their moral vice of heavy drinking” (44) and “lung transplantations” should not be offered “to people who smoke or have other substance abuse in the last six months” (45) Despite the fact that brain death and human death are not the same, the definition of death has been liberalized in order to give “incessant push to expand the pool of potential organ donors” (46) Thus, prohibition on sale is not without heavy costs which include untimely death, poor quality of life, higher disease burden, moral bias and premature certification of death. Is it consistent with human dignity?

Sale is violative of equity?

1.   The apprehension that the organs will become costly, going beyond the reach of common man is not true. Costs can always be controlled by the state by regulatory mechanisms as is being done in case of other goods and services. Furthermore, socio-economic inequalities reflect themselves in all walks of life, not only in organ transplantation. The whole healthcare system is subject to market forces. Many drugs, equipments, appliances, procedures and services are prohibitively costly and are not accessible to all those who need them. In many jurisdictions, they have to be imported from the developed and industrialized countries which, at times, monopolize their trade. Despite strong objections from the public who desire healthcare as a welfare measure there has been increasing commodification of healthcare services. Organ transplantation is also a part of this overall milieu.

2.   Purchase of the organs is likely to have only marginal impact on the cost of transplantation procedures. In many countries, including India, where there have been reports of organ trafficking, kidneys are sold for as little as 200-500 US $ while the reports on total cost of a kidney transplantation vary widely, ranging from 1000 US $ (47) to 8000 US$ (48)  Dr. Raymond Crockett, debarred from practicing in Britain in 1990,   for professional misconduct, arranged kidneys from Turkish people for 2500-3500 Pounds but charged 66000 Pounds from the patients for each transplantation. (49) This means that cost of organ is just a fraction of the total transplantation cost which, in fact, is much higher if the post transplantation  immuno-suppresive therapy and the other follow-up care is taken in to account. The apprehension in some quarters that organ sale will create a market mechanism that will enhance the transplantation costs is unfounded. Rather, the free availability of organs will reduce the costs of transplantation by curbing the expenses incurred on clandestine operations and the middle-men who are invariably associated with the organ trade, as is clear by the recent exposures in London (50) and Punjab (51)  Organ transplantation is a costly medical intervention, mainly because of the high fees of  the surgeons and others involved in the process.  Organ sale therefore is not likely to enhance the transplantation costs substantially.  Moreover, in case organ sale is legitimized the cost can always be regulated by the state as is being done in case of other commodities. A better option to reduce the transplantation costs is to regulate the surgeons fee, nursing home charges, prices of equipments, appliances and drugs.

3.   As regards the concern that once organ sale is legitimized organs will mainly be sold by “those who cannot afford to keep their organs”, (52) the matter requires deeper examination. As per the available input, in almost all cases, organs have been sold by persons in the state of abject poverty. In one case when I asked an organ seller as to why he sold his kidney his reply was devastating: “I had nothing else to sale!” Persons surrounded by such brutal poverty and social deprivation do not have many options. Even when their organs are intact their lot is miserable as they suffer from hunger, diseases and scorn. Society has so far done nothing to alleviate their suffering. Selling of organ may provide them with some additional means and prolong their existence. If organ sale amounts to exploitation of the poor it is a continuum of long drawn process of their exploitation watched by the society for centuries. They have been selling all that they possess in order to continue their existence. At the end, organs are the only source of money to prolong their existence for some more time. How can the society stop them from this act unless the society  provides them with adequate means to survive.  Why is this sudden concern for the poor? A society passive to their problems for ages has got no authority to interfere with the arrangement evolved by them to safeguard their survival. In case society truly feels that they should not sale their organs their genuine needs should be addressed so that they are not forced to sale their organs. What kind of morality is this to snatch from the poor the only asset offered to them by the Nature? The prohibition on sale of organs has worsened the  poor’s  lot. Buyers quite often refuse to pay or do not pay the agreed price. The vendor cannot assert his claim because of the fear of being prosecuted. Thus the strategy which was evolved for protecting the poor has been causing just the opposite impact. There is one more aspect to this issue. If a person who is not poor and in whose case there is no possibility of being exploited chooses to sell his organ will he be allowed to do so? If not, it means that the reasons for prohibiting organ sale are grounded in some other considerations, not in the concern for the poor..

4.   The argument that permitting organ sale is not an equitable proposition since it restricts availability of organs only to affluent sections of the population is misconceived.  How far is it fair to deny healthcare to those who wish to buy it through their legitimate money, earned by honest means, on the ground that it is not available to others due to their inability to pay? And if that is fair, why have we chosen a system of pricing the healthcare  despite the fact that many cannot pay even for basic necessities such as food and drinking water? Ours is an essentially heterogeneous society and equity has to be defined in realistic and pragmatic terms.

5.   Prohibition on organ sale generates inequity by exerting undue pressure on the near relative who  may “feel compelled to overlook the risks of organ donation when their loved one stands to receive so great a benefit” (53) This pressure amounts to coercion which is as bad as that exerted by the poverty and as such “should equally rule out donation” (54) The sale provides a wider choice and the vendor may be much more healthier than the donor and the organ may be much more compatible with the recipient. Furthermore, during “removal of a vital part like kidney the donor is subjected to a major surgical intervention which is not without risk. The recipient who is already sick is also exposed to a major surgical procedure with possibilities of complications. This means that two members of the same family are placed in a vulnerable situation thereby affecting the fate of other members of the family also. In case of any complications or untoward outcome the said family may be the victim of serious adversities. As such it seems safer to accept donation from a member of a different family” (55)

6.   There is also a concern that there  may be trans-national movement of organs. The affluent countries, with their money power,  may drain organs from the poorer countries thereby imparting undue vulnerability to their population. This again is a problem of regulation which can always easily be handled by banning exports of human organs or by adopting other suitable strategy.

7.   The purpose of allowing organ sale is not to improve health status of the sellers or to award them “a long-term economic benefit”, as conceived by some (56) Such economic or health benefit does not occur in altruistic donations too but they are permissible. The reasons for permitting organ sale are grounded in the concern for saving lives of terminally ill patients with the help of available medical knowledge and technology by curbing “a contrived shortage created by existing organ procurement policies.” (57) As regards poverty and ill health, they are rooted in factors other than organ sale and need to be addressed accordingly.

Conclusion

Those who were earlier destined to die carry a hope to survive, provided the biotechnology is allowed to unfold itself. It may be worth appreciating that medicine is always need-based i.e., it is an aid to overcome physical or mental  disability or disease. It cannot be equated to justice, art, or spirituality. It is also worth remembering that the right to relief from pain and suffering is intrinsic i.e. it is non-divestible. Any social policy leading to infringement of such a valuable right has to be founded on equally vital considerations.  Donor and recipient are the major stakeholders in policies relating to organ transplantation and as such any policy that does not take into account  their perspectives and  views is not valid. Organ sale is essentially rooted in the urge to survive. Recipient wants to survive against a terminal illness, seller wants to survive against povertyThe ethicists continue to debate the moral content of biotechnological promises, subordinating therapeutic advantages to ‘higher’ goals but I am forced to draw the same conclusion which I did in  1995 i.e.,

“Neither  the diseased persons nor the genetic relations provide an answer to trading in human body parts.”

“Live human body constitutes a vital source of supply of organs and tissues and the possibilities of its optimum utilization should be explored”

“There is no scope for dogmatic postures and open-mindedness should be the approach while dealing with the issue of organ transplantation”

“Society owes a duty to save the life of a dying man and in the event of failure to do so, it is absolutely immoral to interfere with his own arrangements by making unrealistic laws.”

“The scarcity need to be urgently overcome otherwise unwarranted trade and crime are liable to thrive”

“Commercialization should be curved by making the enforcement agencies efficient and not by depriving a needy person of his genuine requirements. Legislative craftsmanship lies in providing an answer without curtailing freedom of the people” (58)

There is near universal agreement that human tissues should not be commercialized. But, unless the expressions like ‘human’,  ‘ownership’ and ‘commercialization’ are appropriately conceived and defined the ethics will remain obscure.

References

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(41)     Jeffrey Kahn. Wanted: Tall, Smart and Fertile. Bioethics Examiner Spring 1999 Volume 3 Issue 1 p1

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